Compliance Conversations by Healthicity: Recent Episodes
CJ Wolf
Compliance Conversations is a monthly podcast for healthcare professionals and compliance officers who want to stay on top of the compliance game. Host CJ Wolf has in-depth conversations with industry experts to explore the riddles and complexities of the compliance world. Wolf chats with fellow compliance experts, auditors, physicians and government officials. Compliance Conversations is produced by Healthicity.
We’re excited to share a new episode of Compliance Conversations where CJ Wolf, MD talks with healthcare compliance expert Nancy Clark, the Senior Manager of Health Care Services at EisnerAmper! In this episode, Nancy brings decades of experience in coding and revenue management to address improper payments—a costly issue for healthcare providers. Listen in as we dive deep into: - The most common coding errors and how to avoid them - How to leverage Medicare’s transparent data to stay compliant - Steps you can take to safeguard your practice’s revenue and reputation Whether you’re in compliance, billing, or coding, this episode is packed with actionable insights that could save you time, money, and stress.
We’re thrilled to announce a major milestone for Compliance Conversations – our 100th episode! Over the years, we’ve had the privilege of hosting industry experts to hear their invaluable perspective on best practices, trends, and real-world scenarios in compliance and auditing. This special episode is a celebration of our journey and the incredible community that’s made it possible! Join CJ Wolf, MD, Debi Behunin (Healthicity Vice President of Product), Brian Burton (Healthicity Chief Compliance and Privacy Officer), Remo Peshkepia (Healthicity Product Manager), and Sarah Crane (Marketing and Brand Manager) for insider insights on: - The evolution of compliance and auditing. - Key milestones for Healthicity, including Audit Manager and Compliance Manager developments. - Insights from the Healthicity team on where compliance is headed. Thank you for being part of this journey! Here's to many more episodes of helping you navigate the complex (and interesting!) world of compliance.
In this episode, CJ Wolf, MD, and E/M coding expert Sharisa Freeman discuss her journey and insights into mastering the complexities of E/M coding. Here's a quick look at what you can expect from this episode: - The Evolution of E/M Coding: Changes in guidelines that shifted the focus to Medical Decision Making. - Medical Decision Making Tips: Understanding the three essential sub-elements: number of problems, data reviewed, and risk. - Documentation Challenges: Common issues with lower-level visit documentation and how to address them. - Networking and Continuous Learning: The value of staying updated on coding changes and connecting with peers. - Advice for New Coders: Sharisa’s top tips for those just starting in the field. Check out their conversation today – and thank you to Sharisa for sharing her time and insights on Compliance Conversations!
Ever wondered what it’s like to testify as an expert witness? We talk about that and more in this episode of Compliance Conversations! We invited compliance expert Rebecca Busch to explore her incredible journey from trauma nurse to legal expert in healthcare fraud and compliance. Join us as Rebecca shares: - Her transition from nursing to healthcare fraud examination - The key legal challenges in compliance she’s faced as an expert witness - Practical advice on how to stay ahead of compliance trends - Tips and insights on depositions
Tune in to this episode of "Compliance Conversations" where we dive deep into the world of innovation and biotech with our special guest, Steve VanNurden! In this episode, CJ Wolf, MD, talks with Steve VanNurden, CEO of Fitzsimons Innovation Community and Associate Vice Chancellor of Biotechnology at the University of Colorado Anschutz Medical Campus. Listen in as they explore the unique integration of academic and entrepreneurial ecosystems, discuss the reinvention of tech transfer, and reveal the keys to building a thriving biotech community. You'll hear: The vision behind Fitzsimons Innovation Community and its role in advancing healthcare innovation. - The unique benefits of integrating academic medical centers and biotech communities. - Real-life examples of startups and research breakthroughs happening in Colorado – and why it’s a powerful hub for healthcare innovation. - How the Community addresses regulatory and funding challenges to accelerate innovation. - Whether you're in healthcare, compliance, biotech, or simply passionate about innovation, this episode offers valuable insights and inspiration.
In this episode, Maeve O'Neill, MEd, LPC-S, CHC, CDTLF, the National Compliance Director for Circa Behavioral Healthcare Solutions, joins us to share insights from her three decades of experience in mental health and addiction services as she provides valuable insights into the unique challenges and best practices for compliance in this field. Tune in as we discuss: - The complex web of regulations: The intricate layers of compliance in behavioral health, from state regulations to accreditation standards, and how organizations can effectively navigate them. - Building effective compliance programs: The importance of simplifying compliance processes and aligning them with organizational goals to create robust and practical programs. - The role of compliance in patient care: The critical connection between compliance and quality care, highlighting how a strong compliance program can support staff well-being and ultimately benefit patient outcomes. We appreciate Maeve’s time and expertise in talking about this vital topic!
Medicare audits can be a daunting challenge for any healthcare provider. With a maze of regulations, different types of audits, and a complex appeal process, it’s easy to feel overwhelmed. That’s why we invited Alicia Shickle, AHFI, CHC, CPC, CPCO,CPMA, CRC, the President and CEO of ProCode Compliance Solutions LLC, to share the knowledge and strategies you need to navigate this tricky terrain. Tune in to the episode as we discuss: - The top issues that trigger Medicare audits - How to prepare your practice and avoid common pitfalls - The five levels of Medicare appeals and how to effectively manage them - Why proactive compliance programs are crucial for your practice Thank you, Alicia, for sharing your time and expertise with us! About Alicia Shickle Alicia has decades of clinical and administrative healthcare experience. Her areas of expertise include revenue cycle integrity, documentation, coding and billing compliance, Medicare, MSP, and Medicaid regulations, practice workflow and operations, compliance program assessments, development, and implementation. Alicia provides advisory services to attorneys, healthcare administrators, providers, and organizations. She frequently works with business litigation and health law practices on fraud and abuse intervention and providing independent and objective assessments for both plaintiff’s and defense teams. She works closely with clients on both routine and complex documentation and coding reviews. She provides in-depth coding and claims data analysis, education, and assists providers with navigating complex regulatory and policy requirements, identifying and mitigating potential FCA risks while optimizing revenue. She has extensive experience developing and implementing effective compliance programs including all seven elements. Alicia served as the Director of Compliance for the American Academy of Professional Coders (AAPC). She has worked with some of the top consulting and health law practices and, was a Family Practice Administrator for over a decade. Alicia has presented educational training boot camps and seminars nationally on compliance, documentation and coding, and practice management. She was a medical billing and coding instructor at a community college. She is a frequent author for online physician blogs, and journals. Alicia is an Accredited Health Care Fraud Investigator (AHFI) with the National Health Care Anti-Fraud Association (NHCAA), and is certified in Healthcare Compliance (CHC, CPCO) through the Health Care Compliance Association (HCCA), and AAPC. She is a Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), and certified in Risk Adjustment Coding (CRC). She is also a Certified Physician Practice Manager (CPPM). Alicia is an active member of the American Academy of Professional Coders (AAPC) and served as the President of AAPC’s Manhattan Local Chapter for two years. She is a member of the Health Care Compliance Association (HCCA), and the National Health Care Anti-Fraud Association (NHCAA), and American Health Lawyers Association (AHLA). She is a member of American Health Information Management Association (AHIMA), the National Alliance of Medical Auditing Specialists (NAMAS), and a member of Medical Group Management Association (MGMA).
Heidi McKinnon, PharmD, CHC, a seasoned compliance expert, shares insights from her journey from retail pharmacy to head of compliance at Capital Rx, a leading pharmacy benefit manager. In this episode, Heidi shares her unique path and extensive experience in the compliance world. We delve into the evolving landscape of digital pharmacy, discussing: - The true meaning of digital pharmacy and how it differs from telepharmacy and online pharmacies. - The regulatory challenges faced by digital pharmacies and strategies to stay ahead of ever-changing rules. - The impact of digital pharmacies on patient care and medication access. - The intricacies of reimbursement and licensing in the digital pharmacy space. - Practical tips for compliance officers new to the digital pharmacy sector. Heidi McKinnon, PharmD, CHC Heidi McKinnon is a dedicated healthcare professional with a Doctor of Pharmacy (PharmD) degree and a Certified Healthcare Compliance (CHC) credential. With extensive experience in the pharmacy and healthcare industry, Heidi brings a wealth of knowledge and expertise to her role as Head of Compliance at Capital Rx. About Capital Rx Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA) dedicated to advancing our nation's healthcare infrastructure to improve drug price visibility and patient outcomes through innovative solutions and cutting-edge technology. To learn more about Capital Rx and their mission to create a better healthcare experience, visit Capital Rx's website. Contact Information For more information or to get in touch with Heidi McKinnon, you can reach out via LinkedIn.
