Sunday, January 26
-Pre Conference Pre Conference
08:00 AM - 09:30 AMP01: Ethics and Compliance Work Plan Essentials that Effectively Mitigate Risk Andrea Share, Exec Director, Ethics/Compliance Strategy & Ops, Kaiser Permanente Chanelle Gamble, Compliance Manager, Kaiser Permanente
- Explain the importance of conducting an ethics and compliance risk assessment and the relevance of risk assessments in an integrated care setting
- Describe the key components of a risk assessment, how to conduct a risk assessment, and the role of work planning for effective mitigation
- Introduce a "simple six step" approach to conducting a risk assessment, review a framework for defining risk, and discuss key takeaways for how the connection between risk assessment and work planning delivers business value
09:30 AM - 09:45 AMNetworking Break Mingle with your peers in the foyer before your next session starts.
09:45 AM - 11:15 AMP02: Cyber Threats and Compliance Challenges: How to Manage Technology Risk Jennifer Griveas, Chief Human Resources Officer & General Counsel, Eliza Jennings Senior Care Network Michael Gray, Eliza Jennings
- Identify biggest security threats to healthcare organizations
- Identify the value of integration of knowledgeable IT personnel into high-level operations team as a means to ensure compliance and effective risk mitigation
- Describe how best to implement technology solutions to enhance efficiency and productivity without sacrificing organizational security
12:30 PM - 02:00 PMBreakout Sessions#P03P03: The A to Zs of FDR, Delegate, and Subcontractor Oversight Steve Bunde, VP Integrity & Compliance & Internal Audit, HealthPartners Laurena Lockner, Sr Mgr Monitoring & Compliance, HealthPartners Rebecca Fuller, Corporate Compliance Officer, PrimeWest Health
General Compliance#P04P04: Compliance 2020: Compliance and Business Roles in Today’s Complex Regulatory Environment James Taylor, Manager, PricewaterhouseCoopers Christopher Schroeder, Director, PricewaterhouseCoopers Taline Avakian, Director of Compliance and Medicare Compliance Officer, Harvard Pilgrim Health Care
- Prevent: Learn about CMS and state requirements for FDR, delegate, and subcontractor oversight and areas of audit focus
- Detect: Understand due diligence, contracting, risk assessment, and auditing and monitoring strategies - including key partnerships
- Correct: Discover what to do when issues are identified and how to incorporate those into the correct CMS Program Audit Universe
- Key developments and trends across the healthcare industry related to the evolving role of compliance and the role of business units
- How compliance has helped define the role of meeting regulatory requirements
- An understanding of embedded compliance support and/or performance/program support teams/units, and how risk ownership is driving the role of business units
02:00 PM - 02:15 PMNetworking Break Mingle with your peers in the foyer before your next session starts.
02:15 PM - 03:45 PMBreakout Sessions#P05P05: Effectively Managing Internal Investigations and Regulatory Disclosures Anne Crawford, Director, ATTAC Consulting Group LLC Annie Shieh, Sr Compliance Counsel, Central Health Plan of California Lori Benso, Member, Strategic Health Law
General Compliance#P06P06: Compliance Goals in Risk Adjustment Coding Dana Brown, President, Reimbursement Mgmt Consultants, Inc. Dott Campo, Manager, Risk Adjustment Division, Reimbursement Mgmt Consultants, Inc. Rebecca Welling, Senior Director- Coding Compliance, Providence Health Plan Rebecca Welling, Senior Director- Coding Compliance, Providence Health Plan
- Methods to determine if communication infrastructure supports prompt identification of potential issues
- Strategies for initiating timely investigations that determine beneficiary and organizational impacts
- Common themes and regulatory disclosure approaches when deciding whether self-reporting to regulators is required or advisable
- Attorney-client privilege and litigation risk-management strategies
- Overview of Risk Adjustment reimbursement in the MA and ACA models
- Review of Risk Adjustment coding, HCC code capture accuracy, review of coding guidelines, rules & regulations
- In-depth review of most common compliance issues in coding in an RA environment, isolating the issues and giving tools to analyze them and make good compliant decisions
03:45 PM - 04:00 PMNetworking Break Mingle with peers and between sessions.
