Medical Cost Containment
Diagnosis codes and modifiers aren’t just billing details—they tell the story that determines how your claims are paid. When these elements don’t align, hospitals face denials, delays, and compliance risks. This session will break down how to accurately connect coding choices with billing practices to ensure claims reflect true clinical intent, reduce audit exposure, and secure appropriate reimbursement.
Learning Objectives:
- Recognize the most common coding and modifier missteps that lead to denials and learn how to avoid them through stronger documentation and coding practices.
- Implement strategies to bridge gaps between clinical, coding, and billing teams—ensuring consistent, compliant claims that tell the right story from documentation to payment.
Revenue Cycle Management
Stephanie Sjogren
Director, Coding and Provider Reimbursement
EmblemHealth/Connecticare
Stephanie Sjogren is a director of coding and provider reimbursement, working with payment integrity to ensure proper claims adjudication and to prevent fraud, waste, and abuse. Prior to joining ConnectiCare/EmblemHealth, she performed provider audits and education at a women’s healthcare group. Sjogren has also worked with physicians and staff to integrate and use electronic health record systems effectively and to stay in compliance with the Centers for Medicare & Medicaid Services’ rules and regulations. Her areas of specialty are payment integrity, auditing, and clinical documentation improvement.
Industry benchmarks to measure the impact of payment integrity currently don't exist, making it challenging to optimize performance and areas of opportunity. Standards are extremely complicated due to varied member populations and an inconsistent approach to calculating metrics.
In this groundbreaking panel discussion, learn how a Working Group of payer and vendor SMEs have been collaborating over the last six months to develop a standard approach to calculating savings PMPM across LOB and audit programs. This session will share standard definitions and calculations, so attendees can understand how to calculate and compare their savings PMPM.
Payment Integrity
Moderator
Natalie Clayton
Head of Market Intelligence
Kisaco Research
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.
Dr. Priscilla Alfaro, MD, FAAP, CPC, CPMA, COC, CIC, CFE, CRC
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.
Karen Ballard
Director of Consulting Services
CGI
Karen Ballard is Director of Consulting Services, CGI, where she is responsible for managing the CGI ProperPay payment integrity platform. With a nearly 20-year career in the health payer space, Karen possesses a deep knowledge of claims processing, product management, payment integrity, and the Blue payer dynamic. Prior to joining CGI, Karen held a variety of positions in claims operations, BlueCard, and payment integrity during her 17-year tenure with Elevance Health (Anthem).
Karen holds a Bachelor of Arts and a Master of Business Administration from Southern New Hampshire University. She co-founded and previously co-facilitated the Blue PI Committee, comprised of payment integrity leaders from all 33 Blue Cross and Blue Shield plans and partnered with the Blue Cross and Blue Shield Association to drive change in the payment integrity space.
Curated meetings based on your RCM/PI painpoints and investments -30 minutes each -3 meetings per registered individual -All those not scheduled to take meetings will be encouraged to take part in interactive sessions, competitions and activities in the exhibition room.
Medical Cost Containment
Medical Cost Containment
This session will explore the financial impact of federal legislation updates, such as upcoming price transparency rules, on both payment integrity and revenue cycle management programs. We’ll examine how these changes are expected to drive new cost pressures, reshape audit and payment practices, and create fresh challenges for both payers and providers. The discussion will also focus on collaborative strategies - how both sides can work together to ensure compliance, mitigate financial risk, and proactively adapt their programs to achieve better outcomes in a shifting regulatory landscape.
Medical Cost Containment
Dave Cardelle
Chief Strategy Officer
AMS
Symone Rosales
Director of Revenue Cycle Regulatory Research
SSM Health
Deborah Knight-Lauricia
Senior Director, Revenue Cycle Strategic Initiatives
Cleveland Clinic
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), the largest customer-owned health insurer in the United States. HCSC provides access to care nationwide through Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas as well as through its broad portfolio of companies. Crystal has 20 years of experience in deriving intelligence from data and mobilizing teams to action.
At HCSC, she leads the Strategic Initiatives & Partnerships team, which leads key programs such as Payment Integrity, Responsible AI and AI Literacy and Workforce Readiness. She is passionate about real-world applications of data-driven insights, storytelling through data, and building high-performance teams.
Prior to joining HCSC in October 2022, Crystal held several roles at previous organizations, including delivery of data science advisory services, management of healthcare and government customer portfolios, and the development and launch of several new products. She began her career in data as an epidemiologist, first for the City of New York, then with Memorial Sloan-Kettering Cancer Center but has called downtown Chicago home for the last 11 years.
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
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.
Medical Cost Containment
Mark Buehrer
PE Founder & CEO
heartfoods
Priya Kesavan
Principal, Azure AI Systems Strategy
Microsoft
Priya Kesavan is an AI Strategy Principal at Microsoft. In her current role, she leads the development of long-term strategies and roadmaps for Microsoft's in-house AI hardware systems. In the past, Priya held several leadership positions in product management for SoC and systems development at Intel and Cisco. Driven by a passion for harnessing AI to address complex real-world challenges and improve user experiences, she is a strong advocate for "AI for good." Priya is also committed to empowering women in technology and AI, spearheading initiatives to foster their growth and advancement. She holds a degree in Computer Engineering from Madras University.