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As fraud schemes become increasingly complex, healthcare organizations must stay ahead of evolving threats that impact both clinical and financial integrity. This session will explore the latest fraud trends across the healthcare landscape - from billing manipulation and phantom providers to evolving schemes in hospice, home health, telehealth, and behavioral health. Join industry leaders as they share real-world examples, warning signs to watch for, and proactive strategies for detecting, preventing, and responding to fraud across care settings.

Payment Integrity

Author:

Michael Devine

Director Special Investigations Unit
L.A Care
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Michael Devine

Director Special Investigations Unit
L.A Care

Author:

Peter Monson

Sr. Manager, Special Investigations Unit
UCare HP

Peter Monson is the Sr. Manager of the Special Investigations Unit at UCare, where he leads a team dedicated to preventing, detecting, and correcting fraud, waste, and abuse in health care claims. With more than a decade of investigative and leadership experience across health plans and state government, he has overseen some of the most significant Medicaid fraud cases in Minnesota’s history and has redesigned investigative practices to maximize efficiency and impact.

In addition to his role at UCare, Peter previously served as President of the Midwest Insurance Fraud Prevention Association, fostering collaboration between private insurers and government agencies to strengthen fraud prevention efforts. He holds a Bachelor of Science in Criminal Justice and minor in Psychology from North Dakota State University.

... read more

Peter Monson

Sr. Manager, Special Investigations Unit
UCare HP

Peter Monson is the Sr. Manager of the Special Investigations Unit at UCare, where he leads a team dedicated to preventing, detecting, and correcting fraud, waste, and abuse in health care claims. With more than a decade of investigative and leadership experience across health plans and state government, he has overseen some of the most significant Medicaid fraud cases in Minnesota’s history and has redesigned investigative practices to maximize efficiency and impact.

In addition to his role at UCare, Peter previously served as President of the Midwest Insurance Fraud Prevention Association, fostering collaboration between private insurers and government agencies to strengthen fraud prevention efforts. He holds a Bachelor of Science in Criminal Justice and minor in Psychology from North Dakota State University.

Author:

Mandi Heiple

Director of Payment Integrity
Medica

Mandi Heiple is the Director of Payment Integrity at Medica, where she leads a high-performing team dedicated to ensuring accurate, compliant, and efficient claims payment across commercial and government lines of business. She oversees end-to-end payment integrity strategy – from prospective editing and coding validation to retrospective audits. Her teams drive measurable savings while protecting provider relationships and improving member experiences.

With over 20 years in healthcare operations and payment integrity, Mandi has focused on designing and implementing solutions that close process gaps, reduce improper payments, and strengthen compliance frameworks.

... read more

Mandi Heiple

Director of Payment Integrity
Medica

Mandi Heiple is the Director of Payment Integrity at Medica, where she leads a high-performing team dedicated to ensuring accurate, compliant, and efficient claims payment across commercial and government lines of business. She oversees end-to-end payment integrity strategy – from prospective editing and coding validation to retrospective audits. Her teams drive measurable savings while protecting provider relationships and improving member experiences.

With over 20 years in healthcare operations and payment integrity, Mandi has focused on designing and implementing solutions that close process gaps, reduce improper payments, and strengthen compliance frameworks.

Author:

Karen Weintraub

Executive Vice President
HEALTHCARE FRAUD SHIELD

With 25 years of data and 20 years of healthcare experience, Ms. Weintraub is currently responsible for the design and development of the company’s healthcare fraud detection software products and services. She provides subject matter expertise on system design and workflow, business rule development, data mining and fraud outlier algorithms as well as SIU policies and procedures. Prior to joining Healthcare Fraud Shield, managed SIUs on various healthcare investigations for all commercial, Medicaid and Medicare business and claims of fraudulent activity. Ms. Weintraub received a BA in Criminal Justice from the University of Delaware and an MA in Criminal Justice from Rutgers University. Ms. Weintraub is a Certified Professional Coder for Payers (CPC-P), a Certified Professional Medical Auditor (CPMA) from the American Academy of Professional Coders, a Certified Dental Coder (CDC) from the American Dental Association, and the founder of the Hamilton, NJ AAPC chapter. She is also an Accredited Healthcare Fraud Investigator (AHFI) from the National Healthcare Anti-Fraud Association (NHCAA). Ms. Weintraub Taught CPT Coding, Fraud & Audits, and Medical Billing, Laws and Ethics and the local community college. 

... read more

Karen Weintraub

Executive Vice President
HEALTHCARE FRAUD SHIELD

With 25 years of data and 20 years of healthcare experience, Ms. Weintraub is currently responsible for the design and development of the company’s healthcare fraud detection software products and services. She provides subject matter expertise on system design and workflow, business rule development, data mining and fraud outlier algorithms as well as SIU policies and procedures. Prior to joining Healthcare Fraud Shield, managed SIUs on various healthcare investigations for all commercial, Medicaid and Medicare business and claims of fraudulent activity. Ms. Weintraub received a BA in Criminal Justice from the University of Delaware and an MA in Criminal Justice from Rutgers University. Ms. Weintraub is a Certified Professional Coder for Payers (CPC-P), a Certified Professional Medical Auditor (CPMA) from the American Academy of Professional Coders, a Certified Dental Coder (CDC) from the American Dental Association, and the founder of the Hamilton, NJ AAPC chapter. She is also an Accredited Healthcare Fraud Investigator (AHFI) from the National Healthcare Anti-Fraud Association (NHCAA). Ms. Weintraub Taught CPT Coding, Fraud & Audits, and Medical Billing, Laws and Ethics and the local community college. 

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

Author:

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. 

... read more

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

Author:

Natalie Clayton

Head of Market Intelligence
Kisaco Research
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Natalie Clayton

Head of Market Intelligence
Kisaco Research

Author:

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.  

... read more

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.  

Author:

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.

... read more

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.

Author:

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.

... read more

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

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

Author:

Dave Cardelle

Chief Strategy Officer
AMS
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Dave Cardelle

Chief Strategy Officer
AMS

Author:

Symone Rosales

Director of Revenue Cycle Regulatory Research
SSM Health
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Symone Rosales

Director of Revenue Cycle Regulatory Research
SSM Health

Author:

Deborah Knight-Lauricia

Senior Director, Revenue Cycle Strategic Initiatives
Cleveland Clinic
... read more

Deborah Knight-Lauricia

Senior Director, Revenue Cycle Strategic Initiatives
Cleveland Clinic

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), 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.

... 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), 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.

Author:

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

... read more

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

 

Mark Buehrer

PE Founder & CEO
heartfoods

Mark Buehrer

PE Founder & CEO
heartfoods

Mark Buehrer

PE Founder & CEO
heartfoods