Rise

Track 1: Risk Adjustment Strategies

Autonomous Coding: Enhancing Risk Adjustment Processes and Optimizing Accuracy in Health Care

• Explore how autonomous coding systems leverage advanced algorithms, natural language processing (NLP), and machine learning to automatically assign standardized codes to medical diagnoses and procedures, reducing the need for manual intervention 
  
  
• Outline the strategic approach to planning and implementing autonomous coding systems, focusing on key milestones, integration timelines, and the importance of aligning technology with existing healthcare workflows 
  
  
• Discuss the significant improvements in coding accuracy brought about by autonomous coding, highlighting the reduction in errors, faster processing times, and the overall impact on the efficiency and quality of chart reviews 

Presented by GEBBs  

Track 2: Integrating Silos

Achieving Proactive Gap Closure with Emergent Technology  

• Learn how new prospective risk adjustment solutions help health plans and providers improve coding and documentation 
  
  
• Understand the financial and operational benefits of closing risk gaps concurrently with claims processing for Medicaid populations 
  
  
• Gain business and actuarial insights into the available opportunities for market expansion 

Chris Lance, Chief Product Officer 
Edifecs 

Track 3: Quality and Member Experience

To Be Announced

Track 4: Payer/Provider Strategic Alignment

Laying the Groundwork for Value-Based Care: Payer-Provider Interoperability to Enhance Prospective Risk Management 

• Share the key components and capabilities of a best-in-class risk identification, capture, and management program 
  
  
• Discuss optimization of the provider and care team experience, workflow and technology optimization, data and analytics use, and performance management processes 
  
  
• Share real life provider examples of the impact to performance through timely data, insight, and analytics sharing between providers and their payer partners 

Alexandra Povlishock, MHA, Vice President 
Optum 

Track 5: Technology/Data Analytics

Tech/ Data Analytics: Shaping the Future of Value Based Care – Key Trends and Advancements 

• Trusted AI: Harness technology for better productivity with generative AI, ML, and advanced data analytics means organizations understand how to evaluate vendors to ensure transparency and compliance  
  
  
• Unified VBC Platform: Leverage a unified platform for holistic views of patient conditions to enable better decision-making, more accurate risk stratification and meet quality benchmarks more consistently  
  
  
• Changing Care Models: VBC models are changing fast. Understand how to adapt to new value-based care reimbursement models (V24 to V28)  

Paul Burke, Chief Product Officer 
Reveleer 

Track 1: Risk Adjustment Strategies

Enhancing Payer-Provider Collaboration Through Prospective Risk Adjustment

• Evaluate and close diagnosis gaps collaboratively across structured and unstructured data 

• Access complete patient health profiles together to identify diagnosis gaps 

• Integrate clinical insights directly into EHR workflows to improve care coordination 
  
  
• Streamline workflows to ensure accurate diagnosis capture and documentation before claims submission 

Presented by Apixio  

Track 2: Integrating Silos

To Be Announced

Track 3: Quality and Member Experience

Relentless Pursuit of Excellence: Transforming the Member Experience to Achieve the Triple Aim 

• Implementing Proven Best Practices: Leveraging effective approaches to manage costs while advancing population health, early detection, and preventative care 

• Proactive Engagement: Engaging members in their preferred modality with personalized interventions to enhance member experience and address Social Determinants of Health 

• Risk Adjustment Integration: Aligning risk adjustment with quality improvement and SDoH gap closure efforts 

John Criswell, Founder, CEO, Chairman  
Porter  

Track 4: Hot Topics

To Be Announced

Track 5: Future of Health Care

Autonomous Risk-Adjustment Coding: The Next Frontier for Completeness, Accuracy, & Speed

• Understand the latest developments in risk-adjustment coding technology, from yesterday's NLP to today's deep-learning AI 

• Assess opportunities to increase completeness, specificity, and accuracy to find missing HCCs and advance coding integrity 

• Measure the operational impact of deep-learning AI for RA coding, based on real case studies 

Andrew Lockhart, CEO 
Fathom Health 

RISE Innovation Theater

Research Findings: A Study of the Interactions Between Clinicians and Patients Since the Pandemic

This phenomenological study gets at the essence of our motivations.  You will walk away with a better understanding how to engage with key stakeholders, particularly those that have experienced COVID and in the wake of all these regulatory changes.   

Leave with insights and strategies to yield better engagement and better performance in light of "cuts" imposed by greater restrictions on risk, quality, and other key areas.  

Dr. Shannon Decker, Principal    
VBC One   

RISE Regulatory Compliance Theater

Anatomy of a Whistleblower Case: Examining a Successful False Claims Act

from initial sealed whistleblower complaint alleging risk adjustment fraud to DOJ investigation, intervention and ultimate settlement  

Many of the biggest Medicare Advantage insurers face False Claims Act lawsuits accusing them of risk adjustment fraud. Most of those lawsuits were initiated by whistleblowers who were current or former employees of the plans.  

Follow along with whistleblower Teresa Ross, a former Director of Risk Adjustment at Group Health Cooperative (GHC) and her whistleblower counsel as they take you through the story of Ross’s successful whistleblower lawsuit against health insurers GHC and Independent Health for alleged risk adjustment fraud.  

Learn about the risks posed to GHC and Independent Health by their use of the same risk adjustment coding vendor.  Hear about the types of evidence uncovered in the whistleblower’s and DOJ’s joint investigation that led to successful settlements with both insurers.     

Attendees will leave this session with:   

• An understanding of the mechanics of a False Claims Act case launched by a whistleblower including the dynamics between the whistleblower and DOJ in jointly investigating and prosecuting cases of alleged risk adjustment fraud.  