In this episode, we welcome back Hal McCard, Counsel at Spencer Fane, to delve into the complexities of financial relationships with physicians, including essential insights on compliance with STARK and Anti-Kickback statutes. CJ Wolf, MD, and Hal McCard discuss: - Hal’s extensive career in healthcare law and his journey to becoming a leading expert in the field. - Detailed explanations of STARK and Anti-Kickback statutes and their implications for healthcare organizations. - Practical advice on maintaining compliance in physician contracting, from fair market value documentation to auditing processes. - The importance of centralized arrangements tracking systems and how they can help mitigate compliance risks. - Real-world examples and valuable insights from Hal’s experiences as in-house counsel and external advisor. Check out the episode to gain valuable knowledge and practical tips to enhance your compliance programs and safeguard your organization against potential pitfalls.
Are you intrigued by the rapid evolution of telehealth and its impact across the globe? Then you won’t want to miss our latest podcast episode where Keisha Wilson and CJ Wolf discusses the nuances, challenges, and opportunities in international telehealth services! In this episode, we discuss: COVID-19’s Impact on Telehealth: Learn how the pandemic prompted a reevaluation of international telehealth practices and regulations. Compliance and Legalities: Keisha dives into the intricate details of understanding and navigating international laws and compliance issues, ensuring seamless and legal telehealth services across borders. Challenges and Solutions: From infrastructure limitations to insurance hurdles, Keisha shares real-world examples and innovative solutions to delivering healthcare to remote and underserved populations. Global Collaborations: Get insights into how organizations like the International Society for Telemedicine and eHealth (ISfTeH) and the World Health Organization are shaping the future of telehealth. Regulatory Requirements: Understand the various certifications, permits, and legal considerations necessary for practicing telehealth internationally. Tune in to our latest episode and join us in exploring the dynamic world of international telehealth.
In this episode, our host CJ Wolf sits down with Laidy Diana Martinez, a coding supervisor, to discuss the world of GI coding and compliance. Episode Highlights: - Introduction to GI Coding Challenges: Understand the common hurdles and how to overcome them. - Screening vs. Diagnostic Colonoscopies: Learn the critical differences and their coding implications. - Essential Modifiers: Find out which modifiers to use and when. - Documentation Best Practices: Discover what’s needed for accurate and compliant GI procedure billing. - Medicare and Payer Policies: Stay up to date with the latest changes and requirements. Laidy Diana Martinez, with her extensive experience as a coding supervisor, brings valuable insights and practical advice that can help enhance your coding accuracy and compliance efforts.
Our latest episode of Compliance Conversations features Johanna Brown, the recipient of Healthicity's 2023 Compliance Officer of the Year Award! Join our host, CJ Wolf, as he delves into Johanna’s journey in compliance, her leadership philosophy, and the qualities that make her an outstanding compliance officer. Here’s what you can expect: - Career Journey: Learn about Johanna’s path from journalism to compliance. - Leadership Insights: Discover her secrets to fostering teamwork, maintaining work-life balance, and navigating the complex world of healthcare compliance. - Heartfelt Recognition: Hear the glowing recommendations from her colleagues and what they appreciate most about her approach to compliance.
We’re excited to announce a new episode of Compliance Conversations! Join CJ Wolf and special guest Kimberly Jolivette Williams as they explore the complexities of anesthesia coding and billing. In this episode: - Kimberly’s journey from unit secretary to compliance expert. - Unique aspects of anesthesia coding and essential resources. - The importance of modifiers in compliance and billing. - Tips for accurate documentation and minimizing compliance risks. Don't miss out on Kimberly's expert advice and passion for lifelong learning. Here are some additional resources around this important topic: Centers for Medicare & Medicaid Services Anesthesiologists Center - https://www.cms.gov/medicare/payment/fee-schedules/physician/anesthesiologists-centerCertified Anesthesiologist Assistants Now Authorized to Practice in Washington State - https://www.asahq.org/about-asa/newsroom/news-releases/2024/03/certified-anesthesiologist-assistants-now-authorized-to-practice-in-washington-state#:~:text=SEATTLE%20%E2%80%93%20Washington%20state%20Gov
Our latest episode of Compliance Conversations features CJ Wolf, MD, and Brian Burton, our Chief Compliance and Privacy Officer, sharing their key takeaways from two of the most prominent industry conferences: HCCA's Compliance Institute and AAPC's HEALTHCON. Find out what they had to say about insights on the OIG’s new General Compliance Program Guidance, industry-specific updates, and so much more. From discussions on artificial intelligence in compliance to the latest developments in Medicare Advantage and risk adjustment, this episode offers valuable insights for professionals across the healthcare spectrum. We also wanted to share a few resources CJ and Brian mentioned during their chat: - Our webinar on Leveraging Data Analytics for Proactive Compliance Management (https://www.healthicity.com/resources/leveraging-data-analytics-proactive-compliance-management-webinar)- The section of our Resource Center dedicated to the OIG’s General Compliance Program Guidance (https://www.healthicity.com/resources/topic/oig-gcpg)
We're thrilled to share the latest episode of Compliance Conversations featuring a Jeni Colarusso, a seasoned nurse and an expert in telehealth and Tele-ICU systems. In this episode, Jeni dives deep into the transformative power of telehealth, particularly in critical care environments. Episode Highlights: - Jeni’s extensive experience in surgical and cardiac ICU settings. - An in-depth look at Tele-ICU and its role in expanding access to specialist care in remote areas. - The impact of technology on patient outcomes and hospital efficiency. - Insightful discussion on overcoming healthcare disparities through innovative telehealth solutions. Jeni shares not only her professional journey but also gives us a peek into the future of healthcare where geography no longer limits access to top-notch medical expertise.
Are you navigating the complex world of healthcare compliance, particularly when it comes to Medicare and Advanced Beneficiary Notices (ABNs)? We've got you covered in the latest episode of Compliance Conversations, featuring industry expert Keisha Wilson, founder of KW Advanced Consulting. Keisha brings over two decades of healthcare experience to the table, offering invaluable insights into the intricacies of ABNs. This episode delves deep into what ABNs mean for healthcare professionals and patients alike, recent changes to ABN forms, compliance risks, and the importance of proper education and implementation within healthcare settings. Why Tune In? - Uncover the essentials of ABNs: Learn what ABNs are and why they're critical in healthcare from a seasoned expert. - Stay updated: Get the scoop on the latest ABN form changes effective from June 2023 and how they impact practices. - Avoid common pitfalls: Keisha discusses frequent compliance risks and how to navigate them effectively. - Engage in comprehensive learning: From policy implementation to case studies, this episode is packed with actionable advice and best practices. Keisha's journey from aspiring social worker to healthcare compliance consultant adds a unique perspective to understanding patient communication and the nuances of Medicare coverage. Her passion for compliance and patient care shines throughout the conversation, making it a must-listen for anyone in the healthcare sector. You can also read a recent blog post from KW Consulting on ABNs. Keisha Wilson, CCS, CPC, CPCO, CPMA, CRC, CPB, Approved Instructor, is the Founder/CEO of KW Advanced Consulting LLC, Minority Women Own Business Enterprise (M/WBE) Certified, with 20+ years in healthcare specializing in various areas of compliance. Multi-specialty, Telehealth/Telemedicine, Risk Adjustment, provider and coder training. She currently sits on a Board of Directors for an outpatient mental health clinic. Keisha is a licensed PMCC who teaches coders looking to become Certified Risk Adjustment (CRC) and hosts various compliance documentation and coding webinars. She is a published author, having written for AAPC editors on Primary Care Coding Alert, Healthcare Business Monthly, and KW Advanced Consulting coding articles. Keisha can speak at various events this year, including the AAPC Regional Conference on Philidelphia and Cohen's Coding Summit on Telehealth in the U.S. vs Internationally.
