Building a successful Special Investigations Unit takes more than just hiring investigators. It requires the right mix of people, technology, and processes to detect and act on fraud across commercial, Medicaid, and pharmacy lines of business. In this session, Carl Reinhardt draws on over two decades of SIU leadership at Anthem to share a practical blueprint for building and scaling an effective investigations function. Attendees will learn.
- The key roles, skill sets, and team structures needed to build an SIU from the ground up
- The tools and applications required to support investigations across multiple lines of business and geographies
- How to scale SIU operations as membership grows, and lessons learned from managing investigations across commercial and Medicaid populations

In this panel discussion, payment integrity leaders from regional and mid-size health plans will share how they are building data workflows that support day-to-day PI operations. The session will focus on how to move from fragmented systems and static reporting to connected, actionable workflows that enable earlier intervention and better decision-making.

- Connecting core data sources (claims, eligibility, provider, UM) to support effective PI workflows
- Turning analytics into usable insights for reviewers and operations teams
- Building scalable, standardised workflows for triage, case management, and audit tracking

Building a successful Special Investigations Unit takes more than just hiring investigators. It requires the right mix of people, technology, and processes to detect and act on fraud across commercial, Medicaid, and pharmacy lines of business. In this session, Carl Reinhardt draws on over two decades of SIU leadership at Anthem to share a practical blueprint for building and scaling an effective investigations function. Attendees will learn.
- The key roles, skill sets, and team structures needed to build an SIU from the ground up
- The tools and applications required to support investigations across multiple lines of business and geographies
- How to scale SIU operations as membership grows, and lessons learned from managing investigations across commercial and Medicaid populations

How do we scale high-impact clinical integrity programs using smart targeting to reduce review volume while increasing savings? 

While traditional payment integrity concepts continue to deliver more savings, AI and advanced technologies are enabling new PI concepts. How are health plans identifying the “next big thing” in payment integrity? This panel will explore how leading organizations are scaling new savings concepts, the role of AI in accelerating discovery and prioritization, and what will differentiate top-performing payment integrity programs in the year ahead.
- How new PI concepts are identified, vetted, piloted, and scaled
- How to prioritize the right opportunities without overwhelming PI teams or creating provider abrasion
- New tech-enabled billing (e.g., digital therapeutics, remote monitoring, AI-assisted services) and unlisted codes

Payment integrity is evolving from a downstream claims audit function to a proactive, critical lever for upstream cost avoidance. Payment integrity leaders note that ‘shifting left’ can cut administrative duties by at least 10-15%, in addition to improving provider abrasion. But evolving to cost avoidance not only requires a shift in mindset, but an evolution in how data, AI tools, and cross-functional collaboration are used to enable proactive decision making.

- Case studies: Critical strategies for launching pre-pay programs and measuring ROI
- How AI is expanding pre-pay capabilities and required governance
- Rethinking the impact and attribution of provider education initiatives