HPRI Nashville Agenda | Kisaco Research

HPRI Nashville Agenda

3rd Annual Healthcare Payment & Revenue Integrity Congress Nashville | February 5-7 2025
5-7 February, 2025
Millennium Maxwell House Nashville

Jump to: Pre Day | Day One | Day Two | Day Three

Printable version

Pre Day: Tuesday, 4 Feb, 2025
Wine Tasting/Music
Day One: Wednesday, 5 Feb, 2025
Registration – Payer/Provider Speed Networking Sessions
8:30 – 9:30

Payment Integrity Overview – A look at 2025

An overview of the most significant fraud trends and payment integrity technologies and strategies going into 2025.

Author:

Kelly Bennett, JD, CFE, AHFI

Medicaid Program Integrity Chief
Agency for Health Care Administration

Kelly Bennett graduated from the University of Tampa and Florida State University College of Law.  She has been a member of the Florida Bar since 1997 and is a Certified Fraud Examiner and an Accredited Health Care Fraud Investigator.  She has worked at the Florida Agency for Health Care Administration since 2001 and has served in several roles, including as a Senior Attorney within the Medicaid Division of the Office of the General Counsel, the Assistant Bureau Chief for the Bureau of Medicaid Program Integrity, the Agency’s Medicaid
Fraud Liaison, and is currently the Chief of Medicaid Program Integrity, where she has served since July of 2014.  She is currently the President for the National Association for Medicaid Program Integrity and is an active participant in training and collaboration initiatives with the National Health Care Antifraud Association.

... read more

Kelly Bennett, JD, CFE, AHFI

Medicaid Program Integrity Chief
Agency for Health Care Administration

Kelly Bennett graduated from the University of Tampa and Florida State University College of Law.  She has been a member of the Florida Bar since 1997 and is a Certified Fraud Examiner and an Accredited Health Care Fraud Investigator.  She has worked at the Florida Agency for Health Care Administration since 2001 and has served in several roles, including as a Senior Attorney within the Medicaid Division of the Office of the General Counsel, the Assistant Bureau Chief for the Bureau of Medicaid Program Integrity, the Agency’s Medicaid
Fraud Liaison, and is currently the Chief of Medicaid Program Integrity, where she has served since July of 2014.  She is currently the President for the National Association for Medicaid Program Integrity and is an active participant in training and collaboration initiatives with the National Health Care Antifraud Association.

Author:

Dr Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE

VP Payment Integrity
Blue Cross NC

Dr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.

... read more

Dr Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE

VP Payment Integrity
Blue Cross NC

Dr. Priscilla Alfaro is a seasoned healthcare professional with extensive experience in executive medical management, fraud prevention, and healthcare analytics. A certified medical coder, fraud examiner, and auditor, she has a proven track record of improving healthcare efficiency and preventing fraud, waste, and abuse across various roles and affiliations, including the Texas HHS and Anthem.

9:30 – 10:45

Collaborating for Consistent Payment Integrity Metrics

This session will emphasize the importance of collaboration among stakeholders in developing and implementing consistent payment integrity metrics. Participants will explore strategies to improve data sharing, standardize measurement methodologies, and enhance fraud detection efforts.

Author:

Monique Pierce

Payment Solutions & Operations
Cohere Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

... read more

Monique Pierce

Payment Solutions & Operations
Cohere Health

Monique is a Strategic Executive Healthcare Leader with proven ability to develop solutions and maximize the benefits of Payment Integrity programs.  She is known for having excellent domain knowledge and being driven, high performing, and having a deep dedication to recruiting and developing top talent.

 

Monique started her Payment Integrity career at Oxford HealthPlans in the COB and Subrogation Department after spending time in Payment Policy.  When United Healthcare acquired many health plans in the early 2000s like Oxford, Monique was tagged as part of the Optum team to integrate the processes and people into the COB systems that she had built at Oxford.  She led systems development, quality, reporting, operations, vendor management and was responsible for creating innovative proactive programs that more than doubled savings to $1.4B in three years.

 

Monique developed a successful program that reduced interest expense on late claims for UHC, assisted a communication company to develop COB tools and assisted in strategic system projects before joining SCIO Health Analytics in 2014 to develop new products - specifically prepayment programs.

In 2015 she became the product owner of SCIOMine, the company’s internal audit application and managed the roadmap.  Monique also owned

strategic direction for operational metrics and reporting including executive scorecards. Monique was promoted to VP of Business Opportunities and Client Engagement where she improved Audit Recovery TAT by 39% and reduced client implementations TAT by 11% and the Level of Effort by 18% while increasing the count of implementation projects by 126%.