In this episode, we're joined by Kandi O'Brien, the Founder of Delegated Credentialing Pro’s and an expert with extensive experience in credentialing and compliance. Kandi shares her fascinating journey in healthcare, from clinical roles to owning urgent cares, and ultimately specializing in compliance and credentialing. We discuss the importance of credentialing, its various aspects, and why it's crucial for patient safety, regulatory compliance, and maintaining organizational reputation. Tune in to our conversation to learn more about: - The significance of credentialing as the first step for providers entering healthcare facilities. - The distinction between facility credentialing and professional (provider) credentialing. - The complexities of enrollment and why it's not synonymous with credentialing. - The concept of delegated credentialing and its benefits for organizations, including improved efficiency and revenue generation. - The primary source verification process and ongoing monitoring for compliance. - The potential challenges and considerations associated with delegated credentialing.Kandi's LinkedIn: https://www.linkedin.com/in/kandio/Delegated Credentialing Pro's: https://www.linkedin.com/company/delegated-credentialing-pro-s/
This Compliance Conversations episode is a must-listen for anyone in healthcare compliance or coding. We invited Leslie Boles, Co-Owner and President of Revu Healthcare, to chat about identifying coding compliance risks within healthcare organizations. Tune in to Leslie and CJ Wolf’s discussion for more on: - The importance of staying curious and adaptable - The significance of regular audits and assessments in proactively identifying compliance risks - Common coding compliance risks and blind spots within organizations - Strategies for mitigating compliance risks, including the role of data analytics and technology They also talk about one of the most important things to keep top-of-mind – staying humble and acknowledging gaps in knowledge to drive continuous improvement.
Biometric technology can sometimes feel like sci-fi – which is why it raises so many great compliance questions. That’s why we invited Dr. Mohamed Lazzouni, the Chief Technology Officer at Aware, a leading company in the field of biometrics, to join us for our latest episode of Compliance Conversations. In this episode, Dr. Lazzouni shares insights into the exciting developments in biometrics and its pivotal role in healthcare. From access control to fraud prevention, Dr. Lazzouni and I discuss the impact on compliance and security in the healthcare industry. Listen now to gain a deeper understanding of: - How biometrics enhance healthcare access control - Real-world applications of biometrics in preventing fraud - The intersection of biometrics and compliance in healthcare - The future of wearables and AI in biometric healthcare interventions
Ready for a crash course into regulatory considerations in health tech? In this episode of Compliance Conversations featuring Susan Walberg, a seasoned regulatory and compliance professional and published author of fiction and non-fiction In this interesting interview, Susan shares her journey from novels to HIPAA, offering a behind-the-scenes look at the challenges and triumphs of navigating compliance in the rapidly evolving health tech landscape. Tune in to the episode to discover: - Some surprising realities of health tech compliance - Real-word intriguing cases (like the Jelly Bean dilemma!) - Key lessons for startups and small organizations as they navigate compliance concerns Thanks to Susan for joining us for this episode – we hope you enjoy! Susan Walberg has worked in health care for nearly 30 years, from working as a fraud investigator at a health plan, to a regulatory attorney and privacy officer for a very large health system. She has worked as a compliance officer, and a subcontractor working with CMS on Part C and D Medicare fraud and abuse. Susan has also worked as an interim compliance officer for a range of healthcare organizations, designing and building compliance programs unique to the needs of those organizations. Her specific experiences include helping clients manage a Corporate Integrity Agreement and developing programs for new organizations or those going through an organizational transition. Susan has trained and mentored many new compliance professionals, and strives to help those new to compliance to succeed in their roles. As a consultant, Susan uses her passion for building, creating, and organizing compliance programs along with a true understanding of the needs of healthcare organizations to help create programs that really fit within the each client’s unique culture and environment.
Tune in to this episode of Compliance Conversations interview with Maya Turner, a seasoned expert in the healthcare industry with close to 30 years of experience in auditing, coding, billing, compliance – you name it. Maya shares her perspective on the evolution of telehealth, especially in the context of recent changes and challenges brought by the COVID-19 pandemic. Maya and CJ also discuss: - Significant changes in telehealth regulations from its early days to the present - Telehealth’s crucial role in addressing healthcare disparities - The importance of proper documentation in telehealth visits - Compliance issues and risks that auditors and coders should be aware of We welcomed an unexpected guest during the episode – Maya's dog! See if you can hear the friendly canine interruption. Maya is a seasoned certified coder and auditor, boasting nearly 30 years of experience and subject matter expertise to many coding compliance subjects; she especially is sought after for her in-depth knowledge base of pro fee multi-specialty practice, primary care, hospitalists, telehealth, in-patient and SNF billing. She is also a published author, having written articles for AAPC and HCCA, and currently is a part of the ACDIS Leadership Council. She showcases her unmatched three-dimensional thinking in complex subject matters, Mayas’ success is marked by her clear and well received presentation style, reflecting her profound understanding and expertise. Maya also has a consulting company, Turner Expert Consulting Services, LLC.
Dr. Adam Robinson, an internal medicine physician and founder of Aimedica, joined CJ Wolf, MD to explore the promises and pitfalls presented by AI in the healthcare landscape. Dr. Robinson provides valuable insights into the current state of electronic medical records, the impact of the 21st Century Cures Act, and the potential for AI to revolutionize patient care. Tune in to our latest episode, “Beyond the Buzzwords: Understanding AI's Role in Healthcare,” to hear CJ and Adam's discussion on: - Existing challenges with electronic medical records, such as data interoperability issues and the siloed nature of patient information. - The implications of the 21st Century Cures Act and its role in making healthcare data more transparent and interoperable. - Successful applications of AI in imaging specialties, highlighting the potential for improved diagnostics. - The current lack of comprehensive regulations for AI in healthcare and predictions around the emergence of potential FDA regulations in the future.
In this episode, Jenny Hamilton the Clinical Project Research Manager at Barrow Neurologic Institute, joins CJ Wolf, MD for an in-depth discussion on compliance considerations for clinical trials. From the complexities of protocol deviations to the vital role of Institutional Review Boards, they cover a wide range of topics. Tune in for valuable insights into the compliance landscape of clinical trials and learn more about the crucial role patients play in advancing medical research. Jenny and CJ also cover: - The importance of informed consent in clinical trials - Insights into FDA audits and the role of Clinical Research Associates - The fascinating and diverse landscape of global clinical trials You can also learn more about Jenny’s work here. https://www.barrowneuro.org/centers-programs/als-neuromuscular-disease/
If you haven’t had the time yet to read all 90+ pages of the OIG’s New Compliance Program Guidance, we’ve got a great place for you to start. We invited Sarah Couture, a nurse turned compliance consultant, to discuss the new guidance with us in our latest episode of Compliance Conversations. Join Sarah and CJ Wolf, MD as they break down the essential elements and updates, including: - The evolving role of Chief Compliance Officers - The significance of incentives in compliance programs - Collaborative risk management approaches - Emphasizing medical necessity in billing audits Sarah is the Principal of Couture Compliance, an organization dedicated to elevating compliance program effectiveness through tailored compliance solutions. You can reach her at sarah@couturecompliance.co.
In the age of technology, data, and artificial intelligence, there’s one often-overlooked workplace tool: soft skills. That’s why we invited Jay Anstine, the founder of Bluebird Healthlaw partners, to chat with CJ Wolf, MD about communication and navigating work environments. In our new episode of Compliance Conversations, “From the Boardroom to the Exam Room: Diplomatic Communication in Healthcare,” Jay and CJ discuss: - Real-world, complex scenarios with patients and clinicians - How to adapt your communication style for different audiences - Learning various communication tactics so you can effectively interact with physicians, leaders, and executives - Addressing compliance concerns in a group setting Jay Anstine is the founder of Bluebird Healthlaw Partners, a consulting firm with a mission to help compliance officers change the perception of compliance in their organizations. For over 20 years, he has worked on the provider and payer side of the healthcare market, consulting to leaders and clinicians about compliance program matters. He routinely writes and speaks about compliance program requirements and is a faculty member at the University of Southern California’s Gould School of Law, teaching courses on healthcare compliance. Jay recently wrote a book entitled, Navigating the Politics of Healthcare: A Compliance Officer’s Guide to Communication, Relationships, and Gaining Buy-in, which is available on Amazon or at Barnes and Noble. In his book, he talks about how there are two worlds within healthcare-the world the general public experiences in receiving care, and the world industry workers experience in providing that care. Jay’s theorizes it is the second world where the politics of healthcare lives, which impacts the effectiveness of a compliance program. His book then provides strategies to improve the compliance officer’s ability to communicate effectively with their healthcare leaders in order to gain buy-in to the compliance program. You can find Jay at www.bluebirdhealthlaw.com. He has a blog dedicated to communication strategies for compliance officers. You can also find him on LinkedIn.
