AU07: UPIC Audits – The Who, What, Where, When and Why

Joint presentation with Wayne van Halem and Stephen Bittinger regarding current litigation and compliance regarding the use of statistical sampling and extrapolation and AI software tools for auditing and claims review by payors and CMS. The presentation will cover the law, regulation, and guidance, or lack thereof for AI, that suppliers should know in using AI software tools, self-auditing with statistical sampling and extrapolation, and how to challenge both when used by payors or CMS. The presentation will also cover current litigation against payors for use and abuse of AI and extrapolation and DOJ investigations of use and abuse of AI by providers and suppliers. 

Innovation in the DME industry is no longer optional.  It is a competitive necessity. Yet, whether you are launching a digital ordering platform, integrating with telehealth partners, or redesigning patient onboarding functions, regulatory gray areas are unavoidable.  How should you approach compliance when innovation can outpace regulation?

This session is for innovators—founders, growth leaders, product teams, and forward-thinking executives—who are pushing the DME industry forward. Our panel of legal, compliance, and industry experts will offer practical, real-world guidance on how to strategically build your compliance infrastructure—how to integrate compliance best practices with operational scaling—to foster trust and mitigate potential legal and reputational risks. You’ll walk away with a compliance mindset that aligns with your business goals—so you can innovate boldly and within legal guardrails.

Speakers will discuss:

• Why innovators should care about compliance
• Common compliance “hot zones”— where innovation meets regulation
• Structuring partnerships compliantly
• Scaling for effective compliance — compliance that does not kill growth
• Enforcement trends and future risk

Learning Objectives: 

After attending this session, participants will be able to:

1. Spot common compliance risk areas for fast-growing or tech-forward DME businesses and learn strategies for mitigation.
2. Appreciate key considerations in designing compliant workflows (e.g., e-prescribing, patient intake, delivery tracking) that meet both user needs and regulatory standards.
3.  Evaluate partnership opportunities, particularly those with potential referral sources, through a compliance lens and without killing the deal.
4. Leverage compliance as a value-add in product development, fundraising, and go-to-market strategies, especially when engaging with payers or institutional partners.
5. Design and implement scalable internal controls that support growth-stage operations without stalling progress.

In today’s evolving healthcare landscape, collaboration is key to combating fraud, waste, and abuse in the DMEPOS sector. This dynamic panel brings together payers, providers, and consultants to shift the narrative from “us vs. them” to a unified approach to payment integrity. Attendees will gain a comprehensive understanding of claims processing workflows, audit strategies, common fraud, waste, and abuse patterns, and recent trends. Panelists will share real-world insights and actionable strategies to foster transparency, improve compliance, and build trust across the healthcare continuum.

Attendees will:

1. Understand the end-to-end claims processing lifecycle and how it impacts payment integrity as a provider and payer.

2. Be able to describe common fraud, waste, and abuse schemes and learn about current trends in the DMEPOS space and how they are identified. 

3. Learn collaborative strategies that providers and payers can use to prevent fraud, waste, and abuse before it occurs.

4. Understand the role of advisors and compliance officers in bridging gaps between stakeholders.  

5. Leave with action steps to enhance fraud, waste, and abuse prevention/detection and payment integrity efforts.