 

In 2020 Monique joined Devoted Health, a startup company with the goal of building the first ever integrated Payment Integrity Program.  The company has one system, great data, and a great mission; to change health care by treating every member as if they are family.

 

In her spare time, Monique volunteers her time in the community on the Board of Directors of SCARE NH and works in her family business LARP Portal with her husband Rick.

Author:

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

... read more

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

Author:

Catherine Pesek Bird

Physician Advisor
Lakeland Regional Health – Florida

Before coming to LRH, Dr. Pesek practiced as an academic cardiologist at a large Big Ten medical center, leading teams of fellows, residents, and medical students.  She provided direct patient care to cardiac patients, including transplant recipients and pregnant patients with either acquired or congenital heart disease. She worked on quality improvement programs in heart failure, sepsis, cardiac catherization, and medication adherence.

Prior to medical school, Dr. Pesek taught high school chemistry. She has written a book on understanding and determining end-of-life medical choices. She enjoys playing tennis and golf.  She is a proud alumna of the University of Notre Dame.

... read more

Catherine Pesek Bird

Physician Advisor
Lakeland Regional Health – Florida

Before coming to LRH, Dr. Pesek practiced as an academic cardiologist at a large Big Ten medical center, leading teams of fellows, residents, and medical students.  She provided direct patient care to cardiac patients, including transplant recipients and pregnant patients with either acquired or congenital heart disease. She worked on quality improvement programs in heart failure, sepsis, cardiac catherization, and medication adherence.

Prior to medical school, Dr. Pesek taught high school chemistry. She has written a book on understanding and determining end-of-life medical choices. She enjoys playing tennis and golf.  She is a proud alumna of the University of Notre Dame.

10:45 – 12:00
One-To-One Structured Networking
12:00 – 1:00

Payment Integrity Basics – Getting Started

Author:

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

... read more

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Author:

Jodi Powell

Director of Payment Integrity
HCSC

With two decades of experience in the intricate realm of medical claims, I am currently serving as a Director within the Office of Payment Integrity, where my passion for precision and accountability fuels my work. My expertise lies in both pre- and post-claim payment accuracy, ensuring that our solutions not only meet regulatory standards but also uphold the highest level of integrity for patients and providers alike.

Throughout my career, I have developed a keen eye for detail and a strategic mindset, enabling me to identify inefficiencies and implement new solutions that enhance medical cost reduction. By fostering collaboration across teams, I have led initiatives that optimize processes and improve financial sustainability, ultimately benefiting all stakeholders involved.

I pride myself on my ability to transform challenges into opportunities for growth and innovation. My commitment to excellence and adherence to ethical standards has earned me a reputation as a trusted leader in the field. I am excited to connect with professionals who share a similar vision of advancing 

... read more

Jodi Powell

Director of Payment Integrity
HCSC

With two decades of experience in the intricate realm of medical claims, I am currently serving as a Director within the Office of Payment Integrity, where my passion for precision and accountability fuels my work. My expertise lies in both pre- and post-claim payment accuracy, ensuring that our solutions not only meet regulatory standards but also uphold the highest level of integrity for patients and providers alike.

Throughout my career, I have developed a keen eye for detail and a strategic mindset, enabling me to identify inefficiencies and implement new solutions that enhance medical cost reduction. By fostering collaboration across teams, I have led initiatives that optimize processes and improve financial sustainability, ultimately benefiting all stakeholders involved.

I pride myself on my ability to transform challenges into opportunities for growth and innovation. My commitment to excellence and adherence to ethical standards has earned me a reputation as a trusted leader in the field. I am excited to connect with professionals who share a similar vision of advancing 

Enhancing Medicare Part D Fraud, Waste & Abuse Program (FWA)

Author:

Helen Liu, Pharm.D.

Health Plan Leader
Independent

Helen Liu, PharmD, brings 29 years of diverse pharmacy experience, blending clinical expertise, operational efficiency, technological innovation, and management across various healthcare settings.
Over the past four years, Helen has successfully led pharmacy operations at ATRIO Health Plans (Medicare), achieving significant milestones in PA/ST, FWA, MTM programs, resulting in over $4.5M in savings. She’s conducted formulary analyses to support actuary Medicare annual bid submissions, including IRA and M3P programs, collaborated with partners and the Pharmacy Benefit Manager (PBM) to identify cost-saving opportunities through formulary alternatives, biosimilars, and rebate strategies, and partnered in the RFP PBM selection process and resolved complex pharmacy-related issues through cross-departmental collaboration.
Before ATRIO, Helen spent seven years at Kaiser Permanente, where she served as Regional Assistant Director to implement hospitals Drug Use Management Program. Her efforts led to over $20 million in savings through inventory management, drug cost-saving initiatives, and the standardization of clinical content/practice guidelines.