In this episode of Compliance Conversations, we’re taking an in-depth look at the revenue cycle and coding. We’re joined by Stephanie Perry, the outpatient medical supervisor for e4health, as she shares insights from her 12 years of experience in coding, auditing, training, and leadership roles within the healthcare industry. Tune in to our episode, “Coding Strategies for Successful Revenue Cycle Management,” to understand modifiers, status indicators, and their significance in the reimbursement process. Stephanie sheds light on how coding decisions can either facilitate or hinder the smooth progress of claims through the revenue cycle.
In this episode, we welcomed Stacey Crudup, Chief Compliance Officer at The SEES Group, to share her insights on why building relationships with team members on the front lines of healthcare is essential in driving strong compliance programs. Stacey's experience and practical advice shed light on the benefits of understanding the business, spending time with your internal teams, and creating value through compliance efforts. Tune in to our new episode, “How Compliance Teams Can Build Trust to Accelerate Success,” to hear more about: - Stacey's journey into compliance from an IT background - The importance of building relationships in the world of compliance - Practical tips for embedding compliance into operations - Overcoming obstacles in the process - How to add value to your organization through compliance Stacey has unique expertise in recognizing the role of compliance in daily health care operations and communicating effectively with staff at all levels about the practical application of compliance principles. She is experienced in developing and executing organizational policies and procedures related to legal questions in the health care environment, compliance, and risk management.
We're excited to introduce a thought-provoking podcast episode that dives into the world of compliance in healthcare and explores the ever-evolving challenges compliance professionals face in their careers. In this episode, “A Candid Conversation on Challenges and Balance in a Compliance Career,” Dieter Lehnortt and CJ Wolf share their insights on the complexities of the healthcare compliance landscape. From dealing with government regulations to navigating the uncharted territory of Artificial Intelligence, they cover it all. Key takeaways from the podcast: - Explore the potential of AI in compliance and the importance of using it appropriately to enhance efficiency. - The significance of establishing boundaries, delegating tasks, and prioritizing for a better work-life balance. - How to make compliance approachable more approachable for colleagues who find it intimidating
Join us for a deep dive into healthcare and nursing facility compliance during this episode. Discover the ever-evolving landscape and common challenges faced by providers as CJ Wolf and Paige Pennington share their expert insights.
Whether you're a compliance professional, an HR specialist, or simply interested in the evolving landscape of workplace culture, our latest Compliance Conversations episode offers valuable takeaways for everyone. We invited Kyle Manwaring, a DEI professional, for a great conversation about the possibilities at the intersection of DEI initiatives, compliance, and organizational culture. Tune in to our new episode, “Exploring Diversity, Equity, and Inclusion in Compliance,” to learn more about: - The fundamentals of DEI and its various components. - The importance of DEI for organizations, both ethically and financially. - Strategies for fostering a more inclusive and equitable work environment. - The role of executives in championing DEI efforts.
We’re joined by Sara Richards, a newly certified coder, as she shares insights into the intricacies of medical coding and how it aligns with compliance in the healthcare industry. Sara and CJ Wolf, MD, discuss: - The certification process and how Sara prepped for the exam - What the coding exam is really like – and what’s changed (and hasn’t changed) over the last few decades - Career opportunities in the coding industry
Assembling the ideal compliance team is no small task – and that’s why it can be such a puzzle. We invited Sarah Couture, a former nurse turned compliance executive, to share her insights on structuring effective compliance teams.
Tune in to our new episode, “The Art of Building a Successful Compliance People Strategy,” as we discuss: - Important considerations for building a strong compliance team - Why compliance liaisons can boost your program’s effectiveness - Real-life examples of compliance staffing done right (and not so right) - Strategies for compliance officers to approach succession planning and mentorship
Sarah currently serves as a Senior Managing Director at Ankura, and she is also a faculty member for the Health Care Compliance Association (HCCA). She started her career as a nurse and made the transition to compliance when she saw an opportunity to support and strengthen health care compliance.
If you’d like to hear more from Sarah, you can sign up for her upcoming HCCA webinar!
If you’ve been in the Healthicity community for a while, you might know that we conduct annual surveys every year for compliance and auditing professionals.
We know there’s no shortage of surveys in this world, but here’s why you should take ours – it's designed to gather vital information to benefit you and your organization, and because you’ll get a handy dandy report after we analyze the responses.
Get a look behind the survey scenes on our latest episode of Compliance Conversations, “The Marketing Team: What We Do in the Shadows,” where Healthicity’s Sr. Director of Marketing, Kyle Brogdon, steps from the editing booth into the recording booth to talk about what makes our survey different.
Take the compliance survey here: https://www.healthicity.com/en/resources/2023-annual-compliance-survey
Take the auditing survey here: https://www.healthicity.com/resources/2023-annual-auditing-survey
Investigations are a natural part of any compliance professional’s career – but that doesn’t make them any less intimidating.
We invited Eric Allen, a highly regarded compliance professional with experience spanning academia, hospital institutions, and more, to join us for an episode of Compliance Conversations!
In this episode, “Compliance Investigations 101,” Eric and I discuss the nuances of investigations, including:
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How to set investigations up for success from the get-go
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Navigating the emotional side of interviews and ongoing investigations
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Why mannerisms and body language are crucial in the age of remote interviews
“Think like a lawyer, talk like a human, and start with your audience."
Those three key principles drive Kirsten Liston’s innovative approach to compliance training, and it’s why we invited her to join us on our latest episode of Compliance Conversations!
Kirsten is the CEO of Rethink Compliance and a two-time author. We’re grateful she shared her time and expertise with us on our latest episode!
Technology is integrated into everything we do – including healthcare. But what are the regulatory implications of new software platforms in the medical industry?
We invited Ali Aga, the Founder and CEO of Flowbit®, to share his insights on our latest episode of Compliance Conversations. Ali is a digital innovator, software developer, and healthcare insider with a unique perspective on the regulatory processes behind healthcare software.
“The scene can’t begin until we start paying attention to each other.” -- David Pasquesi
If you think improv comedy and healthcare compliance and coding require opposite skillsets, you might be surprised by our latest podcast episode...
We invited Dr. Mike Smith, a multi-talented physician and improv aficionado, to join us for our latest episode of Compliance Conversations. Dr. Smith is currently an Attending Physician at the University of Nebraska Medical Center and a Consultant for Healthcare Improv.
Doctor, firefighter, marine biologist, compliance officer? We're not sure the last one makes many kids’ list of their dream careers, but here we all are! We love learning about how people got into compliance and how they continue advancing their own knowledge in the field. That’s why we invited Steve Naughton to join us for this episode of Compliance Conversations.
It’s no secret that private equity is playing an accelerating role in the healthcare industry – but what does that mean for compliance professionals? This Compliance Conversations features a conversation about why private equity can work with – not against – healthcare organizations.
The compliance and coding worlds are filled with acronyms – and we’ve got another one for you: CDI. That stands for Clinical Documentation Improvement, and it’s a crucial piece of the healthcare puzzle. We invited Joanne Spethman, a Coding, CDI, and HIM Consultant, to share insights from her 30+ year career in inpatient and professional coding, CDI and HCC auditing on our latest episode of Compliance Conversations.
Is your compliance effectiveness review process due for a tune-up? Our latest episode of Compliance Conversations features Larry Plutko and CJ Wolf discussing strategies for looking under the hood of your program and preparing your organization for what’s ahead in corporate compliance.
Does the thought of more board oversight of your compliance program inspire consternation or curiosity? Tune in to our latest episode of Compliance Conversations to find out why board-level collaboration can benefit not just your program, but your entire organization.
HCCA’s 27th Annual Compliance Institute is around the corner – want a sneak peek? Tune in to our latest episode of Compliance Conversations featuring Adam Turteltaub, the Chief Engagement & Strategy Officer for the Society of Corporate Compliance and Ethics and the Health Care Compliance Association!
What do you get when two attorneys and a compliance expert sit down for a chat? This episode of Compliance Conversations! Tune in to our conversation with Sean McKenna, a partner in Spencer Fane LLP’s Dallas office, and Keith Dugger, a shareholder in Hall Render’s Dallas office. Sean and Keith bring unique perspectives to our discussion filled with insights and tips for healthcare compliance professionals.
