- Update on new CPT codes and "old" CPT codes and how to document
- Learning Objectives:
- Learn about new CPT codes coming January 2025
- Understand the documentation required for the codes
David Flannery
Director of Telegenetics and Digital Genetics
Cleveland Clinic
David Flannery is a "pioneer" in telemedicine, having started telegenetics clinic in 1995 in Georgia. He’s currently the Director of Telegenetics and Digital Genetics at Cleveland Clinic. He has expertise with ICD-10 coding and CPT codes. He oversaw the revenue cycle management for the 300+ physician practice group at the Medical College of Georgia. He served on the American Medical Association's Digital Medicine Payment Advisory Group, developing new CPT codes for telemedicine and digital medicine.
9: 30 – 11 – AI Symposium
9:30 – Introduction
9:30 – 10:30 – The Future of AI in Healthcare Payments (Panel)
Panellists: Monique Pierce, Conor McCauley, Frank Shipp, Tom Everett
Moderator: David Ott, CGI
10:30 – 10:50 – Vendor Demos of AI Capabilities
10:50 – 11:00 – Optimizing AI in Healthcare Payment Integrity
Speaker: Natalie Clayton, Private Consultant
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.
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.
Frank Shipp
Executive Director
Johns Hopkins Medicine
Frank E. Shipp currently serves as Executive Director of the Johns Hopkins Clinical Alliance, the clinically integrated network of Johns Hopkins Medicine. The network includes over 3,000 providers, consisting of both employed and independent practices.
Frank transitioned to value-based care after 25 years of hospital-based operations experience in both community and academic health systems. During the past nine years, Frank has held executive positions in a Payor-Provider Organization in NYC and has built a highly successful CIN over a five-year period in Northern New Jersey. Frank speaks regular at national healthcare conferences regarding value-based care strategies and tactics.
Frank completed his MBA at Fairleigh Dickinson University, is a certified Fellow of the American College of Healthcare Executives and a trained Black Belt in Lean Six Sigma from Villanova University.
Thomas Everett
Subject Matter
Expert Independent
David Ott
Director Consulting Payment Integrity
CGI
David Ott has over 28 years of experience in the healthcare and financial services industries. David has provided leadership and direction to department leaders and teams that support a variety of functions, including business development, payment integrity, claims processing, global project management and quality practices.
CGI
Website: https://www.cgi.com/us/en-us
Founded in 1976, CGI is among the largest IT and business consulting services firms in the world. We are insights-driven and outcomes-based to help accelerate returns on your investments. Across hundreds of locations worldwide, we provide comprehensive, scalable and sustainable IT and business consulting services that are informed globally and delivered locally.
This presentation will explore the various factors impacting claims trends, including utilization rates, unit costs, provider billing issues, claim payment mishaps, and inaccuracies in loading member benefits and provider rates. A key strategy to address these issues is the implementation of a robust payment integrity process. By combining the efforts of internal staff and expert vendors, payment integrity processes can significantly influence claims trends, thereby enhancing the overall profitability of health plans.
We will delve into specific examples to assess whether payment integrity efforts have successfully bent the claims trends or maintained them at a steady level. Additionally, the presentation will cover effective communication strategies with actuaries to ensure accurate data analysis and reporting. This dialogue is crucial for aligning strategic objectives and operational tactics with the actuarial insights necessary for informed decision-making in health plan management.
- Understanding of how to assess changes in claim trends
- How to effectively communicate with actuary teams to ensure accurate data analysis and reporting
Harold Davis
VP, Product Growth
Rialtic
Rialtic
Website: https://www.rialtic.io/
Rialtic is a modern healthcare technology platform focused on payment accuracy. Built by a team of seasoned industry veterans, Rialtic addresses the most important areas of the payment process. Payment policies are highly configurable and customizable: insurers can edit or build their own bespoke policies, while providers can analyze potential reimbursement levels. Robust analytics features across claims, lines of business, payments, and policies provides insightful business intelligence to users. By continuously sourcing, ingesting, and structuring healthcare payment policy documents and data, customers can confidently make up-to-date decisions. Keeping security and compliance top of mind, Rialtic empowers healthcare organizations to work off the same platform with rigorous security controls, a standard in enterprise software.
