Medical Cost Containment
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Wednesday, 10 Sep, 202508:00am09:00am
Discover how to turn price transparency from a regulatory requirement into a strategic advantage across revenue cycle management and payment integrity. This session will explore how hospitals and health plans can leverage pricing data to drive smarter audits, reduce payment disputes, and strengthen compliance, all while improving patient trust and financial outcomes.
Learning Objectives:
- Understand how both hospitals and health plans can integrate pricing data into payment integrity processes to proactively identify discrepancies, minimize denials, and resolve disputes more efficiently.
- Learn best practices for aligning data sources, contract terms, and audit strategies between health plans and hospitals to ensure ongoing compliance with price transparency regulations and avoid penalties
Medical Cost ContainmentAMS Intelligent Analytics
Website: http://www.amspredict.com/
Advanced Medical Strategies (AMS) is the premier provider of payment integrity, risk management, and business intelligence solutions to identify and address excessive claims, prevent and recoup overpayments, and effectively manage the risks associated with high-cost claimants and group health underwriting.
09:55am10:35am11:05amIndustry benchmarks to measure the impact of payment integrity currently don't exist, making it challenging to optimize performance and areas of opportunity. Standards are extremely complicated due to varied member populations and an inconsistent approach to calculating metrics.
In this groundbreaking panel discussion, learn how a Working Group of payer and vendor SMEs have been collaborating over the last six months to develop a standard approach to calculating savings PMPM across LOB and audit programs. This session will share standard definitions and calculations, so attendees can understand how to calculate and compare their savings PMPM.
Learning Objectives:- Learn about standard definitions and calculations for savings PMPM that apply to any type of plan, across LOB, region, and program audit
- Understand how to develop savings PMPM metrics that are comparable to a standard industry range
- Provide feedback on the approach to ensure benchmarks are applicable to your organization
- Access resources and expert guidance to support development of benchmarks
Payment IntegrityDiagnosis codes and modifiers aren’t just billing details—they tell the story that determines how your claims are paid. When these elements don’t align, hospitals face denials, delays, and compliance risks. This session will break down how to accurately connect coding choices with billing practices to ensure claims reflect true clinical intent, reduce audit exposure, and secure appropriate reimbursement.
Learning Objectives:- Recognize the most common coding and modifier missteps that lead to denials and learn how to avoid them through stronger documentation and coding practices.
- Implement strategies to bridge gaps between clinical, coding, and billing teams—ensuring consistent, compliant claims that tell the right story from documentation to payment.
Revenue Cycle Management12:00pm01:30pmHospice care is meant to support patients in their final months of life, yet inappropriate or prolonged utilization continues to raise clinical, ethical, and payment integrity concerns. This session will provide critical insights into what constitutes appropriate hospice enrollment, how to identify red flags for overutilization, and strategies hospitals and health plans can use to ensure hospice services align with medical necessity.
Learning Objectives:- Understand the clinical criteria for appropriate hospice enrollment and identify common patterns of misuse that may lead to unnecessary costs and compliance risks.
- Gain tools and best practices for conducting eligibility reviews, improving documentation scrutiny, and collaborating across teams to prevent improper payments while supporting appropriate patient care.
Payment IntegrityAs value-based care continues to reshape payment models, many health systems struggle to balance financial performance with care quality goals. This session will offer practical strategies to use denial data, coding insights, and care coordination metrics to strengthen value-based outcomes—without sacrificing revenue. This discussion will highlight how to engage teams, optimize processes, and identify sustainable financial opportunities within value-based contracts.
Learning Objectives:- Learn how to use denial patterns and audit insights to improve documentation, coding accuracy, and contract performance.
- Gain strategies to foster physician buy-in and leadership collaboration, finding “win-win” solutions that support both revenue integrity and value-based care success.
Revenue Cycle Management02:25pm03:05pmPayment integrity can be challenging to navigate, especially for smaller or regional health plans new to this field. In this session, experienced leaders will share their insights on how emerging trends - such as the growing use of AI and the increasing demand for timely data exchange - are shaping the field. The panel will provide practical advice on building a strong foundation, avoiding common challenges, and improving savings for plans at any stage of their payment integrity journey.