... read more

Helen Liu, Pharm.D.

Health Plan Leader
Independent

Helen Liu, PharmD, brings 29 years of diverse pharmacy experience, blending clinical expertise, operational efficiency, technological innovation, and management across various healthcare settings.
Over the past four years, Helen has successfully led pharmacy operations at ATRIO Health Plans (Medicare), achieving significant milestones in PA/ST, FWA, MTM programs, resulting in over $4.5M in savings. She’s conducted formulary analyses to support actuary Medicare annual bid submissions, including IRA and M3P programs, collaborated with partners and the Pharmacy Benefit Manager (PBM) to identify cost-saving opportunities through formulary alternatives, biosimilars, and rebate strategies, and partnered in the RFP PBM selection process and resolved complex pharmacy-related issues through cross-departmental collaboration.
Before ATRIO, Helen spent seven years at Kaiser Permanente, where she served as Regional Assistant Director to implement hospitals Drug Use Management Program. Her efforts led to over $20 million in savings through inventory management, drug cost-saving initiatives, and the standardization of clinical content/practice guidelines.

1:00 – 2:30
One-To-One Structured Networking
2:30 – 3:30

Harmonizing Tech and Talent: Revolutionizing COB Operations

  • In this session, we will delve into the practical applications of automation and data analytics, driving toward highest efficiency and effectiveness in your work, showcasing their benefits and limitations. We'll discuss real-life examples to illustrate the tasks AI can efficiently handle and the areas where human expertise remains crucial. Attendees will gain a comprehensive understanding of how these technologies can be leveraged within the sector, as well as insights on when to consider hiring or training staff to complement and enhance these tools.
  • Learning Objectives: Understand how key automation, including AI, can increase accuracy, consistency and throughput in your operations - Explore how shifts in inventory prioritization can deliver higher results in other insurance identification

Author:

Beth Franke

Staff Vice President, Payment Integrity Coordination of Benefits
Elevance/Anthem

Beth Franke started her career in the healthcare industry over 30 years ago. During that time, she has held management and leadership positions within large healthcare organizations such as Elevance Heath, Humana, Inc. and Kindred Healthcare and served as principal consultant for the Commonwealth of Kentucky, launching the state’s first self-funded health insurance model. She has also managed multi-discipline teams within special investigations, claims, enrollment and billing, corporate applications, mobile strategy, care management and enterprise project management office. Her current role as Staff Vice President has positioned her to oversee the Coordination of Benefits organization in Payment Integrity with over 500+ associates.

Beth has a BS in Mathematics and Computer Science from Centre College. She is a Project Management Professional (PMP), a Certified Professional Coder (CPC) and earned a Master Six Sigma Black Belt (MBB) certification from Villanova University. She also serves as a certified professional coach and was recognized as an Emerging Leader at Elevance Health.

Beth and her husband line in Louisville, KY and have five adult children. She enjoys hiking, biking and traveling with her family and is also active with several volunteer organizations, providing food, shelter, and other needed services for those less fortunate.

... read more

Beth Franke

Staff Vice President, Payment Integrity Coordination of Benefits
Elevance/Anthem

Beth Franke started her career in the healthcare industry over 30 years ago. During that time, she has held management and leadership positions within large healthcare organizations such as Elevance Heath, Humana, Inc. and Kindred Healthcare and served as principal consultant for the Commonwealth of Kentucky, launching the state’s first self-funded health insurance model. She has also managed multi-discipline teams within special investigations, claims, enrollment and billing, corporate applications, mobile strategy, care management and enterprise project management office. Her current role as Staff Vice President has positioned her to oversee the Coordination of Benefits organization in Payment Integrity with over 500+ associates.

Beth has a BS in Mathematics and Computer Science from Centre College. She is a Project Management Professional (PMP), a Certified Professional Coder (CPC) and earned a Master Six Sigma Black Belt (MBB) certification from Villanova University. She also serves as a certified professional coach and was recognized as an Emerging Leader at Elevance Health.