• An appreciation for the different types of practices DOJ has found to constitute risk adjustment fraud when engaged in by health plans and their vendors.    
• An understanding of how to create an environment in which whistleblowers feel safe to raise their concerns internally and have them remedied in a way that eliminates the need for a whistleblower to go external and raise concerns with the Government by filing a False Claims Act complaint in federal court.   

Teresa Ross 
Whistleblower 

Mary A. Inman, Partner 
Whistleblower Partners LLP 

Max Voldman, Partner 
Whistleblower Partners LLP 

Track 1: Risk Adjustment Strategies

Unlocking Better Access to Care: How Prospective Risk Adjustment Can Make a Difference

• Learn how HCC suspecting and targeting analytics inherently identifies and prioritizes at-risk members facing access challenges 

• Hear how in-home assessments and telehealth programs can support members without consistent access to care to determine the current state of their conditions and to promote continuity of care 

• See how prospective risk adjustment can both fund the collection of SDOH data and establish connections with community-based organizations, while simultaneously generating additional revenue for your organization 

Jimmy Liu, VP, Analytics and MRR Solutions  
Advantmed  

Track 2: Integrating Silos

To Be Announced

Track 3: Quality and Member Experience

From Data Mining to Decision-Making: Utilizing Member Data to Uncover Risks and Enhance Health Outcomes

• Learn how member data can be leveraged as a powerful predictive tool for critical health outcomes 

• Discuss the current gaps between data collection and actionable insights for physical and behavioral health outcomes 

• Explore emerging technologies and methodologies for enhancing data analysis 

Cory Busse, VP, Strategy & Sales Enablement 
Icario  

Robert Garnett, Vice President, Government Analytics and Health Benefits Cost of Care 
Elevance Health 

Barb Nelson, Director of Clinical Services Optimization 
Medica Health Plans

Track 4: Hot Topics

To Be Announced

Track 5: Technology/Data Analytics

AI-Driven AgeTech: Transforming Health Care for Independent Aging

• Discover the latest AgeTech innovations that enable older adults to live independently and thrive in their golden years 

• Explore cutting-edge advancements in digital health management and AI-driven care that are redefining the health care landscape 

• Understand how AI technologies like GenAI and Retrieval-Augmented Generation (RAG) can enhance member engagement, reduce costs, and optimize health care operations 

• Gain insights into AI-powered solutions, such as contact centers and smart chatbots, that are reshaping the aging experience and empowering older adults to live independently 

Presented by Duos 

RISE Innovation Theater

Lessons in Building a Compliant Risk Adjustment Program

In order to take advantage of Shared Savings opportunities, AdventHealth needed to undergo a practice transformation from a Fee for Service to Model to providing value-based care.   

Part of this transformation included educating clinicians on proper Coding Documentation Integrity.     

• Hear about one Health System’s transformational journey in building a compliant Risk Adjustment team, with learnings on internal buy in, provider education and operational processes   

• Gain insights into overcoming barriers and coming out on the other side of success, with focus on good people, strong policies and procedures, and technology          

• Discuss what’s worked in provider education and engagement, including incentives, relationship building and tapping into provider mentors    

Michael Zeli, Executive Director of Clinical Documentation Integrity PHSO
AdventHealth

RISE Regulatory Compliance Theater

To Be Announced

RISE Innovation Theater

Integrating AI with ERM to Optimize Risk

Building an Enterprise Risk Management model can be difficult; building one that effectively integrates AI is even more so. Designing an ERM risk taxonomy that identifies and defines the larger AI risk profile enables strong governance to have line of sight into potential risks. Risk leaders that optimize ERM design principles create clear classification models for tracking AI risks, resulting in high leadership/board engagement and strong mission alignment. In a world of increasing vulnerability to cyber and operational risk emerging from AI, effective ERM practices can eliminate excessive complexity and nuance, and instead, provides purposeful direction and improved comprehension to assist building out an organization's AI risk profile. This session will examine effective strategies on how to optimize building AI into an ERM model to enhance risk identification, monitoring, and mitigation efforts. 

Amir St. Clair, Vice President, Enterprise Risk Management 
Advocate Health 

RISE Regulatory Compliance Theater

Ensuring Payment Integrity in Your Risk Adjustment Program

Risk adjustment has changed.  In today’s landscape it is crucial to protect your organization from over coding and regulatory audits.  Join us for this interactive session as we discuss ensuring payment integrity from various angles including: 

• EMRs  
• Vendor solutions 
• Vigorous education and audit programs  

Colleen Gianatasio, Director, Clinical Documentation Integrity and Coding Compliance   
CDPHP   

RISE Innovation Theater

Coding Accuracy at Its Highest Level

Let's take a deep dive into coding practices to ensure accuracy of data to avoid CMS fines. We will discuss:  

• Coding specificity   
• How to avoid common coding errors and/or omissions  
• Effective documentation guidelines 

Deb Curry, MBA, RHIA, CCS-P, CRC, Risk Adjustment Programs Director 
Medical Mutual 

Track 2: Integrating Silos

A Documentation Journey

This session walks through the foundation of value-based care and the importance of accurate documentation, including: 

• Impact on patient complexity 
• Impact on quality metrics 
• Impact on appropriate resources and programs 
• Impact on the patient  
• Utilization and cost trends  

Donna Malone, CPC, CRC, AAPC Approved Instructor, AHCCA, RAP    
Director Risk Capture – Population Health  
Mass General Brigham   

Track 3: Hot Topics

The Changing Landscape of The Pharmacy Under IRA, From a Health Plan Perspective

• Describe the final rules and how this will impact the overall pharmacy    

• How to implement the programs and anticipate the impact of the changes     

• How to anticipate and continue identifying opportunities for growth and cost savings 

Helen Liu, Pharm.D.
Health Plan Leader/ Senior Consultant