Learning Objectives:- Learn how to evaluate vendor capabilities and build strategic alliances that scale with your needs.
- Get a framework for launching a PI strategy appropriate for your plan’s size and strategic direction.
- Understand current trends such as the merging of fraud and integrity functions and the shift toward collaborative data-sharing.
Payment IntegrityAlivia Analytics
Website: https://www.aliviaanalytics.com/
Your most expansive Payment Integrity and FWA partner for medical, pharmacy, vision, and dental claims. This features our powerful, configurable Alivia 360™ Platform that provides pre- and post-payment flexibility and considerable cost savings across the healthcare claims management process. It seamlessly transitions between FWA detection and Payment Integrity solutions including clinical and non-clinical audit scenarios, first- and second-pass claims editing, and COB/TPL. Alivia 360™ not only ensures comprehensive financial oversight but full adaptability to operational needs. Alivia integrates AI as an assistant, not a replacement, prioritizing ethical use, human oversight, and compliance with industry standards. Our solutions are offered as SaaS or tech-enabled services that build strong cases against inappropriate billing practices, identify new recoveries missed by legacy vendors, deliver actionable analytics, and offer automated corrections. Alivia enables healthcare payers to streamline vendor management, improving control and strategic decision-making. Schedule a discovery meeting and demo.
Denial management isn’t just about fighting back—it’s about understanding why denials happen and fixing the root causes upstream. This session will focus on how hospitals and health systems can use audit findings and denial data to identify coding gaps, documentation weaknesses, and process breakdowns that lead to preventable denials. Learn how to close these gaps through stronger internal collaboration across revenue cycle, coding, and clinical teams, while also using data-driven insights to foster more productive payer relationships.
Learning Objectives:- Learn how to analyze denial patterns and audit results to uncover documentation, coding, and process issues—enabling proactive prevention rather than reactive rework.
- Discover best practices for improving internal workflows, fostering collaboration between clinical and revenue cycle teams, and ensuring that claims reflect accurate, defensible coding and clear clinical intent.
Revenue Cycle Management04:30pm -
Thursday, 11 Sep, 202508:55am09:00am
Payer-provider abrasion remains one of the biggest barriers to efficient payment, timely care, and operational success. Too often, denials, delayed payments, and prior authorization disputes stem from misaligned expectations, incomplete data, and unclear communication—not true disagreement. This session will offer a candid, solutions-focused discussion on what payers really need from providers, what providers can do upfront to reduce friction, and how both sides can work together to minimize rework, prevent avoidable denials, and create shared wins.
Learning Objectives:- Gain clear insights into how providers can proactively align documentation, coding, and authorization workflows to meet payer requirements and reduce denials and appeals.
- Learn practical approaches to improve data sharing, reduce ambiguity in clinical and billing documentation, and foster payer-provider partnerships that lead to faster resolutions and fewer administrative burdens.
- Explore strategies to move beyond transactional interactions and build trust-based partnerships between payers and providers—focusing on shared goals like timely care, accurate payment, and operational efficiency.
Medical Cost Containment09:55am10:35am11:05amAs AI use rapidly expands across health plan operations, understanding how these technologies will be governed is essential. In this session, experts will take a deeper dive into the current state of AI governance frameworks and the legislative landscape shaping their use. Health plan leaders will gain timely insights into what’s happening now—and what’s coming next—in AI oversight, helping them prepare their organizations for compliance, accountability, and responsible innovation.
Learning Objectives:- Learn how to assess, document, and monitor AI models used in claims review, fraud detection, and payment integrity to ensure they meet accountability, explainability, and compliance standards.
- Gain actionable insights into current and pending legislation on AI use in healthcare, and understand what steps your organization should take now to align with evolving regulatory expectations and avoid audit risks.