Career paths are rarely linear – they're filled with twists, turns, and a little luck. That’s why we’re excited to have Sandy Giangreco Brown, the Director of Coding and Revenue Integrity at CliftonLarsonAllen LLP, on our podcast to discuss her career trajectory with our host, CJ Wolf, MD. Sandy's resume includes job titles like Certified Nursing Assistant, EMT firefighter, Coding Education Supervisor, and more. She shares her unique career path and the creative (and cost-effective) ways she finds time to continue advancing her education.
What do nurses and clinicians really think of compliance teams? We weren’t afraid to ask! Check out our latest episode of Compliance Conversations for an insightful discussion on clinical and compliance collaboration.
We're switching things up in our latest episode of Compliance Conversations! This time I’m in the hot seat, with Nick Merkin interviewing me. Nick is a healthcare attorney and the CEO of Compliagent, a nationwide consulting firm specializing in compliance infrastructure. Check out this episode, “Turning the Tables: Our Guest Interviews Our Host CJ Wolf,” as we discuss: The winding road to careers in compliance Real-life scenarios and questions that blend medical knowledge with compliance expertise How to build strong relationships with doctors and medical officers Why compliance officers need to think holistically about big picture issues and granular challenges
What do the housing, automotive, technology, and healthcare industries all have in common? Compliance programs and professionals! Borrowing best practices from other businesses is a vital strategy for evolving healthcare compliance programs. That’s why we invited Asha Muldro of Guidepost Solutions to chat with us for our latest episode of Compliance Conversations. Tune in today!
Looking for strategies to enhance the partnership between physicians and compliance teams? Listen to this conversation between CJ Wolf and Jay McVean as they discuss effective ways to foster deeper teamwork between clinical teams and compliance professionals.
Many people say the only constant in healthcare is change – but how do you develop as a leader and advance your skillset in the midst of continual evolution?
We invited George Vukotich, Ph.D., to share his thoughts for our latest episode of Compliance Conversations. Listen in to CJ and George’s insightful discussion!
An inpatient stay for a clinical study can complicate the billing process – here are some real-world tips and strategies to help you ensure clear communication, optimize electronic health records, and much more.
Looking to make a great hire? Hiring in a specialized field is challenging – hear insights straight from the experts on finding the right team member. Tune in to a conversation with CJ Wolf and Mary Veazie on hiring the right person with the right skillset to manage complex research-related coverage analysis and billing.
Mary Veazie, a CPA specializing in clinical research finance, sat down with CJ Wolf, MD, for an insightful conversation about the stumbling blocks many organizations don’t anticipate with clinical research billing.
Kristen Poat, RHIT, sits down with our host, CJ Wolf, MD, in this episode of “Compliance Conversations.” Kristen manages auditing and compliance for a nephrology clinic in Illinois and was gracious enough to join our podcast guest family.
In this episode of Compliance Conversations with host CJ Wolf MD, Wolf sat down with Nick Merkin JD to talk about value, proof, and living in a post-COVID-19 compliance world.
Don’t risk failing an audit. Guest and expert medical auditor, La Tanya McNair will show you how to pass a Radiation Oncology audit with flying colors.
For an honest and informative dialogue on what it's really like to spend your days in compliance. This episode is for folks looking for a new career and seasoned professionals alike. In this episode, we cover:
- A snapshot of a compliance officer’s unpredictable day
- Career regrets and wisdom gained
- Tips to help you understand if compliance is right for you
We chat about everything from the various routes one might take to land the position, the do’s and don’ts of packing for a work trip (and embarrassing packing fails), the complexities of things like acquisitions, and how to take a proactive approach to auditing.
In this episode, you’ll learn how AI is used to reduce compliance risks and inform the FDA about adverse events.
Listen in for a lively and educational chat on what to do once you find yourself in compliance. This episode is for folks just beginning their journey and folks who have been at it for a while.
During our discussion, we chatted about our journeys to compliance, how folks can begin or transition to a career in compliance, and we outline precisely what a compliance expert does every day. And? It’s not nearly as dull as our kids think.
This conversation covered a lot of ground. They chatted about the requirements around consent and group therapy, rules around disclosure to help a patient, HIPAA standard practices with teens, and the often hidden realities of the Opioid epidemic. Listen to the episode now or on your commute.
When it comes to compliance for mental health services, you’ve got to pay extra attention to your billing and coding. Learn a brief history of Psychotherapy and compliance risks associated with therapy services.
As compliance professionals in a healthcare setting, we can never know too much about physical and mental health. Plus as human beings, there’s nothing more important than the health and wellness of our friends, family, and coworkers.
Learn from our compliance expert, CJ Wolf, and Psychiatrist, Dave Paulson, about how to optimize mental health outcomes in this episode.
Our compliance expert, CJ Wold M.D., spoke with two Reiki practitioners, Justin Larsen and Julie Crane R.N., about the history, science, and practical uses of Reiki.
Recently, I sat down with Brian Burton, our new Chief Compliance and Privacy Officer, for an all-new episode of the Compliance Conversations podcast. Given the time of year, and his area of expertise, we focused our discussion on a topic on many people’s minds: Privacy and Security Risk Assessments. I know these assessments can be daunting to approach or, as Brian put it, “I think a lot of organizations struggle with what does that mean, and how can I accomplish this activity with the minimum amount of effort, but still know that it’s accurate, and that your organization is protected from cyber security threats.”
Having worked in the healthcare industry for more than 15 years, Brian become an expert in all things project management and technology. He's devoted most of his career to developing, implementing, and providing oversight for Compliance and Privacy program initiatives, working with more than one hundred healthcare facilities. Considering Brian’s vast experience, we discussed the symbiosis between project management and risk assessments, and how organizations should “initiate a project, then execute, monitor, control, and close,” in order to successfully identify and mitigate their risks. To hear more of Brian’s advice and best practices, listen to our latest episode of Compliance Conversations, “A Pro’s Guide to Conducting Your Annual Privacy and Security Risk Assessment,” where we cover topics including:
• How to Protect Your Organization from Cyber Security Threats • What Tools You Should Use to Conduct Your Annual Security Risk Assessment • Which Cyber Security Framework Your Organization Should Deploy
Around Healthicity, we love nothing more than to provide answers to some of your most pressing questions. And boy, do we get a lot of them.
Because of this, we asked you to send us the questions that most perplex you while on the job. We got a ton of great questions (thank you), some of which even had us scratching our heads, too. So, I took a bunch of your questions to our resident auditing experts, Stephani Scott and Lori Cox, and sat down for a little chat. What we Then, we took a handful of those questions and and sat down to discuss them during this episode of Compliance Conversations, titled “Ask an Auditor Anything.”
Here’s a sneak peak at some of the questions we discussed, and answered:
Can Documentation of a Previous Allergic Reaction be Used Under ROS, or Only PMH? If the physician states "same/unchanged from last visit" to History will they receive credit for reviewing the last visit information? If the Documentation States “NO PFSH," Is This Applicable On a New PT or Consult Visit?
It’s that time of year again, when everyone is either breathing a sigh of relief because they’ve just completed their annual HIPAA risk assessment, or they’re cramming to get it done before year’s end.
In the spirit of HIPAA season, we decided to turn the tables on CJ. So in this latest episode of Compliance Conversations, we had our very own SVP, Jeremy Schow, interview our local HIPAA expert, CJ Wolf, MD, to discuss all things HIPAA. And he had a lot to say.
“The number one reason we do a risk assessment is it's a requirement. Number two though, it's good practice, right? We're in the business of helping patients, and we want to keep that information private and confidential. So, it's a good business practice,” CJ observed, before going on to answer all sorts of questions around HIPAA, including:
Should I Conduct an Assessment Every Year? How Do I Conduct an Effective HIPAA Risk Assessment? What are Some Common HIPAA Mistakes I Should Avoid?
In part two of my conversation with Christopher Chandler, a Technical Manager of Professional Documentation and Coding, at Intermountain Healthcare, we dove into the NCCI policy manual.
It’s been a hot topic, as of late. Mostly because, as Chandler put it with a grin, “people hate the NCCI Policy Manual. They see it as a big book of rules that stops them from getting paid for the stuff they are doing.” But as you’ll hear, the manual is so much more. For instance, sometimes you can bill two codes together and, other times, you can’t. And when you need to know the answer, you consult the NCCI manual. Because many commercial payers have adopted these edits as well, it’s become an indispensable resource for any compliance billing department that’s using today’s best practices.
