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

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

• 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.

The healthcare landscape is fraught with complexity and financial pitfalls and small-to-medium-sized health plans often find themselves vulnerable to inflated claims, hemorrhaging millions annually.

Payment integrity products like DRG Coding and Clinical Validation, Hospital Bill Audits, Data Mining, and more, can offer immediate reinforcement against dubious claims. But which products should be deployed, when should they be implemented, what are the best practices for their utilization, and how do you effectively evaluate their impact?

In this session, discover how merging clinical expertise with AI technology enhances payment integrity solutions and evaluate in-house, outsourced, or combined approaches based on reassignment and appeal overturn rates for optimal financial protection.

In a world where healthcare fraud runs rampant and financial losses mount, a strategic plan for payment integrity stands as a beacon of hope for small to medium-sized health plans, offering a formidable defense against the forces of fiscal depletion. This discussion will provide a framework for developing a strategic approach to financial stability.

History of Hospital at Home and Telehealth Services
Post Pandemic Growth and Barriers
Hospital at Home vs Home Health

Reduced Payer and Provider Costs
Developing Reimbursement Policies
Identifying Potential Fraud, Waste and Abuse

Lesson objectives:

- Overall knowledge of hospital at home and telehealth services
- How to create effective reimbursement policies for emerging healthcare services

Every payer can agree on one thing. There is fraud, waste, and abuse happening that they cannot see or see fast enough with the limitations of current claims data-centric technology stacks. One more technology in the stack doesn't solve the problem of not being able to see dynamic behaviors, relationships, and outliers that lead to over-payments on basic CMS edits as well as undetected complex fraud and collusion schemes. More claims data-centric technology is not the solution. Dynamic provider-centric risk detection technology coupled with continuously-credentialed provider integrity data is the solution for increased FWA detection and near real-time prevention. That's because stacks of claim data-centric technologies (even those using conventional artificial intelligence) will never see what providers are doing individually, in relationship with all other providers, and in relationship to all other claims on each-and-every claim submitted.

This session will focus on the benefits of a provider-centric FWA prevention approach powered by artificial intelligence that is dynamic and uses both supervised and unsupervised machine learning for detection beyond rules-based technologies. It will highlight strategies for FWA prevention at five points along the claims workflow including pre pre-payment, pre-payment, and post-payment positions. Fraud and SIU teams will be particularly interested in this combination of technologies to detect and automatically package fraud and collusion schemes you can’t see now or can’t see fast enough with the limitations of claim-centric approaches.

1. Understand the FWA detection limitations of claims data-centric approaches
2. Understand how a provider centric-approach such as Integr8 AI increases FWA detection and prevention
3. Understand the benefits of provider-centric FWA prevention pre pre-payment, pre-payment, and post-payment

• This session delves into prevalent billing and coding errors encountered in healthcare reimbursement postpayment and prepayent processes, shedding light on their potential to result in overpayments for payers. Through case studies and practical examples, Healthcare Fraud Shield can showcase effective strategies for identifying common errors, such as incorrect billing of maternity care services.
• This session will walk through:
• Appropriate coding for delivery services 
• Proper billing practices at it relates to antepartum and postpartum care 
• How to detect patterns of inappropriate claim submissions