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 

Anna Carley, RHIT, Senior Director - CRM, Payer Solutions 
GeBBS Healthcare Solutions  

Dr. Shannon Decker, Principal    
VBC One   

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 

Brian Murtha, Director of Risk Adjustment Digital Strategy 
Centene 

Jennifer Holman, Director of Risk Adjustment Programs 
Centene 

Track 3: Quality and Member Experience

RISE to the Challenge: Community-Driven Solutions for Health Equity in Medicare Advantage

This panel discussion will delve into the complex issues of trust, cultural humility, and Black infant mortality. Within the context of Medicare Advantage, panelists will explore how community-centered design, philanthropic investment, and patient-centric care can create meaningful change. 

• Community-Centered Design: We'll explore how community-based organizations and residents can be empowered to shape healthcare solutions that address the unique needs and challenges facing Black families 

• Addressing Social Determinants of Health: The panel will discuss how factors beyond healthcare access, such as housing, education, and economic stability, contribute to Black infant mortality and how Medicare Advantage plans can leverage their resources to address these issues 

• Philanthropic Investments: The panel will examine how philanthropic dollars can be strategically deployed to support community-driven initiatives focused on reducing Black infant mortality 

• Patient Experience: We'll highlight the importance of culturally competent care and personalized approaches to ensure minoritized families feel heard, understood, and empowered within the healthcare system 

 
Expected Outcomes: 

• Gain a deeper understanding of the complex factors that improve awareness and access and contribute to Black infant mortality 
• Learn how Medicare Advantage plans can partner with communities to develop and implement impactful solutions 
• The discussion will inspire collaboration and action among stakeholders to address this critical health equity issue 
• Cultivate trust and cultural humility within their work, leading to improved health outcomes for minoritized communities 

Moderator  

Veronica Villalobos, JD, VP DEI Strategy, Enterprise Equitable Health Institute 
Highmark Health/ Allegheny Health Network  

Dr. Margaret Larkins-Pettigrew, Senior Vice President and Enterprise Chief Diversity, Equity and Inclusion Officer, Enterprise Equitable  
Health Institute for Highmark Health / Allegheny Health Network 
Dean for Obstetrics and Gynecology  
Drexel School of Medicine 

Kenya Boswell, SVP Community Affairs, Corporate Affairs 
Highmark Health 

Dr. Eugene Scioscia, Chief Patient Experience Officer, Obstetrics and Gynecology 
Allegheny Health Network 

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 

Arati Swadi, MBA, Vice President of Product 
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 Topic

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 

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 Topic

Stars and Savings: A Playbook for Medicare Advantage Success

• Cutting Costs and Reducing MLR: Learn proven methods and untapped categories to unlock cost savings opportunities and lower your MLR 
• Case Studies and Best Practices: Hear from industry leaders about successful adaptations to previous CMS changes, providing a roadmap for navigating the current landscape 
• Future-Proofing Your Plan: Explore forward-thinking strategies to ensure your Medicare Advantage plan remains competitive and compliant in an evolving regulatory environment 

•  

Dr. Edward Likovich, CEO 
Nymbl 

Lori Rund, VP Government Programs  
Blue KC 

Dr. Robert Mirsky, Former CMO 
Aetna Medicare  

Charlotte Yeh, Former CMO 
AARP 

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

OIG Updates and Guidance for Managed Care

OIG will provide updates on recent oversight and enforcements efforts in managed care.  The panel will discuss recent and ongoing audits and evaluations regarding Medicare Advantage plans that continue to raise concerns about the accuracy of risk adjustment data and payments.  OIG also will discuss compliance issues for managed care and discuss recent fraud cases and trends.     