But the manual can be daunting, and oftentimes difficult to decipher. Which is why during this episode of Compliance Conversations, "A Deep Dive Into the NCCI Policy Manual," Chandler and I jump right into the ins-and-outs of the manual, and discuss the three main topics of the manual, including:
Knowing Exactly What’s Included in a Surgical Package Understanding Multiple Procedure Overlaps Billing Protocols for Inherent Services
Recently, I sat down with Christopher Chandler, a Technical Manager of Professional Documentation and Coding, and we had a lot to cover during our podcast. So much so, that we actually recorded two new podcast episodes. In this first episode, Understanding the Nuance of NPP Coding, we dove into the world of non-physician practitioner (NPP) coding.
NPPs, as Medicare calls them, are made up of a number of different provider types. They include nurse practitioners, physician assistants, certified nurse anesthetists, clinical nurse specialists, amongst others. The world of NPPs is ever-changing as hospitals are, in Chandler’s words, “developing new ways of providing care to patients… and help alleviate the burden that physicians are feeling, with the amount of patient load that they have.”
If your hospital or clinic has a number of NPPs, it could be a signal to payers to keep an eye on your claim submissions. Which makes it all the more critical that your billing department has the tools to correctly code your NPPs. Listen to our newest episode of Compliance Conversations:, where Chandler and I discussed everything NPP, including:
Identifying the Difference Between Shared Services and Incident Two Avoiding Double Billing the Patient and the Payer Following the Intense Guidelines of Shared Services
For this installment of Compliance Conversations, we interviewed Jake Geertsen, a Technical Manager in the documentation and coding, who specializes in telehealth. It’s a fast-growing segment of healthcare, which has spawned a lot of questions around the field. Not least of which is: What exactly is telehealth? According to Geertsen, telehealth is “a collection of means or methods for enhancing healthcare, public health, and health education delivery and support, using telecommunication technologies.”
Just ten years ago, few of us were carrying around the computing power we commonly find in our pockets and purses today. Nor did we know the benefits this technology could have to, as Geertsen puts it, “to the patient, the healthcare organization looking to cut costs, to insurance companies also looking to cut costs. In many scenarios, this is an area of innovation and improvement.”
Understand the History and Evolution of Telehealth Implement Proper Coding and Billing Compliance Practices Stay Current with Ever-changing Medicare Regulations and Payer Policie
I sat down with Tyler Griffeth, a Technical Manager of Professional Documentation and Coding at Intermountain Healthcare, to discuss a couple of his favorite Medicare Internet Only Manuals (IOMs), specifically the National Correct Coding Initiative (NCCI) Policy Manual and the Claims Processing Manual.
The NCCI Manual, about which he jokingly said, “I’ve got mine laminated, I can read it in the tub with a little bit of bubbly” is just one of his favorites. Meanwhile, the Claims Processing Manual, “Is a really great resource if you’re dealing with things like denials, but also if you’re involved in a RAC audit.”
Tune in to my most recent episode of Compliance Conversations, How to Earn a Huge ROI from Medicare’s IOMs, and learn how to:
Use the NCCI Policy Manual to Clarify Procedure Codes to Physicians Leverage the Claims Processing Manual to Avoid Denials Apply Situational Modifiers in Conjunction with Codes
Whether you’re dealing with medical devices or new drugs–regardless if it’s a product or a service, and whether that product or service ever even leaves the United States, export controls affect every organization in one way or another. That’s why I was so excited to sit down with Export Controls and Compliance expert, Wendy Epley, the president of Epley Consulting, for this episode of Compliance Conversations.
As a compliance professional in healthcare, you might hear the word “export” and think ‘I don’t ship anything out of the country, so export controls don’t apply to me.’ But surprisingly it does! Epley explained, “[export controls] is referring to a very complicated network of federal agencies and regulations that are interconnected to regulate or control how things are to be protected in order that they are not used in a way that would cause harm...regardless of where those persons are located, including if they are here within the United States.” Epley also went into detail about the foreign corrupt practices act, an important act for many of you in various healthcare compliance roles. “Just a few years ago, Teva Pharmaceutical Industries paid nearly five hundred and twenty million...for its role in violations with the FCPA.” Said Epley.
Find out how export controls apply to all of you healthcare compliance professionals out there. Tune in to my latest episode of Compliance Conversations, Export Controls: The Most Important Compliance Element You Probably Haven’t Heard Of, to learn why:
One Doctor Went to Prison For His Research Some Medical Equipment and New Drugs Pose A Risk You Need to Institute Export Protocols and Training in a Research Uni Setting Teva Pharmaceutical Industries Paid Nearly $520 Million in Violations
Listen to this most recent episode of Compliance Conversations, How to Build a Mutually Beneficial Relationship with Your Compliance Committee, with special guest, Judith Maber-Fox, to learn how to:
Build a Mutually Beneficial Relationship with your Compliance Committee Engage Sr. Leadership to Actively Support the Committee Create Opportunities That Give You a Seat at the Table
For this Compliance Conversations episode, I’ve got a special treat for you: Dr. Ira Specter. He spent many years as a practicing OBGYN physician and is also a certified coder and medical auditor. After practicing medicine for a few decades he went on to run a large medical management company, where they did billing collection, coding, compliance, and ICC10 courses for sixty-five physicians. Because of his unique perspective, we tackled bridging the gap between coding and auditing and physician documentation.
I asked Dr. Specter, “what’s the biggest area for improvement for physician documentation?” After a brief pause, he said, “Let me start by saying, by and large, most physicians are under coding.” It seems, according to Specter, that physicians are “cutting off their own legs,” and also “cherry picking” codes. What does that mean?
Listen to this episode to find out what Dr. Specter views as the biggest mistakes physicians are currently making and learn: What Coders/Auditors Should Look Out For in Physicians Documentation Why Physicians Should Never Cherry Pick Codes The Pitfalls of Copying and Cloning.
There are a lot of barriers in compliance. In this installment of Compliance Conversations, I chat with Eric Dominguez, the chief compliance officer at Emerus, a management company that specializes in healthcare systems. “Part of the services we provide to these joint ventures is a compliance program.”
Dominguez explains some of the common hurdles of aligning with partners. “It’s a challenge and at the same time, it’s really a great opportunity for growth.” So how do Dominguez and his group manage compliance on such a big scale? And how can we get better at it ourselves?
Listen to this episode to learn how to: Tackle Compliance Like a Large Hospital Group Manage the Unique Challenges of Micro-Hospitals Navigate Policies and Procedures for Hospital Licensing
Whether it’s an EMR or a compliance software solution, you want technology to do the work for you, not make you do extra work. Knowing where tech disappoints has helped Healthicity’s president, and my guest on my most recent episode of Compliance Conversations, Barry Johnson, D.D.S., to create software solutions that healthcare organizations really want. And, according to the US Government, solutions that healthcare organizations really need.
“Recently at HCCA, we heard government officials telling the people that were at the meeting that compliance has got to move into the digital age and start doing things with software rather than spreadsheets.”
It doesn’t matter if you’re an early adopter or tech-adverse, this informative and fun episode will bring you up to speed on all things healthcare technology from the largest challenges to the newest tools and gadgets that save lives or make your workday a whole lot easier. If tech has got you down: Johnson just might have a solution for you.
Tune into this episode of Compliance Conversations, Taking the Trauma out of Technology with Barry Johnson, D.D.S., to learn:
- Tech Trends (and Failures) in Healthcare
- Upcoming Advances in Healthcare to Watch For
- How to Make Tech Work For You
- What the US Government Has to Say About Technology in Compliance
I’ve been getting a lot of requests to do a show about coding and billing and I couldn’t think of a better guest than my friend and former colleague, Jay McVean, an expert in billing and coding compliance with the University of Texas Health Science Center in Houston.
Starting out, I had to ask: What’s the biggest coding and billing compliance issues in medical school, with faculty, and academic medical centers? This is where McVean’s expertise really shines and it’s an area that doesn’t get talked about nearly enough.
McVean explained, “One of the biggest challenges we face in this ever-growing clinical world is that our teaching physicians really must understand who they’re working with...When various people are touching the notes, documenting portions of the visit, at the end of the day physicians are really confused about if they have a TPA situation, or if this is a shared split visit if I’m in the hospital, and how much of the note to document versus an NP or a PA.”
