Webinar: Demystifying Genetic Test Coding & Clinical Review

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The science of genetics has unlocked exciting advancements in health and life sciences. Unfortunately, enabling cost-effective access to clinically appropriate genetic testing can also be administratively frustrating and burdensome for health plans, especially medical directors and care management staff.The sheer number of tests and ambiguity in billing codes make it challenging to identify the test that was performed. Confusion about which medical policy to apply leads front-line staff to escalate cases to medical directors who then face long, complex reviews.

Meanwhile, developing and maintaining policy is a significant undertaking. Rapidly evolving evidence and testing options quickly render policies out-of-date.

Fortunately, in recent years, new solutions have emerged. Health plan leaders have combined innovative, evidence-based medical policies with tech-enabled capabilities to establish more adaptable, effective programs. In this webinar, health plan leaders will discuss their perspectives on what’s really working to manage this dynamic space.

 

Priscilla Alfaro, MD
VP, Payment Integrity
Blue Cross and Blue Shield of North Carolina

Dr. Priscilla Alfaro is currently Vice President of Payment Integrity for Blue Cross and Blue Shield of North Carolina. Previously, she was the Chief Medical Officer for Zelis. Prior to Zelis, she worked as the Staff VP for Quality Code Reviews and Provider Education with Anthem’s Payment Integrity (PI) team. She led a team of clinical auditors and provided strategic input and clinical guidance to SIU and the other areas within PI. Before joining Anthem, she served as the medical director for the Texas Office of Inspector General. She published an article in Health Care Fraud, Waste, and Abuse in AAP News in 2010 and made many presentations on the transition to ICD-10. From 2018- June 2019, she served as the Chairman of the Medical Advisory Board for the National Health Care Anti-Fraud Association (NHCAA). She is a Board-certified Pediatrician and spent 20 years in clinical practice. She holds many coding certifications including a Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Outpatient Coder (COC), and Certified Inpatient Coder (CIC), as well as a Certified Fraud Examiner (CFE). She is a member of the AMA, AAP (National, Texas, Hawaii chapters), AAPC, NAMAS, Texas Medical Association, Travis County Medical Society, and the Association of Certified Fraud Examiners (ACFE).

 

Mary Davis, MD
Chief Medical Officer
Security Health Plan

Mary Davis, MD, is Chief Medical Officer at Security Health Plan of Wisconsin, Inc. Dr. Davis is a fellow of the American Academy of Family Physicians, and has served as a Chief Medical Officer and Medical Director consultant for several years. She has held Chief Medical Officer posts at such health plans as Scott and White, Network Health Plan and Dean Health Plan and MCS, Inc., in Puerto Rico, and was Medical Director at Wellmark BCBS. She has served on many health related and volunteer boards throughout her career.

Dr. Davis earned her medical degree at Temple University School of Medicine and completed her residency at the University of Wisconsin-Madison. She practiced family medicine in Columbus, Wis., before she began her administrative work. She has completed additional training in coding, project management, communication and leadership and holds a Certified Physician Executive certification from the American Association of Physician Leadership.

 

Josette Gordon-Simet, MD, MBA
Chief Medical Officer
Blue Cross and Blue Shield of Nebraska

Dr. Gordon-Simet is the Chief Medical Officer for Blue Cross Blue Shield Nebraska and leads BCBSNE’s clinical initiatives, including strategic oversight of the company’s medical policies, medical review processes, population health management and equity strategies. Prior to her role as CMO, Dr. Gordon-Simet was senior medical director at BCBSNE. Previously, she was chief medical officer and vice president of medical affairs for Think Whole Person Healthcare, where she directed clinical enhancement programs. She has also been a medical director and practicing physician with CHI Health in Omaha.

Dr. Gordon-Simet is passionate about patient education and support of childhood health improvement initiatives. She is a board member of Building Health Futures, a non-profit organization focused on improving underserved children and youth’s health through collaboration and advocacy.

Dr. Gordon-Simet earned her medical degree from Temple University’s Lewis Katz School of Medicine and is board-certified in family medicine. In addition, she is a graduate of the University of Nebraska at Omaha’s Executive MBA program and holds a master’s degree in strategic finance from Bellevue University.