04:00 PM - 05:30 PMBreakout Sessions#P07P07: Special Supplemental Benefits and the FDRs that Provide Them - Unique Monitoring Challenges They Pose Jennifer Del Villar, Dir Gov Pgms Compliance, Cambia Health Solutions, Inc. Gail Blacklock, Compliance Officer , Inter Valley Health Plan
General Compliance#P08P08: Establishing a Best-Practice Approach for Your Compliance, Privacy, and Security Programs Bret Bissey, Vice President, Chief Compliance Officer, Gateway Health Kelly McLendon, Managing Partner, CompliancePro Solutions
- Unique monitoring challenges with unique FDRs
- Monitoring the member match - right member to the right supplemental benefit
- Tracking & monitoring health outcomes
- Learn how to utilize, in detail, the elements of the DHHS OIG Model Compliance Program(s) to develop a best practice for your compliance efforts
- Learn how to utilize the HIPAA Privacy and Security regulations and conduct a program assessment to create a best practice standard in your organization.
- Learn how best to formulate security, privacy, and compliance education programs in your organization, including a focus on being compliant at the top of the organization, by utilizing market knowledge to stimulate learning.
Monday, January 27
09:15 AM - 09:45 AMNetworking Break Mingle with peers and exhibitors between sessions.
09:45 AM - 10:45 AMBreakout Sessions#101101: The Compliance Officers Guide to a Successful Audit Michelle Rigby, Director, BluePeak Advisors, LLC Wendy Edwards, President & Chief Executive Officer, ATRIO Health Plans, Inc
General Compliance#102102: Exclusions v. Preclusions - Insights,Analytics, and Monitoring Best Practices after 1 Year of Releases Michael Rosen, Co-Founder, ProviderTrust, Inc Annie Shieh, Sr Compliance Counsel, Central Health Plan of California Liza Filtz-Freimark, Manager, Provider Operations, DentaQuest
- What can you do today to be prepared for an audit tomorrow?
- What resources does a compliance officer use to help identify gaps and prioritize issues in a lean organization with competing priorities?
- Consultants, a compliance officer’s best friend to support mitigation efforts, staffing augmentation, audit prep, and audit support
General Compliance#103103: Implementing a GRC Solution to Manage and Enhance Auditing & Monitoring Natalie Ramello, Vice President Chief Institutional Compliance Officer, UT Southwestern Rebecca Blades, Senior Manager, Audit & Monitoring, CommunityCare HMO, Inc.
- Trends, analytics, and learnings from the first year of monitoring & implementation
- Learn the crossover between the CMS Preclusion List and Federal and State Medicaid Exclusion Lists
- Predictive insights and future considerations for your provider network operations and SIU teams
- A roadmap for implementing a comprehensive GRC solution within their organization including how to make GRC successful and how to make it CMS compliant
- Best practices for adoption of a GRC model for auditing and monitoring
- An understanding of how to tie risks, policies and controls to your auditing and monitoring activities
10:45 AM - 11:00 AMNetworking Break Mingle between sessions with exhibitors.
11:00 AM - 12:00 PMBreakout Sessions#201201: Dual Products and MMP: Navigating State and Federal Oversight Deanna Simonds, Compliance Officer, UnitedHealthcare Anjenette Fenske, Compliance Officer, UnitedHealthcare Marla Rothouse, Centers for Medicare & Medicaid Services
General Compliance#202202: How Bias and Perception Impact Compliance Ahmed Salim, Director of Ethics and Integrity, iRhythym Walter Johnson, Assistant Privacy Officer, Inova Health System
- The Bipartisan Budget Act of 2018 sets forth requirements for increased integration for Dual Special Needs Plans (DSNPs) by 2021. These unprecedented requirements will impact the landscape of duals products.
- This panel will provide insight on best practice, challenges, and the future state of dual products from both compliance officers from multiple managed care plans.
- The audience will hear perspectives from several seasoned compliance professionals overseeing different fully integrated dual products.