Beth and her husband line in Louisville, KY and have five adult children. She enjoys hiking, biking and traveling with her family and is also active with several volunteer organizations, providing food, shelter, and other needed services for those less fortunate.

A Journey through the Development and Deployment of a Pre-Payment Modelling System

Showcasing one health plan’s process for creating a pre-payment system focused on reducing provider abrasion by paying more claims correctly the first time.

Author:

Jordan Limperis

Data Scientist
LA Care

Highly motivated Data Scientist with a strong background in healthcare data and systems. Experienced in Inpatient Hospital and Laboratory Epic Systems, where I applied data-driven insights to improve clinical and operational efficiency. Currently, I am pursuing my career at L.A. Care, focusing leveraging advanced machine learning techniques to analyze noisy data, ensuring accuracy and efficiency in healthcare operations, particularly in payment integrity.

... read more

Jordan Limperis

Data Scientist
LA Care

Highly motivated Data Scientist with a strong background in healthcare data and systems. Experienced in Inpatient Hospital and Laboratory Epic Systems, where I applied data-driven insights to improve clinical and operational efficiency. Currently, I am pursuing my career at L.A. Care, focusing leveraging advanced machine learning techniques to analyze noisy data, ensuring accuracy and efficiency in healthcare operations, particularly in payment integrity.

Author:

Edgar Dominguez

Claims Integrity Business Manager
LA Care

Healthcare Operations expert with 20+ years of healthcare payer experience including 12+ years in Claims Administration with multiple fortune 200 companies.  I’m currently focused on implementing payment integrity initiatives aimed at cost avoidance by the use of data analytics.  I am a firm believer that data science is the wave of the future and will afford the healthcare industry with boundless opportunities to mitigate waste and reduce overall healthcare costs.

... read more

Edgar Dominguez

Claims Integrity Business Manager
LA Care

Healthcare Operations expert with 20+ years of healthcare payer experience including 12+ years in Claims Administration with multiple fortune 200 companies.  I’m currently focused on implementing payment integrity initiatives aimed at cost avoidance by the use of data analytics.  I am a firm believer that data science is the wave of the future and will afford the healthcare industry with boundless opportunities to mitigate waste and reduce overall healthcare costs.

3:30 – 4:45
One-To-One Structured Networking
4:45 – 5:15
Session in Partnership with Healthcare Fraud Shield
5:15 - 6:00

The Payer-Provider Panel: Mandates, EMR Systems and Collaboration

This session will bring together payers and providers to discuss the challenges and opportunities presented by healthcare mandates and electronic medical record systems. Participants will explore strategies for effective collaboration to improve patient care and reduce administrative burdens.

Author:

Lourdes Centeno Fanjoy

Subject Matter Expert
Independent

With over 15 years of experience in revenue cycle management, compliance, payer policy advising, and executive presentations, Lourdes is a results-oriented leader dedicated to optimizing operational strategies and driving corporate success. Her resource allocation, process redesign, and capacity planning skills enable her to enhance profit margins and achieve strategic goals. Lourdes brings expertise in Medicare and Medicaid reimbursement policies, ensuring effective and compliant financial practices.

... read more

Lourdes Centeno Fanjoy

Subject Matter Expert
Independent

With over 15 years of experience in revenue cycle management, compliance, payer policy advising, and executive presentations, Lourdes is a results-oriented leader dedicated to optimizing operational strategies and driving corporate success. Her resource allocation, process redesign, and capacity planning skills enable her to enhance profit margins and achieve strategic goals. Lourdes brings expertise in Medicare and Medicaid reimbursement policies, ensuring effective and compliant financial practices.

6:00
Closing Comments
6:00 – 7:00
Networking drinks
Day Two: Thursday, 6 Feb, 2025
9:00 – 10:30
AI Symposium

AI for PI

Author:

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

... read more

Christopher Draven

Senior Director of Payment Integrity Analytics & AI
HCSC

Christopher Draven is Senior Director of Payment Integrity Analytics & AI at HCSC where he leads a cross-functional team focused on delivering actionable insights and savings. He has over 25 years experience in healthcare, starting in direct patient care.

Author:

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

... read more

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

A Discussion about Artificial Intelligence in Healthcare

AI for Governance

Author:

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

... read more

Crystal Son

Executive Director of Enterprise Data Analytics Solutions
HCSC

Crystal Son is an Executive Director of Enterprise Data Analytics Solutions at Healthcare Service Corporation (HCSC). She has 19 years of experience in deriving intelligence from data. 