• Learn about recent OIG reports and actions identifying fraud and improper payments as well as continuing concerns regarding health risk assessments   
• Understand the OIG compliance concerns and steps that can be taken to help avoid costly problems   
• Implement education programs and internal audits to reduce inaccuracies in documentation and billing and coding      

Jacqualine Reid, Social Science Analyst, Office of Evaluation and Inspections 
U.S. Department of Health and Human Services - Office of Inspector General  

Sarah Kessler, Senior Counsel, Office of Counsel to the Inspector General  
U.S. Department of Health and Human Services - Office of Inspector General  

Carolyn Kapustij, Senior Advisor for Managed Care, Office of Audit Services  
U.S. Department of Health and Human Services – Office of Inspector General  

Isaac M. Bledsoe, Director of Strategic Projects and Initiatives, Office of Investigations 
U.S. Department of Health and Human Services - Office of Inspector General  

Christopher G. Bresette, Director of Medicare Part C Audits, Office of Audit Services  
U.S. Department of Health and Human Services – Office of Inspector General  

Track 1: Risk Adjustment Strategies

Bridging Gaps in Care: In-Home Health Evaluation Visits for Preventive Care

• Understand how an in-home health evaluation visit with your members can be a catalyst for preventive, appropriate, and equitable care 
• See how results collected are made actionable by members, providers, and health plans helping to facilitate disease management, care coordination, and case management referrals 
• Hear how in-home health evaluation visits lead to diagnosis, early intervention and treatment 

Debbie Conboy, SVP, Risk Adjustment 
Signify Health 

Heidi Schwarzwald, MD, MPH, CMO, Home & Community Services 
Signify Health 

Track 4: Payer/Provider Strategic Alignment

Acing Value-Based Care with Point of Care Alerts and Automated Supplemental Data Feeds

• Improving star ratings in the challenging environment by enabling proactive care gap closure and prospective risk stratification 
• Leverage standard FHIR Implementation guides to scale bi-directional data exchange for improving delivery of patient care and member satisfaction 
• Learn from payers and providers experiences how access to accurate and timely data has helped reduce burden, improve compliance & achieve better outcomes 

Presented by Healow Insights  

Track 5: Hot Topic

Maximizing Compliant Yield in Times of Premium Pressure and Increased Regulatory Scrutiny

• Understand how various regulatory changes are impacting risk adjustment programs 
• See how incorporating primary care physicians in risk adjustment programs can drive superior financial and clinical results  
• Learn about a new, PCP-centric home assessment model that results in more compliant RAF yield and better patient outcomes  

Presented by Vatica health 

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

Track 4: Provider Focus

Don't Box Me In: A Lesson in Saving a Life

• Health maintenance must be a focus of our patient care 
• Some causes for why patients avoid seeing providers 
• How focusing on health maintenance can save lives and allow patients to live healthier, longer lives 

Donna Furlong, RN Clinical Services Senior Director 
Banner Medical Group 

Track 5: Future of Health Care

Advancing Patient Engagement in Medicare Advantage: Defining, Operationalizing, and Measuring Impact

• Define patient engagement and recognize its potential to improve member outcomes and experience in Medicare Advantage programs. 
• Identify effective strategies to operationalize patient engagement across all phases of member journey, with a focus on scalability and inclusivity. 
• Learn how to measure the impact of patient engagement on healthcare outcomes, and how to leverage  

Moderator:  
Laura Cooley, PhD, Editor-in-Chief 
Journal of Patient Experience 

Rachel Biblow, Associate Editor of Strategy, Innovation, and Outcomes 
Journal of Patient Experience 

Namita Seth Mohta M.D., Executive Editor 
NEJM Catalyst Innovations in Care Delivery 

Track 1: Quality and Member Experience

Making a Right Turn in The Intersection of Quality and Member Experience in a Dual eligible Environment

• Learn how to enhance member experience and quality for dual eligible members 
• Understand how to develop person centered, and equitable member experience initiatives through quality 
• Learn best practices in Integrating accountability models into quality programs and initiatives to improve member satisfaction and experience 
• Gain insights into how CalAIM is improving member outcomes by implementing Health Equity initiatives that are rooted in quality 

Kailey Collier, Director of Quality Performance 
Kern Health Systems 

Tina Dueringer, RN, BSN, CCM, PCC, CEO, Principal Advisor  
Dueringer Advisors, Inc