General Compliance#203203: Navigating Compliance Challenges for Integrated Payor-Provider Systems Randi Seigel, Partner, Manatt, Phelps & Phillips, LLP Annie Miyazaki, SVP, Chief Compliance & Privacy Officer, Visiting Nurse Service of New York
- Breaking down why people make bad decisions
- Understanding how risk perception and inherent tendencies negatively impact compliance
- Utilizing tools to identify bias to increase compliance within your organization
- Key regulatory considerations relevant to intercompany arrangements, patient/member consent, and other documentation
- Tips for balancing plan versus provider regulatory frameworks and referral source/community partner needs
- Risks and opportunities in data sharing among affiliates under HIPAA and other privacy laws
01:15 PM - 02:15 PMBreakout Sessions#301301: Evolving Landscapes: False Claims Act and Managed Care Fraud Edward Baker, Counsel, Constantine Cannon LLP Nicholas Paul, Supervising Deputy Attorney General, CA Dept Justice
General Compliance#302302: Proactive vs Reactive in Risk Management - "Ring the Bell!" Fredy Rocha, Senior Compliance Manager, Centene Corporation Tiffany Lewis, Director, Compliance, IlliniCare Health
- Medicare Advantage plans, Medicaid MCOs, and their partners, are increasingly attractive targets for FCA whistleblower lawsuits
- The U.S. DOJ and State MFCUs face many challenges, but are gaining traction against managed care fraud, including risk adjustment and network compliance fraud.
- Having a written compliance plan is not enough. MCOs must develop and implement systems that steer clear of FCA liability.
General Compliance#303303: Rx Data Driven Compliance Monitoring: Opioid Prescribing, Dispensing, and Utilization Francis Grabowski, Director, PricewaterhouseCoopers Ben Wright, Director, PricewaterhouseCoopers Sandhi Ton, Manager - Risk Management Analytics, SCAN Health Plan
- Identify challenges and explore practical experiences for conducting an effective risk assessment while building a proactive monitoring and auditing plan
- Identify proactive risk management, which consists of mitigating the risks of threat events before these might possibly occur and negatively impact the organization
- Identify reactive risk management, which consists of responding to risk events as they occur to mitigate negative impacts to the organization
- Regulators are increasing focus on how plans are responding to the opioid crisis and compliance has a growing role in developing the strategy and controls related to provider prescribing practices, pharmacy dispensing, and member drug utilization.
- Incorporating insights gained through the fact-based analysis of trends and outliers is a solid base from which to launch an aggressive attack on the crisis.
- Advanced analytics, such as network analysis, can further help plans understand overlap between providers, pharmacies, and members, allowing the identification of unexpected connections and potential bad actors.
02:15 PM - 02:30 PMNetworking Break Mingle with exhibitors between sessions
02:30 PM - 03:30 PMBreakout Sessions#401401: Expert Auditing and Monitoring Practices to Measure Quality of Care and Performance Improvement Strategies in Medicaid Managed Care Michael Walsh, Senior Auditor, Integrity Management Services, INc. Jennifer Tryder, Program Director, Integrity Management Services, Inc. Lori Dillard, Program Director, CMS MCR of MCO Contract, Integrity Management Services
General Compliance#402402: A Compliance Program Facelift: Sculpting a Program from Good to Great Nicole Huff, Chief Compliance & Privacy Officer, St. Luke's Univ Health Network Deborah Johnson, Vice President, Compliance, IlliniCare Health Plan
- Understanding MCO performance measurement data and what is required to be produced and reported
- Best practices on performing and selecting Medicaid audits in order to effectively measure quality of care standards and performance
- Examples of MCO policies and procedures that assure the provisions and quality of care are actively monitored and remediated on an ongoing basis, and that the results are used to improve performance
General Compliance#403403: Adjusting the Risk for Medicare Advantage: Recent Enforcement Trends and Litigation Involving Medicare Advantage Risk Adjustment Practices Brandon Moss, Attorney, Wiley Rein Rachel Alexander, Partner, Wiley
- Address increasing state and federal regulatory requirements and enforcement activities
- Discuss strategies to move your compliance program from "Good to Great" with limited resources
- Case scenarios describing how to build partnerships and influence positive outcomes
- Attacks on Medicare Advantage plans’ practices with respect to auditing or reviewing risk adjustment scoring are growing both more complex and popular.
- While the government has been handed some serious setbacks in the last year, cases involving risk adjustment continue to be brought (both civilly and criminally).
- This panel will discuss recent trends in civil and criminal enforcement actions, where courts are lining up on interpreting key regulations, and what all this means for Medicare Advantage providers looking to navigate this high-stakes and ever-changing landscape.
