Executive Vice President
Karen is recognized as a leading subject matter expert in the healthcare fraud, waste & abuse industry. Karen leads the Client Services and SME support teams and is responsible for designing the company’s healthcare fraud detection software and consulting services offerings.
Karen has a BA in Criminal Justice from the University of Delaware and an MA in Criminal Justice from Rutgers University. She is a Certified Professional Coder for Payers (CPC-P), a Certified Professional Medical Auditor (CPMA), and an Accredited Healthcare Fraud Investigator (AHFI) from the National Healthcare Anti-Fraud Association (NHCAA) where she frequently serves as a speaker and faculty member.
The industry changes almost daily with new providers, new claims, new schemes, new suspects…but the broader landscape over the next 2-5 years will likely see continued trending towards value-based care. Value-based care may impact how SIUs analyze claims for potential fraud, waste and abuse (FWA). The value-based care does not eliminate the need for FWA detection and prevention. Payers will still need to monitor for medically unnecessary services, upcoding, unbundling, services not rendered, excessive charges, ineligible members/providers and more. It becomes more of a challenge when the claims data is a blend of claims processed with varying payment methodologies.
Healthcare Fraud Shield is perpetually evolving to adapt to new laws, new payment methodologies, new codesand so much more. In order to adapt effectively and swiftly we shift product enhancement priorities and create new ones after a consistent weekly reevaluation of the varying needs. Those needs are assessed in a few ways:
- Being in constant communication with clients to learn what they are seeing. While many payers share the same product types or are in the same geographic areas, invariably their approaches to assorted scenarios may differ. A vendor needs to be familiar with not just the broader issue, but how each payer is individually impacted.
- READ, READ, AND READ SOME MORE! We need to stay up to date on new legislation, new rules, work plans, industry shifts and anything that is or could result in loopholes for a new scheme.
COVID-19 exemplified the need to adapt. Healthcare Fraud Shield quickly pivoted and developed a COVID-19 dashboard, Artificial Intelligence models and about 150 rules.
Healthcare Fraud Shield provides value in many areas, but most significantly is our commitment to education and training. We provide the entire industry not just our clients with complimentary content through newsletters, Healthcare Fraud Shield run webinars, podcasts and have served as presenters for industry organizations such as NHCAA, HPA, ACAP, AHIP, HCCA and more.
Healthcare Fraud Shield is solely focused to detecting and preventing Fraud, Waste and Abuse (FWA). Our teams are not distracted by other products or initiatives and we have a slew of Subject Matter Experts integrated throughout every aspect of our organization.