As payers increasingly deploy AI and automation to accelerate denials and reduce payments, health systems must evolve their own technology strategies to keep pace. This session will share best practices for integrating AI, automation, and machine learning into revenue cycle operations—drawing on real-world examples from leading health systems, hospitals and practices. Explore the journey of implementing automation and machine learning while navigating governance, overcoming technical hurdles, and fostering adaptability across teams.
Learning Objectives:- Understand technical and operational obstacles in adopting automation and AI tools, and learn proven strategies to overcome them effectively.
- Gain insights into building flexible governance frameworks, supporting staff education, and fostering adaptability to maximize the impact of emerging technologies in your revenue cycle.
12:00pm12:00pm02:25pm02:55pmEngage with quick, interactive demos from emerging vendors as they present new and innovative payment integrity and RCM solutions. A panel of judges will award the "Innovator of the Year" to the vendor with the most promising technology or approach. Apply here to showcase your solution or sign up here to join the judging panel.
Medical Cost Containment03:45pm04:25pm04:55pmAccurate risk adjustment coding is a cornerstone of effective payment integrity, directly impacting reimbursement accuracy and audit risk. This session will explore how health plans can strengthen HCC coding through targeted audits, technology solutions, and coder education—ensuring proper risk score capture, reducing payment errors, and supporting defensible, compliant payment practices.
Learning Objectives:
- Understand common sources of coding errors and how to use audit findings, coder education, and feedback loops to strengthen HCC coding precision and reduce payment risk.
- Explore how strong auditing practices, clear documentation standards, and focused coder training can help health plans identify gaps, improve coding accuracy, and ensure compliance across payment integrity programs.
As real-time data sharing becomes essential for care coordination, prior authorizations, and value-based care, hospitals and health systems face growing pressure to exchange sensitive information quickly—without compromising security. This session will explore how provider organizations can balance the need for timely data access with robust cybersecurity strategies. Learn practical approaches to mitigate risk, protect patient information, and build the infrastructure needed for secure, compliant data sharing across systems and partners.
Learning Objectives:- Understand key risks associated with real-time data sharing and learn strategies to safeguard PHI while supporting operational and clinical needs.
- Explore best practices for access controls, vendor oversight, encryption, and audit readiness to enable safe data sharing across health systems, payers, and partners.
Jump to: Wednesday, 10 Sep | Thursday, 11 Sep
Meet the PI leaders
Payment integrity leaders and emerging experts from the leading health plans on the East coast will be coming together this May to share their insights on the trends and challenges of the market.
To view the full line-up view the agenda below or click here.
Cathy Newman
Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island
Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island. Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans. In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models. She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.
Monique Pierce
Payment Solutions & Operations
Cohere Health
Monique started her Payment Integrity career in COB at Oxford HealthPlans. After the merger with UnitedHealthcare, she led multiple teams and was responsible for creating innovative programs. Monique joined SCIO Health Analytics in 2014 and was responsible for system and process improvements before being promoted to VP of client engagement and business optimization In 2020, Monique joined start-up Devoted Health and created a full suite of programs from the ground up. Based on a passion for metrics and measuring performance, she centralized and standardized all programs reducing implementation time and maximizing savings. Today, Monique is driving opportunities to improve claim payment by designing and developing new prior auth and claim reconciliation products at Cohere Health.
Drew Satriano
Vice President of Payment Integrity
Highmark Health
Drew Satriano, a seasoned professional with an MBA, CPA, CFE, and JD, brings extensive expertise in payment integrity, accounting, auditing, and legal matters within regulated environments. Notably, he has spearheaded innovative initiatives resulting in a 968% increase in savings since 2014. His recent focus includes leveraging AI and technology for enhanced accuracy and efficiency in provider payment processes.
Michael Devine
Director Special Investigations Unit
L.A Care
Danielle Nelson
FWA Program Manager
PacificSource Health Plan
Danielle M. Nelson graduated from the University of Missouri with a Bachelor of Science in Criminology and Criminal Justice. In 2017, she received a Master of Arts in Management and Leadership from Webster University.