At HCSC, she leads the Strategic Initiatives & Partnerships team, a department that focuses on cross-functional, collaborative analytics delivery on key programs such as Payment Integrity and Stakeholder Engagement, enterprise data and analytics strategy and planning, as well as design and execution of HCSC’s Responsible AI program. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.

Author:

Simi Binning

Responsible AI Lead
HCSC

Simi Binning is an accomplished healthcare professional with over a decade of experience in developing and executing successful strategies that drive business growth. Currently serving as a Responsible AI lead at HCSC, her focus is on AI governance and innovative problem solving.

... read more

Simi Binning

Responsible AI Lead
HCSC

Simi Binning is an accomplished healthcare professional with over a decade of experience in developing and executing successful strategies that drive business growth. Currently serving as a Responsible AI lead at HCSC, her focus is on AI governance and innovative problem solving.

10:30 – 11:45
One-To-One Structured Networking
11:45 – 12:30

The Ongoing Threat of Telehealth Fraud

This presentation will delve into the latest trends and tactics employed by fraudsters, providing actionable insights to safeguard your organization. Attendees will gain a comprehensive understanding of the evolving threat landscape, learn to identify red flags, and implement effective prevention strategies.

12:30 – 1:15

Combating the Opioid Crisis Through Pharmacy Payment Integrity

This session will explore how to identify and prevent opioid-related fraud within pharmacy claims, focusing on strategies to combat the opioid crisis while safeguarding healthcare resources.

1:15 – 2:30
One-To-One Structured Networking
2:30 – 3:00

CA Medicaid Program Integrity

This session will focus on:

  • California’s efforts to combat fraud, waste and abuse in Medi-Cal, California’s Medicaid program.

  • How California is exploiting available data and data sharing opportunities for purposes of Medicaid program integrity objectives.

  • A summary of program integrity best practices from the perspective of a Medicaid Program Integrity Director.

  • California’s future vision with regards to the use of data and data analytics to support its Medi-Cal fraud-control strategy.

Learning Objectives:

  • Obtain program integrity best practices that can be leveraged by the participating entity.

  • Discover new ways to exploit data to identify and develop actionable leads.

  • Performance metrics and return on investment – ways to measure success.

Author:

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

... read more

Bruce Lim

Deputy Director, Audits and Investigations
California Department of Health Care Services (DHCS)

Bruce Lim serves as the Deputy Director, Audits and Investigations, for the California Department of Health Care Services (DHCS) and is the designated Program Integrity Director for Medi-Cal, California’s Medicaid program. Mr. Lim is a certified public accountant (CPA) with over 32 years of audit and financial management experience in both the private and public sectors. Past employers include Kenneth Leventhal and Company, CPAs (Ernst & Young Kenneth Leventhal Real Estate Group), Packard Bell NEC, and the California Department of Food and Agriculture.

3:00 – 3:30

Test, Retest, Profit?

Discussion around the alarming rise of unnecessary lab tests, and the money wasted with this. Implementing robust payment integrity measures to combat such waste and fraud.

3:30 – 4:00

Tailoring Treatments and Curbing Costs with Precision Pharmacy

This session will explore how precision pharmacy can be used to optimize medication therapy for individual patients, leading to improved health outcomes while reducing overall healthcare costs.

4:00
Closing Remarks
End of Main Conference Party
Day Three: Friday, 7 Feb, 2025
9:30 – 10:30
Workshop 1

Applying AI and Data Analytics in Payment Integrity

In this interactive workshop, attendees will review and discuss their own experiences with AI, data analytics, and fraud prevention strategies covered during the conference. The session will focus on how these tools can be used for early issue detection and claims management, while also addressing new federal rules and fraud trends shared by regulatory experts. Walk away with actionable insights tailored to your organization’s challenges.

10:30 – 11:00
Networking
11:00 – 12:00
Workshop 2

Leveraging Interoperability and Data Exchange for Better Payment Integrity

Exchange in conversations with other attendees to understand how enhanced data exchange can streamline workflows, reduce administrative burdens, and improve overall efficiency off the back off the payer-provider panel on Day 1. Review the role of interoperability and data sharing in improving fraud detection, claim accuracy, and cost management that were discussed throughout the event.

12:00 – 1:00
Goodbye Lunch

Jump to: Pre Day | Day One | Day Two | Day Three

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Healthcare Payment & Revenue Integrity Congress