From there, we talked about physician pressures and productivity and how it plays into billing and coding compliance.
Listen in to our latest episode, What You Need to Know About Billing Compliance in Academic Medical Centers, with expert Jay McVean. In this episode we chat about:
Teaching Physician Traps Documentation Issues The Complexity of the Clinical Environment Education and Training Potential EMR Concerns
In this episode of Compliance Conversations, I chatted with Charla Prillaman, the Regional Vice President of Audit Services and 30-year compliance veteran, about the crucial differences between Medical Necessity and Medical Decision Making (MDM).
Prillaman pointed out that both terms are incorrectly used interchangeably, though they have distinctly different meanings. “Medical Necessity is the foundation for payment for all medical services. We find the original or the beginning statement about medical necessity being the overarching criteria all the way back into the social security act…Now the complexity of medical decision making is that it’s intended to somehow or another quantify a provider’s cognitive work in a specific encounter with the patient.” Said Prillaman.
In this highly requested conversation, Prillaman breaks down how to properly document medical necessity and medical decision making and how to quantify something as difficult as “cognitive effort” for MDM.
Tune into this episode of Compliance Conversations, “Recognizing the Differences Between Medical Necessity and Medical Decision Making” with me, CJ Wolf, and Charla Prillaman for the full scoop on Medical Necessity and MDM, including: The History of Both Medical Necessity and MDM Key Differences of Medical Necessity and MDM Ways to Properly Quantify and Document MDM
I recently spoke with Brooklyn Trumpy on what it’s like to be new to compliance. Trumpy graduated in 2009 with a degree in Operations Management and ended up in compliance five years ago when she took a role at Community Health Systems and worked her way into a compliance role.
Trumpy found that being new to compliance was a challenge. She explained how it can be intimidating to learn all of the new rules and regulations and how to piece together the puzzle that is compliance. She initially struggled to make connections and find her tribe within Compliance and it took some time to learn how to stay organized. Trumpy had some expert advice for new compliance professionals that will help them have an easier transition into the world of compliance.
Listen to this episode of Compliance Conversations, "Tips for When You’re the New Kid on the Compliance Block," to learn:
- Which Personality Types are Drawn to Compliance in the First Place
- How to Set Expectations as a New Compliance Professional
- Why It's Okay not to Know Everything Right Out of the Gate
Back in February, CMS announced changes that seem to allow medical students a lot more freedom to document a patient’s medical record. Which could sound like a dream to physicians who might be thinking that the students will help ease the heavy burden of bureaucracy, but auditors are a little worried. Auditors are going, “Wait, hold on, we’ve got to really look at this before we jump the gun.” I spoke with expert compliance auditor, Charla Prillaman, who’s lived and breathed auditing for decades. The hard part, it turns out, isn’t understanding the new rule; the hard part is re-educating doctors.
Tune into our latest episode of Compliance Conversations, The Teaching Physician Rule: A Blessing or a Curse, to learn the: New Specifics of Student Documentation for E/M Services and HPI, Dangers of Improper Documentation Teaching Physician’s Responsibility to Verify and Attest to Student Documentation.
We kicked off this episode of Compliance Conversations with a guest host, our very own compliance expert, Marcie Swenson, and her special guest, Emily Haley, who has worked as a Chief Privacy Officer and Compliance Director at Intermountain healthcare and is currently working in Care Transformation. In the first half of the show, Haley gave us a full fledged rundown on gap analysis, risk analysis and risk management plans. In the second half of the show, we dove unapologetically into the OCR’s phase 2 desk audits and what we can all learn from them.
“Everybody is familiar with OCR’s phase 2 desk audits, where they audited 63 covered entities, and I think 40 something business associates. They used a scale 1 through 5, 1 being the very best risk analysis or risk management plan, and 5 being the very worst...more than half both business associates and the covered entities had scored a 4 and a 5. That’s shocking. That means most of us are not doing the right things.”
Tune into our latest episode of Compliance Conversations, Smart Strategies to Holistically Tackle Your Organization’s Risks, with guest host Marcie Swenson. In this podcast we’ll cover how: Every Department Must Work Together to Reduce Risks Risk Analysis is Dependent on Gap Analysis and Management Plans To Mitigate the Lack of Updated Risk Analysis Information From the OCR
Weed. Pot. Ganja. Marijuana goes by many names and has been a part of the global counterculture scene for decades. But now it’s quickly becoming a part of healthcare, as medical marijuana continues to be legalized across the nation.
In my latest episode of Compliance Conversations, I talked with Judy Cassel, JD, MBA, an expert legal advisor on all things medical marijuana. I asked her how medical marijuana will impact physicians, compliance officers, and hospitals.
There are dangers in prescribing it even if it’s legal. While each state is able to decide on whether or not to legalize medical marijuana, it’s still illegal at a federal level–this is where things get complicated. Cassel explained the dangers of physicians, or a practice, prescribing medical marijuana and how you and your organization can recommend it while still remaining compliant.
Listen to this episode to learn how to: Reduce Opioid Deaths and Addiction Avoid Violating the Federal Law with Medical Marijuana Recommend Medical Marijuana and Stay Compliant
Let’s say you’re a Medicare Advantage organization and one day you receive a notification from CMS that you’ve been selected for program audit. What should you do? Recently, I sat down with Scott Robinson, director of compliance at Davis Vision, and former medicare contractor who used to accompany the folks at CMS to conduct effectiveness audits. Robinson gave me the details on what to do and what not to do when and if you receive the news.
“The first thing is to not panic,” Robinson said, “All you really need to do is explain yourself. You just need to articulate your usual business practices in a way that CMS will understand and agree with.” But doing this requires you to be ready for it.
Tune into this episode to learn how to:
Prepare for a CMS Audit Before it Happens Stay Calm During a CMS Audit Effectively Explain Yourself to CMS
Michael Warner, an Osteopathic physician, board certified in family medicine, turned patients’ rights advocate has a lot say about a patient’s rights to access. Warner is passionate about empowering patients to co-author their medical record.
Through his research, Warner has found that giving patients the opportunity to take control of their information greatly increases accuracy, efficiency, and patient satisfaction. In a post-study follow-up survey, most patients reported that they “appreciated being given the chance to co-author” their medical records. For any healthcare organization, this is music.
Listen to this episode, Patients Empowered: Improving Accuracy Through Co-Authorship, to learn how to: Collect patient data before their visit to maximize efficiency. Share history, exam, and Medical Decision Making with patients for accuracy. How HIPAA’s privacy rule allows patients to amend their records.
In this episode of Compliance Conversations, I sat down with Stephani Scott, VP of Audit Services for Healthicity, to chat about her twenty years of experience and pick her brain on important auditing issues. As all of you know, auditing is a crucial component of an effective compliance program.
Stephani explains how she approaches post-audit education with difficult providers, “I always tell them to be prepared first and foremost.” Then she adds, “make sure you’ve reviewed the audit and you know where they did well. Sometimes the effectiveness depends on your approach.” Scott provides rules for post-audit education, like how to deal with a physician who inherently distrusts auditors or bad apples who code incorrectly on purpose.
Tune in to learn the auditing ropes with expert Stephani Scott and learn how to:
• Build Trust with Providers • Effectively Change Behaviors • Approach Post Audit Educations Like a Pro • Deal with Bad Apples
In this episode of Compliance Conversations: I asked compliance and healthcare law expert Marcie Swenson, “What do you think the hot topics will be for 2018.” And she gave us two answers: “Benchmarking and data breaches and cyber security.”
Organizations will be utilizing OIG guidance to create their own benchmarks and rate their own compliance program. I also asked Marci what she hoped to see differently in 2018 and she passionately responded, “more risk assessments. To be proactive in compliance you have to perform a risk assessment.”
Tune in to this episode of Compliance Conversations: Benchmarking Your Way to Compliance, for hot topic predictions and tips for 2018 including how to: Use the OIG Guide to Benchmark Your Program Prepare for Cyber Threats and Data Breaches Utilize Risk Assessments
Find out how Culture can Solve Compliance Issues “Compliance professionals were people before they were in compliance,” said Rudy Green in our most recent episode of Compliance Conversations. Green told me about his long and interesting path to compliance from an undergraduate degree in organizational behavior, to being drafted into the NFL, then to law school. He did all of this before taking a position as the compliance officer at the University of Texas in Austin. He added, “life experience is what makes a great compliance officer,” he said.