Prior to joining for PacificSource Health Plans (PacificSource) as the Fraud, Waste and Abuse Program Manager in 2022, Ms. Nelson spent seven years working in Special Investigations Units (SIU) of varying sizes at both for-profit and not-for profit organizations, allowing her to gain experience in investigating fraud for government-funded programs, ACA, FEHB, and commercial lines of business. Before moving into fraud investigations in health care, Ms. Nelson spent 15 years in finance, working in consumer lending and back-office operations.
Ms. Nelson is a member of the Association of Certified Fraud Examiners, the St. Louis Chapter of ACFE, and National Health Care Anti-Fraud Association (NHCAA) and a participant with the Healthcare Fraud Prevention Partnership (HFPP).
Conor McCauley
Director, Payment Integrity Clinical Capabilites
Highmark Health
My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.
Cathy Newman
Managing Director Value-Based Strategy
Blue Cross Blue Shield of Rhode Island
Cathy Newman is the Managing Director of Value-Based strategy for Blue Cross Blue Shield of Rhode Island. Her experience in the healthcare industry spans over twenty years working for both large integrated providers, small IPAs, and health plans. In her ten years with Blue Cross, she has worked to advance value-based opportunities from pay for performance to full-risk global capitation models. She is passionate about her work and has been able to develop more collaborative and meaningful relationships with providers throughout the state of Rhode Island.
Monique Pierce
Payment Solutions & Operations
Cohere Health
Monique started her Payment Integrity career in COB at Oxford HealthPlans. After the merger with UnitedHealthcare, she led multiple teams and was responsible for creating innovative programs. Monique joined SCIO Health Analytics in 2014 and was responsible for system and process improvements before being promoted to VP of client engagement and business optimization In 2020, Monique joined start-up Devoted Health and created a full suite of programs from the ground up. Based on a passion for metrics and measuring performance, she centralized and standardized all programs reducing implementation time and maximizing savings. Today, Monique is driving opportunities to improve claim payment by designing and developing new prior auth and claim reconciliation products at Cohere Health.
Drew Satriano
Vice President of Payment Integrity
Highmark Health
Drew Satriano, a seasoned professional with an MBA, CPA, CFE, and JD, brings extensive expertise in payment integrity, accounting, auditing, and legal matters within regulated environments. Notably, he has spearheaded innovative initiatives resulting in a 968% increase in savings since 2014. His recent focus includes leveraging AI and technology for enhanced accuracy and efficiency in provider payment processes.
Michael Devine
Director Special Investigations Unit
L.A Care
Danielle Nelson
FWA Program Manager
PacificSource Health Plan
Danielle M. Nelson graduated from the University of Missouri with a Bachelor of Science in Criminology and Criminal Justice. In 2017, she received a Master of Arts in Management and Leadership from Webster University.
Prior to joining for PacificSource Health Plans (PacificSource) as the Fraud, Waste and Abuse Program Manager in 2022, Ms. Nelson spent seven years working in Special Investigations Units (SIU) of varying sizes at both for-profit and not-for profit organizations, allowing her to gain experience in investigating fraud for government-funded programs, ACA, FEHB, and commercial lines of business. Before moving into fraud investigations in health care, Ms. Nelson spent 15 years in finance, working in consumer lending and back-office operations.
Ms. Nelson is a member of the Association of Certified Fraud Examiners, the St. Louis Chapter of ACFE, and National Health Care Anti-Fraud Association (NHCAA) and a participant with the Healthcare Fraud Prevention Partnership (HFPP).
Conor McCauley
Director, Payment Integrity Clinical Capabilites
Highmark Health
My name is Conor McCauley. I am the Director of Payment Integrity Clinical Capabilities at Highmark. Being a Critical Care nurse, it is easy to see there are issues surrounding healthcare funding. Inserting clinical insights into reimbursement methodologies can lead to affordability and improved patient outcomes. Clinicians are well positioned to make a difference here. My passion is developing an engaged team, effective processes, and surrounding clinicians with the right technology, data, and market insights so they can work at the top of their licensure.