03:30 PM - 03:45 PMNetworking Break Mingle with exhibitors between sessions
Tuesday, January 28
10:15 AM - 10:45 AMNetworking Break Mingle with exhibitors between sessions
10:45 AM - 11:45 AMBreakout Sessions#501501: FWA Oversight for a Small- to Mid-Size Plan Yvonne Zachman Fiedler, Senior Manager, PricewaterhouseCoopers Lisa Gallagher, FWA Investigator, Commonwealth Care Alliance Derek Frye, Audit & Technology Leader, Burchfield Group Alexander Henrichs, Aon
General Compliance#502502: Process Optimization, Organizational Structure, and Best Practices to Boost Appeals & Grievances Outcomes and Compliance Richard Merino, Senior Managing Director, Ankura Nancy Waltermire, Senior Director, Ankura Consulting
- Helping small- to mid-size plans build and maintain an effective FWA program
- How to utilize delegates to provide assistance in an FWA program
- How to prep for a CMS program audit and demonstrate an effective FWA program
General Compliance#503503: Compliance Effectiveness through Channels of Communication and Investigations Andrew Finkelstein, Vice President, Compliance; and Medicare Compliance Officer, Health Partners Plans, Inc.
- Prevention of common audit finding "pitfalls", and industry best practices for remediation, including compliance with new regulations and updates
- OIG Report: How best to identify high overturn rates in your appeals, identifying gaps to increase accuracy and lower overturn rates
- Tackling an end-to-end ODAG process evaluation, developing process improvements, development of effective organization structure, workflows and monitoring workplan on your appeals and grievances.
- Learn effective strategies, best practices, and challenges when establishing communication procedures and investigatory practices
- Identify key metrics for your compliance program to measure the effectiveness of organizational communication and oversight
- Case studies: A look at the compliance framework in action after issues are reported to compliance and acted upon
12:45 PM - 01:45 PMBreakout Sessions#601601: Mental Health Parity: Are You Compliant? Leigh Anne Hodge, Partner, Bradley Arant Boult Cummings Rhea Garrett, CHSPSC,LLC Scott Smith, Partner
General Compliance#602602: Fraud, Waste, and Abuse Program Audits Are Coming to an SIU Near You - Are You Ready? Jala Attia, President, Integrity Advantage Jessica Gay, Vice President, Integrity Advantage
- This presentation will provide an overview of the Mental Health Parity and Addition Equity Act (the "MHPAEA"). The presentation will cover the requirements of the MHPAEA, application of parity laws and rules under the MHPAEA, state parity laws, and state report cards.
- The presentation will address agency auditing activity and the types of violations that are garnering attention from regulators.
- Finally, the presentation will address recent trends in MHPAEA litigation, with a focus on wilderness therapy and Applied Behavioral Analysis ("ABA") cases.
General Compliance#603603: How to Identify and Handle a Contracted Over-Prescriber Mark Horowitz, Pharmacy Audit and Compliance, Kaiser Permamente Joaquin Basauri, Senior Investigator, Kaiser Permanente Carolyn Barton, VP, Compliance & Regional Compliance Officer, Kaiser Foundation Health Plan of Washington
- Assess your Special Investigations Unit’s compliance against fraud prevention, detection, and recovery requirements by understanding key areas reviewed during typical program audits.
- Identify and discuss critical compliance and reporting elements as well as common pitfalls that arise during the audit process.
- Leverage best practices and proactive measures to maintain ongoing fraud, waste, and abuse compliance within your Special Investigations Unit.
- How to identify an over-prescriber and internally escalate the case with the right health plan disciplines
- How to address patient abandonment concerns and network adequacy
- How to navigate the contract termination, external reporting, and PBM controls processes
01:45 PM - 02:00 PMNetworking Break
02:00 PM - 03:00 PMBreakout Sessions#701701: Risk Adjustment Compliance: Can You Afford the Risk? Julie Nielsen, Managing Director, Berkley Research Group Jason Christ, Member, Epstein Becker & Green PC Teresa Mason, Attorney, EBG Law
General Compliance#702702: Telehealth - What’s New: Staying On Top of Innovation!
- The life cycle of the risk adjustment process and member and provider engagement
- Key risks and pitfalls in the risk adjustment process
- How to best coordinate your risk adjustment operational and compliance teams