Moderator
David V. Cardelle, R.Ph.
Chief Strategy Officer, SVP, Health Plan Strategy & Partnerships
Advanced Medical Strategies
Panelists
Dr. Ahmad Kilani MD, MBA, MLS, MSIT, CHCQM-PHYADV, FACP, FACHE
Medical Director
Cleveland Clinic
Kelly Springmann
Provider Enablement & Product Development
Florida Blue
Jenny Raulerson, BSN, MSHI
Sr Clinical Consultant
Florida Blue
During this presentation, Dr Archer and Dr Goyal will:
- Share the idea of clinically integrated revenue cycle key components
- Examine the roles of the clinicians and the revenue cycle staff at each step in the revenue cycle
- Analyze the effects of the clinically integrated revenue cycle in change management in its impact on clinical outcomes, experience and cost of care.
Track 2
Dr Deepak Goyal, MD, MBBS, MBA, CPE, CHCQM, CMRP, CMPC
Executive Medical Director Revenue Cycle and Supply Chain
Monument Health
Dr Brad Archer
Chief Medical Officer
Monument Health
Vendor management strategies for payment integrity are essential to ensure that your organization optimizes financial processes and ensures the recovery of overpayment. Here are some strategies that we will discuss:
- Vendor Selection and Due Diligence
- Stacking Vendors and multi-vendor approach
- Vendor Performance Metrics
- Data Sharing Protocols
- Payment integrity program options
Track 1
Novelette Wallace, MPH, PMP, CSSBB
Head of Payment Integrity
Johns Hopkins Healthcare
Novelette Wallace is a distinguished Payment Integrity Leader with a rich background spanning over 30 years in the healthcare industry. Her extensive experience includes leadership roles within payment integrity, where she has played pivotal roles in both payment integrity vendor organizations and health plans. Throughout her career, Novelette has demonstrated a remarkable ability to build and lead Payment Integrity departments from their inception. Her expertise has been instrumental in establishing robust processes and strategies to identify and recover inaccuracies in claims, contributing significantly to cost of care savings for health plans year after year.
Novelette has held key leadership positions with industry-leading organizations, including Performant Corp, United Healthcare, and Aetna (previously Coventry). In each role, she has consistently delivered results by optimizing payment integrity processes and driving operational excellence. Currently serving as the Assistant Vice President (AVP) of Payment Integrity for Johns Hopkins Health Plans, Novelette continues to bring her wealth of knowledge and leadership acumen to the forefront. Her dedication to achieving and surpassing cost of care savings goals exemplifies her commitment to advancing the financial health and efficiency of healthcare organizations.
With a proven track record of success and a comprehensive understanding of payment integrity within the healthcare landscape, Novelette Wallace stands as a respected leader in the industry, contributing significantly to the success of the organizations she serve
Track 2: Revenue Cycle Management & Revenue Integrity
Toni Case
Vice President, National Sales
CERIS
Debra Hamer
Director, FWA Analytics
CERIS
Ceris Health
Website: https://www.ceris.com/
CERIS has 30 years of prepay and post pay claim review and repricing experience with a 97% client retention rate. Our solutions are deep, consistent, and defensible reviews, which make CERIS the partner of choice for health plans, Medicare and Medicaid plans, and third-party administrators. CERIS’ longstanding review services and clinical expertise offer incremental value and are grounded in a sincere dedication to our valued partners. CERIS' mission is to continue to grow and deliver long term Payment Integrity services for our partners and to help them save.
Track 2: Revenue Cycle Management & Revenue Integrity
Baize will speak about new federal payment integrity efforts that affect Medicare and Medicaid. These efforts will focus on fee-for-service payments, Medicare Advantage, and Medicaid managed care. As the line between public payers and private payers continues to be blurred, the policies and rules coming out of the federal Centers for Medicare and Medicaid Services (CMS) will affect nearly every payer and plan.
CMS continues to place much of its focus on healthcare supplies and services that are fulfilled outside institutional settings. Home-based care, durable medical equipment and disposable medical supplies remain under increased scrutiny as areas that CMS has deemed at high risk for fraud. Laboratories and specialty pharmacies are also being more closely monitored.
Additionally, as required by the 21st CURES Act, electronic visit verification (EVV) of home-based services is now implemented throughout the U.S. Payers should see a reduction in claims for those services, but that depends on whether states implemented EVV consistently, and whether providers willing to commit fraud have already found ways around the technology.
Finally, Baize will provide recent examples of successful healthcare fraud prosecutions from around the U.S.
Track 1
Anthony Baize
Inspector General
Wisconsin Department of Health Services
Anthony J. Baize is the Inspector General for the Wisconsin Department of Health Services. Baize took the position in early 2016 after eight years with Kentucky state government in the Kentucky Cabinet for Health and Family Services, serving as the Deputy Director of Audits and Investigations for the Office of Inspector General and the Director of Business Informatics with the Department of Behavioral Health, Developmental and Intellectual Disabilities.
Baize has served as the Region V representative for the National Association of Medicaid Program Integrity Directors and on the Advisory Board for the Centers for Medicare and Medicaid Services’ Medicaid Integrity Institute. He regularly speaks at national conferences on topics related to Medicaid Program Integrity.
Baize became a certified inspector general in 2022 after completing the Association of Inspectors General Institute. He is also a member of the Internation Association of Financial Crimes Investigators.
Baize was a civil rights consultant for nearly 20 years, serving on the Board of Directors for the National Fair Housing Alliance and the Lexington (KY) Fair Housing Council. Baize has given presentations on fair housing requirements across the United States, but especially in Kentucky, Indiana, Ohio and Tennessee. He has a master’s degree in public administration from Indiana State University, has been married for 29 years and has two daughters.
Track 2: Revenue Cycle Management & Revenue Integrity