| Page 682 | Kisaco Research

Author:

Toni Case

Vice President, National Sales
CERIS
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Toni Case

Vice President, National Sales
CERIS

Author:

Debra Hamer

Director, FWA Analytics
CERIS
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Debra Hamer

Director, FWA Analytics
CERIS

Baize will speak about new federal payment integrity efforts that affect Medicare and Medicaid. These efforts will focus on fee-for-service payments, Medicare Advantage, and Medicaid managed care.  As the line between public payers and private payers continues to be blurred, the policies and rules coming out of the federal Centers for Medicare and Medicaid Services (CMS) will affect nearly every payer and plan.

CMS continues to place much of its focus on healthcare supplies and services that are fulfilled outside institutional settings.  Home-based care, durable medical equipment and disposable medical supplies remain under increased scrutiny as areas that CMS has deemed at high risk for fraud.  Laboratories and specialty pharmacies are also being more closely monitored.

Additionally, as required by the 21st CURES Act, electronic visit verification (EVV) of home-based services is now implemented throughout the U.S. Payers should see a reduction in claims for those services, but that depends on whether states implemented EVV consistently, and whether providers willing to commit fraud have already found ways around the technology.

Finally, Baize will provide recent examples of successful healthcare fraud prosecutions from around the U.S.

Track 1

Author:

Anthony Baize

Inspector General
Wisconsin Department of Health Services

Anthony J. Baize is the Inspector General for the Wisconsin Department of Health Services.  Baize took the position in early 2016 after eight years with Kentucky state government in the Kentucky Cabinet for Health and Family Services, serving as the Deputy Director of Audits and Investigations for the Office of Inspector General and the Director of Business Informatics with the Department of Behavioral Health, Developmental and Intellectual Disabilities.

Baize has served as the Region V representative for the National Association of Medicaid Program Integrity Directors and on the Advisory Board for the Centers for Medicare and Medicaid Services’ Medicaid Integrity Institute.  He regularly speaks at national conferences on topics related to Medicaid Program Integrity. 

Baize became a certified inspector general in 2022 after completing the Association of Inspectors General Institute.  He is also a member of the Internation Association of Financial Crimes Investigators.      

Baize was a civil rights consultant for nearly 20 years, serving on the Board of Directors for the National Fair Housing Alliance and the Lexington (KY) Fair Housing Council. Baize has given presentations on fair housing requirements across the United States, but especially in Kentucky, Indiana, Ohio and Tennessee.  He has a master’s degree in public administration from Indiana State University, has been married for 29 years and has two daughters. 

... read more

Anthony Baize

Inspector General
Wisconsin Department of Health Services

Anthony J. Baize is the Inspector General for the Wisconsin Department of Health Services.  Baize took the position in early 2016 after eight years with Kentucky state government in the Kentucky Cabinet for Health and Family Services, serving as the Deputy Director of Audits and Investigations for the Office of Inspector General and the Director of Business Informatics with the Department of Behavioral Health, Developmental and Intellectual Disabilities.

Baize has served as the Region V representative for the National Association of Medicaid Program Integrity Directors and on the Advisory Board for the Centers for Medicare and Medicaid Services’ Medicaid Integrity Institute.  He regularly speaks at national conferences on topics related to Medicaid Program Integrity. 

Baize became a certified inspector general in 2022 after completing the Association of Inspectors General Institute.  He is also a member of the Internation Association of Financial Crimes Investigators.      

Baize was a civil rights consultant for nearly 20 years, serving on the Board of Directors for the National Fair Housing Alliance and the Lexington (KY) Fair Housing Council. Baize has given presentations on fair housing requirements across the United States, but especially in Kentucky, Indiana, Ohio and Tennessee.  He has a master’s degree in public administration from Indiana State University, has been married for 29 years and has two daughters. 

Author:

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.

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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.

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:

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