Compliance professionals are critical to a company’s success (especially in healthcare). So, it only makes sense that company culture counts. Could company culture be the answer to solving compliance issues? The data suggests yes but — big surprise — it’s not always that easy.
Tune in to this episode of Compliance Conversations to learn how to: Effectively Deal with Complex Issues as They Arise Tackle Risk Assessment the Right Way Use Patience as a Compliance Tool
In this episode, compliance expert CJ Wolf sits down with product development expert Jeff Young to discuss tools that can simplify compliance and make you so much more effective as a compliance officer.
Young explains how tools are changing healthcare organizations, “with the tools that are out there today you can gather data consistently in one location, identify risks based on data trends and decide what to do. Maybe you need to put a new policy in place, or you need to introduce training to your organization. The idea is that it gives you the power to get away from some of this manual work by utilizing technology to help automate and optimize what you’re doing as a compliance officer.”
Regarding random audits, Young asks, “if you’re looking at just ten random records, how do you know those are representative of what the physicians doing, and how does it really help you to understand where you need to focus for that physician?”
Listen to this episode to learn how to utilize technology to decrease manual labor, improve training, easily identify risks, and much, much more!
For this episode of Compliance Conversations, I sat down with Chad Peterson, a senior consultant at a large hospital, in their professional coding and reimbursement group. He educates physicians, mid-level providers/ advanced practice providers and even ancillary staff about E/M coding.
Peterson explained some of the most common E/M coding mistakes. For example, in 2013 they came out with the status of 3 chronic conditions in addition to the already set guidelines. There’s often confusion around when to use regular HPI elements or when to use the status of 3 chronic conditions. “This is something really useful for your physicians,” Peterson added.
Tune in to this episode of Compliance Conversations, “E/M Coding Tips and Risks,” to learn:
How to navigate the gray areas of medical necessity When to use the chronic conditions status Why the risks of EMR upcoding and auto-populating are so grave
I recently talked with Christopher Chandler, a senior consultant at a large medical group in the professional coding and reimbursements department. Christopher explained a whole slew of common misunderstandings of surgical coding. We soon realized that at the end of the day, many people just don’t understand the coding system.
There’s so much confusion about how the coding system works, how ICD coding works with CPT coding, and even more confusion when multiple procedures overlap. It’s cause for a lot of mistakes–and a ton of stress. But, when you really understand the system, you can navigate surgical coding in a way that will accurately reflect what the physician’s doing, regardless of complexity.
Rid your life of added stress by becoming a surgical coding expert by listening to our newest podcast, Common Misunderstandings of Surgical Coding, where you’ll learn how to: Ensure reimbursement through accurate coding Code separate procedures Avoid over-coding, coding post-op work, and more!
In this episode of Compliance Conversations, I sat down with Senior Consultant, Brenden O’Neil, who works in Intermountain’s professional coding and reimbursement department. O’Neil and I had a fascinating discussion on CPT codes and the complicated gray area of coding a laminectomy.
The code has changed, physicians are in limbo, and revenue is being lost. And, there are a number of compliance issues that might arise.
If you’re a compliance officer in an organization with neurosurgeons, you should perform an audit and run some data analytics for the code 22633 or that range of codes that represent fusions anytime a 63047 or laminectomy is reported. Otherwise, there could be trouble on the horizon.
If you’re in healthcare, you won’t want to miss this.
Listen to our newest podcast, Complex Coding, Complicated Compliance, to brush up on: Laminectomy and Potential Compliance Issues Specific Updates to Code 63047 Payers, Medicaid, and more!
In this episode, Sean McKenna, Shareholder at Greenberg Traurig, and I discussed the ins-and-outs DOJ and OIG investigations, and how the federal government is determining who–and how–they prosecute.
While we all know the importance of having a robust, effective compliance plan, Sean also stresses the importance of having an independent and empowered compliance committee. One which refuses to bury it’s head in the sand when compliance issues surface. In his experience, organizations that operate routine, transparent compliance programs will be equipped with the best line of defense.
Tune in to our Compliance Conversations podcast, Proactive Compliance is Your Best Defense, to listen to Sean and CJ dive into:
Why incident reporting and documentation needs to be taken seriously What the OIG constitutes as an illegal kickback How to protect your organization from false claims investigations
In this episode, compliance expert CJ Wolf M.D., and Auditor Superstar Charla Prillaman, spend twenty-five exciting minutes (perfect for your short commute) chatting about how to overcome communication hurdles between auditing and compliance departments. Tune in to their conversation about potential ways compliance professionals can make auditors’ jobs easier, how both departments can leverage each other's expertise, and much, much more. And, be sure to subscribe to the Compliance Conversations Podcast for your regular dose of compliance education.
Nick Merkin, CEO of Compliagent, chatted with me from his home in sunny California about compliance from an attorney’s perspective. Merkin is a lawyer by training and spent the first ten years of his career in healthcare law, primarily in litigation defense.
Merkin explained why it’s so important for organizations to see compliance from an attorney’s perspective. And how his unique point of view provides an additional layer of protection from compliance violations. In this compelling interview, Merkin explains how organizing compliance functions is, “worth it’s weight in gold.”
Tune in to this podcast, An Attorney Talks Compliance, to find out how to: Focus Compliance on Processes and Infrastructure Organize Compliance Functions to Protect Against Litigation Mitigate Legal Liabilities That Might Arise in Healthcare
Back in the 1980’s, Larry Plutko started his career in Healthcare. By the 90’s he found himself fascinated by compliance. And in 2008, he accepted a position of compliance officer in Austin, Texas, where he became an important career mentor to our very own compliance expert, CJ Wolf. Now, Plutko is a compliance consultant who currently sees clients across the country.
In this episode of Compliance Conversations, Wolf interviews Plutko on the compliance career path and how to to become a compliance officer. “I believe in diversity and organizations benefit from having compliance Officers from a number of different backgrounds. Compliance Officers come from all sorts of backgrounds from legal to clinical, ethics and auditing,” said Plutko.
Plutko and Wolf discuss the ways in which compliance is growing rapidly and why it was named one of the hottest career tracks in an article in the Wall Street Journal in 2014. Then, they dive into what it means to be a good compliance officer and how to develop the unique skills necessary to excel.
Tune in to our podcast, The Unique Qualifications Of A Skilled Compliance Officer, to learn how to: Prepare for the Future Compliance Become a Compliance Officer Excel in a Compliance Career
In this episode of our podcast, Compliance Conversations, Wolf and Dunnick tackle documentation, what to do, what not to do, and what you definitely didn’t learn in medical school. Wolf is a compliance expert who went to medical school but found a passion for the compliance side of things. Dunnick is not only a physician with years of practice experience, he’s also a full-time consultant who educates physicians on coding and documentation best practices. Documentation dream team, if we’ve ever seen one.
In this detailed, thought-provoking interview, Dunnick and Wolf dive deep into compliance, coding, and audit risks. Particularly, how to use EHRs effectively and efficiently. Including, why you should be weary of copy and pasting in EHRs, and documentation best practices that every physician should know.
Listen to our Podcast, A Physician Explains Documentation Best Practices, to learn: How to Document Correctly Ways to Reduce Audit Risk Exposure Rules You Didn’t Learn in Medical School
In our newest episode of Compliance Conversations, CJ Wolf sits down with Security and Privacy expert, Steve Spearman, for an enthusiastic chat about how healthcare practices can protect themselves from imminent threats.
In just a few seconds, Wolf and Spearman launch into a dynamic back and forth exchange about why privacy and security matters, how OCR audits have been a gift that keeps on giving and why more organizations need to have a list of their Business Associates on hand. Plus, a little banter about why some companies are forced to negotiate with terrorists.
Listen to our newest podcast, Episode 2 of Compliance Conversations, So Now You Take Security And Privacy Seriously, to learn: Why OCR Audits Have Been A Gift To Security Experts How To Protect Your Organization When Working With Business Associates The Real Reason Your Organization Needs to Backup Your Data
In this episode, compliance expert CJ Wolf M.D., and Auditor Mastermind, Lamon Willis, spend twenty-five captivating minutes (perfect length for your lunch break) chatting about the many ways that auditing best practices support your organization’s compliance. They’ll be bantering about common CCI Audit Errors, Modifier 59 Best Practices and much, much more. Tune in for your weekly dose of compliance and audit education.