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.
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.
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.
Payment Integrity
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
Dave Cardelle
Chief Strategy Officer
AMS
Sandy Giangreco Brown
VP, Revenue Integrity & Education
Spire Orthopedic Partners
Donna Malone
Director Risk Capture, Population Health Management
Mass General Brigham
Corella Lumpkins
Manager of Coding, Compliance and Provider Education
Loudoun Medical Group P.C.
Corella Lumpkins is the Manager of Coding, Compliance & Provider Education at Loudoun Medical Group (LMG) - one of the largest and most diverse physician-owned, multi-specialty Accountable Care Organizations in Northern Virginia/DC suburbs. As a subject matter expert, Corella has over 35 years of experience working in every area of the healthcare revenue cycle. Corella holds a bachelor’s degree and eleven certifications with an extensive background in auditing, billing, coding, implementing corporate compliance programs, CDI, education, denial and practice management. Prior to joining LMG, Corella has held leadership roles at Lifebridge, Medstar, Johns Hopkins and the University of Maryland health systems.
Corella is an author, adjunct faculty member and national speaker currently serving on both the AAPC National Advisory Board and Association of Clinical Documentation Integrity Specialists (ACDIS) Leadership Council. Corella works closely with providers in navigating patient-centric value-based care.
AMS 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.
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.
Specialty Credits for: Core A – CPCO, CPMA
Payment Integrity
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.
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.
- 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
Specialty Credits for: Core A – CPCO, CPMA
Payment Integrity
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.
Thomas Ricketts
Manager, Reporting and Data Analysis
Elevance Health
Thomas is an accomplished professional with 18 years of experience in the healthcare industry, specializing in the Coordination of Benefits. Currently serving as the Manager of Reporting and Data Analysis at Elevance/Carelon. His career is marked by a commitment to leveraging data-driven insights to enhance efficiencies and drive strategic decision-making.
Specialty Credits for: Core A – All specialties with exception of CIRCC, CPMS
Enhancing Medicare Part D Fraud, Waste & Abuse Program
Payment Integrity
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.
Specialty Credits for: Core A – CPCO, CPMA
Payment Integrity
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.
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
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.
Payment Integrity
Moderator
Katherine Brant
President
6 Degrees Health
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.
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.
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.
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
6 Degrees Health
Website: https://www.6degreeshealth.com/
6 Degrees Health is on a mission to reduce the cost of healthcare. We take a service-first approach to our Clean Claim Reviews to ensure accuracy in billing and fair payments. Using our extensive cost containment experience, clinical expertise, and next-generation, purpose-built software, we deliver remarkable savings for health plans. Our proprietary review process leverages CMS and other industry standard guidelines to evaluate every line item and identify billing errors and inconsistencies.
These pre-pay clinical reviews are completed by our team of highly trained and experienced registered nurses to ensure each billed line item is appropriate for reimbursement. This detailed review removes erroneous line items and verifies billing accuracy. Our comprehensive process manages claims during the review stage, as well as through payment and appeals resolution. Our white glove service on appeals allows us to maintain an uphold rate of 97 %, so your savings are secure.
An overview of the most significant fraud trends and payment integrity technologies and strategies going into 2025.
Payment Integrity
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.
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.
Prasanna Ganesan
CEO
Machinify
Machinify
Website: https://www.machinify.com/
Machinify is the trusted AI partner for healthcare admin, providing software and services that enable health plans to accurately and efficiently pay claims, leading to a reduction in provider abrasion. With safe, transparent AI and deep clinical expertise, Machinify brings a unique blend of speed, accuracy, and intelligence health plans need to make healthcare admin more efficient.
The company serves partners of all sizes with its two products:
● Machinify Audit - Medical AI system identifying erroneous claims and performing record review.
● Machinify Pay - AI models and SME expertise to process claims at wire speed, ensuring accurate coding and pricing.