Healthcare payors and providers, as well as employers, are recognizing the importance of value-based care. Pressure to reduce avoidable cost and utilization, coupled with the demand to improve quality outcomes has caused payment models to move from fee-for-service to fee-for value. To succeed in this new paradigm, payors must collaborate with other stakeholders to design and implement value-based care models that meaningful and sustainable. These models must address the needs of all stakeholders, including the payors, providers, employers and the patients.
Learning Objectives:
- Synergistic opportunities for payors and providers to establish value-based programs
- Efficient allocation of resources when implementing value-based care
- Mitigating risk of downside value-based payment models
- Responding to disruptors
Frank Shipp
Executive Director
Johns Hopkins Medicine
Frank E. Shipp currently serves as Executive Director of the Johns Hopkins Clinical Alliance, the clinically integrated network of Johns Hopkins Medicine. The network includes over 3,000 providers, consisting of both employed and independent practices.
Frank transitioned to value-based care after 25 years of hospital-based operations experience in both community and academic health systems. During the past nine years, Frank has held executive positions in a Payor-Provider Organization in NYC and has built a highly successful CIN over a five-year period in Northern New Jersey. Frank speaks regular at national healthcare conferences regarding value-based care strategies and tactics.
Frank completed his MBA at Fairleigh Dickinson University, is a certified Fellow of the American College of Healthcare Executives and a trained Black Belt in Lean Six Sigma from Villanova University.
- This session is designed for organizations without a payment integrity unit presently or a payment integrity unit in its infancy. This presentation will analyze when and how to evaluate pre-pay solutions versus post-pay solutions.
- The presentation will first explore pre-pay options to enhance with your current claims adjudication system and how to implement a new claims editing system to interface with your current claims adjudication system. For post-pay options, presentation will discuss strategies in terms of first-pass, second-pass, and third-pass solutions. Discussion on post-pay contract negotiations will also be presented along with how to deal with provider and hospital pushback when implementing these new solutions.
- A brief discussion regarding Coordination of Benefits (COB) will demonstrate that COB is more an enrolment issue versus a claims issue; asking the question: Should COB be considered in a payment integrity unit? The presentation will end with a focus on how to bring all these actions and issues into a new payment integrity unit.
- Learning Objectives:
- · Analyze differences between pre-pay and post-pay solutions.
- · Compare different strategies and vendor solutions for first-pass, second-pass, and third-pass post-pay solutions.
- · Examine methods to communicate with providers and hospitals to lessen major pushback when implementing these strategies.
- · Discuss if COB should be a payment integrity issue.
- · Evaluate different choices for starting a payment integrity unit.
Dr Michael Seavers
Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics
Harrisburg University
Dr. Michael Seavers is the Vice-Chair of the Harrisburg University Faculty, Department Chair and Program Lead, and Assistant Professor of Healthcare Informatics at Harrisburg University. Dr. Seavers has a varied background in IT, business, and healthcare spanning many decades. Dr. Seavers began as a programmer analyst at Shared Medical Systems and later at General Electric in their Aerospace Division. Dr. Seavers then worked in IT management in the pick-pack-and-ship industry being employed at companies like Book-of-the-Month Club (Time Warner) and Hanover Direct during the .COM expansion.
As the .COM industry went bust, Dr. Seavers moved to the healthcare industry. Dr. Seavers worked at Capital BlueCross for nearly two decades. The first decade was as a Senior Manager in the IT department and the second decade as the Senior Director of Claims and later the Senior Director of Enrollment and Billing. Dr. Seavers focus was automation of labor utilizing software robotics for healthcare.
After a varied career background and various formal degrees, Dr. Seavers is very pleased to be teaching at Harrisburg University.