Payment Integrity
Payment Integrity
Join us for an enlightening fireside chat that delves into the powerful relationship between data mining and Coordination of Benefits (COB) in the healthcare industry. As health plans strive for efficiency and cost-effectiveness, understanding how to integrate sophisticated data analytics into COB processes is crucial for maximizing total plan value.
- Understand the integration of data mining to enhance COB efficiency.
- Learn strategies for utilizing data insights to achieve cost savings and maximize plan value.
- Gain awareness of challenges and future trends in data-driven COB processes.
Payment Integrity
Kyle Pankey
Sales & Growth Leader
Carelon Subrogation
Kyle Pankey has over two decades of experience working within the healthcare and payer operations, with over 10 years specifically tied in to the payment integrity space. Kyle lives in Chattanooga, TN and has served as Carelon Subrogation’s growth leader since mid-2022.
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.
Jennifer Bellcour
Director Carelon Payment Integrity Solutions, Data Mining
Carelon
Jennifer Bellcour is a seasoned leader in payment integrity, currently serving as the Director of Carelon Payment Integrity Solutions, Data Mining. With over 20 years at the company, she has been instrumental in advancing prepay data mining and claims anomaly detection initiatives. Known for her expertise, Jennifer excels at developing talent and building impactful teams to drive innovation. Her diverse background includes claims, billing, customer service, and training, and she is adept at partnering with global teams to support change management. Jennifer holds a Bachelor's degree from Southern New Hampshire University and a Master of Science in Management and Leadership (MSML) from Western Governors University.
Carelon
Website: https://www.carelon.com/
The health of the healthcare system improves when spending is responsible and accurate. Today, platform technology and advanced analytics are paving the way to make that more efficient and more proactive than ever before. Backed by decades of experience, Carelon’s Payment Integrity solutions bring together breakthrough technology and human expertise to help speed your ability to drive cost savings and value for your stakeholders.
Payment Integrity
MedReview
Website: https://www.medreview.us/
MedReview sets itself apart with over 50 years of experience delivering physician-approved pre-pay and post-pay payment integrity services that prioritize billing and payment quality, accuracy, and precision. Every claim reassigned by MedReview is reviewed, approved, and documented by a team of physicians, resulting in the industry’s lowest appeal overturn rate.
Utilizing proprietary technology combined with extensive subject matter clinical and administrative expertise, we achieve a 40% or greater reassignment rate focused on our clients’ specific needs. MedReview provides the full spectrum of payment integrity solutions including DRG and clinical reviews, cost outlier audits, re-admission reviews, data mining and itemized bill reviews.
Partnered with clients across the country, MedReview offers a flexible approach, supporting both complete outsourcing and supplemental enhancements to existing programs. By optimizing recoveries, preventing overpayments, and improving the provider experience, MedReview empowers payors to navigate the complexities of payment integrity with confidence and measurable success.
Uncover Emerging Threats: HCFS shares insights from working with leading health plans, highlighting rising fraud schemes and patterns they’ve detected across the industry.
Prepare for 2025: Gain actionable knowledge on upcoming FWA challenges and learn strategies to strengthen your fraud detection processes, ensuring your organization stays ahead in the evolving landscape.
Payment Integrity
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.
Healthcare Fraud Shield
Website: https://www.hcfraudshield.com/
Healthcare Fraud Shield specializes in fraud, waste, abuse, & error detection and payment integrity for healthcare payers nationally by efficiently stopping claims prior to payment utilizing post-payment advanced analytics and artificial intelligence insights. We save health plans millions annually incremental to existing pre-payment processes using our unique and proven approach. HCFSPlatform™ offers the combination of targeted rules, artificial intelligence, and shared analytics across multiple payers resulting in higher ROI (up to 20:1) compared to other vendors. HCFSPlatform™ software platform was developed by industry leading healthcare subject matter experts and is a component of over 60+ clients including 7 of the 10 largest commercial insurers in the US. Our client satisfaction rating is exceptional with a net promoter score of 94 and client retention rate over 95%.
HCFSPlatform™ is a fully integrated platform consisting of PreShield (prepayment analytics & claim review logic), PostShield (post-payment analytics), AIShield (AI-driven analytic insights), RxShield (pharmacy and pharmaceutical specific analytics), Shared Analytics, CaseShield (SIU/PI case management), QueryShield (ad hoc query and reporting tool), HCFSServices (data mining, investigative, and record reviews), and HCFSAudit (Medical Record Review & SVRS).
In today’s complex healthcare ecosystem, interoperability - the seamless exchange and utilization of data across diverse systems - is the linchpin for success in payment integrity and risk adjustment. When health plans, payers, providers, and vendors collaborate through standardized and efficient data sharing, the results are transformative: accurate payments, fraud prevention, and streamlined processes that scale innovation. However, the absence of a disciplined interoperability strategy can lead to significant inefficiencies.
This keynote will emphasize the critical need for a proactive, stakeholder-driven interoperability plan. Drawing parallels to Six Sigma principles, it highlights how early standardization of data formats, security protocols, and transfer methods prevent downstream inefficiencies, reduce costs, and enhance scalability. Attendees will leave with actionable insights into how interoperability not only smooths immediate business processes but also lays the foundation for long-term industry transformation.
Join us to explore why interoperability isn’t just a technical challenge but a strategic imperative—an essential cornerstone for a resilient, innovative, and efficient healthcare system.
Lesson Objectives:
- Understand the Impact of Interoperability: Learn how seamless data exchange and standardization, improve operational efficiency.
- Explore Real-World Lessons: Case studies help underscore the consequences of poor interoperability planning and the benefits of thoughtful standardization.
- Actionable Strategies for Stakeholder Collaboration: Discover how to develop a disciplined interoperability plan.
Payment Integrity
Dave Cardelle
Chief Strategy Officer
AMS
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.
