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.
Katherine Brant
Monique Pierce
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
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
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
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.
