The Compliance Guy: Recent Episodes

Sean M. Weiss

Sean is the host of “The Compliance Guy” a live production dedicated to the intersection of regulatory compliance and the business of medicine. The show provides timely, accurate, and easy to digest information to healthcare professionals.

The show features interviews of industry leaders, government officials, and others helping to shape the healthcare landscape.

Sean M. Weiss (AKA – The Compliance Guy) has been an industry respected name for more than 25-years. A physician and health system advocate, Sean engages with clients to ensure a “level-playing-field” and due process when allegations and/or accusations of impropriety are leveled by a payor or government investigation agency.

When Sean is not engaging in administrative, civil and criminal matters on behalf of more than 30 nationally recognized law firms and clients, he is serving as a third-party compliance officer for a dozen organization across the country ranging in size and specialty to ensure a “Culture of Compliance”!

Sean is a proud member in good-standing with the National Society of Certified Healthcare Business Consultants (NSCHBC), American Health Lawyers Association (AHLA), National Alliance of Medical Auditing Specialists (NAMAS), and the American Academy of Professional Coders (AAPC). Sean holds 10 (CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, CMC, CMIS, CMOM) national certifications from the Health Care Compliance Association, The National Alliance of Medical Auditing Specialists, Medical Group Management Association (MGMA), The American Academy of Professional Coders and Practice Management Institute.

In this episode of The Compliance Guy, Terry Fletcher and Sean dive into the importance of proactive compliance and staying updated with federal and state healthcare regulations. This discussion is vital for healthcare providers who want to safeguard their practice from compliance risks and ensure they’re informed about the latest industry guidance.

Key topics covered:

The significance of subscribing to authoritative listservs from agencies like OIG, CMS, OCR, and DOJ
How healthcare providers can leverage alerts and newsletters to stay compliant
The importance of understanding the definitions of fraud, waste, and abuse
Practical tips for managing vast amounts of regulatory information in small practices
Common pitfalls, like billing consult codes post-2010 or misinterpreting LCDs
The evolution of healthcare information dissemination, from paper newsletters to digital alerts
The role of exclusion lists and maintaining awareness of provider sanctions
How to tailor subscription strategies to avoid inbox overload but still stay informed
The value of free resources such as CMS alerts, Becker's Health, and decision health publications
The impact of regulatory updates on claims processing and appeal strategies

Summary

Dr. Ron Elfenbein shares his extraordinary journey through the COVID pandemic, his pioneering efforts with monoclonal antibodies, and the unjust legal challenges he faced after speaking out.

This episode highlights the importance of scientific integrity, whistleblower protection, and the fight against political misuse of medical science.

Key Topics

Dr. Elfenbein's background and COVID response
Development and distribution of monoclonal antibodies
Government policies and their impact on COVID treatment
Legal challenges and accusations of healthcare fraud
The politicization of COVID medicine and science
Whistleblower protection and judicial weaponization
The importance of scientific integrity in public health
Lessons learned from the pandemic response

Summary

In this episode, Terry Fletcher and Sean Weiss discuss the frustrations faced by healthcare staff with compliance issues, telehealth documentation, and billing practices. They explore real-world challenges, legal considerations, and practical advice for staff trying to navigate complex regulations.

Key Topics

Telehealth documentation and compliance
Billing and coding accuracy
Staff frustrations and legal risks
Out-of-country medical services
Documentation sufficiency and audits
Always document concerns thoroughly and keep records safe.
Understand the difference between fraud, abuse, and waste.
Research authoritative sources for compliance guidance.
Staff should document all concerns and interactions.
Practice transparency and truthful documentation.

Takeaways

Always document concerns thoroughly and keep records safe.
Understand the difference between fraud, abuse, and waste.
Research authoritative sources for compliance guidance.
Staff should document all concerns and interactions.
Practice transparency and truthful documentation.

Summary

In this episode, Terry Fletcher and Sean Weiss discuss the importance of having up-to-date, written compliance policies in healthcare practices, the risks of relying on memory or outdated policies, and how to effectively implement and audit compliance programs to avoid legal and financial pitfalls.

Key Topics

Importance of written compliance policies
Risks of outdated or missing policies
Auditing practices and place of service
Telehealth policy updates and compliance
Medicaid and Medicare policy challenges
Legal implications of non-compliance
Resources for building compliance programs

Summary

In this episode, Sean Weiss interviews Christina Panos from Wolters Kluwer to discuss the importance of regulatory compliance in healthcare, the capabilities of MediRegs, and how organizations can stay ahead in fraud, waste, and abuse prevention.

Key Topics

Healthcare fraud, waste, and abuse
MediRegs features and benefits
Regulatory updates and alerts
Customizable compliance tools
AI and automation in healthcare compliance
Importance of accurate guidance documents

Here is a link to the Wolter Kluwer MediRegs Website: https://www.wolterskluwer.com/en/solutions/mediregs

Christina Panos, RHIA, ODS

Senior Subject Matter Expert and Sales Engineer, MediRegs

Summary

This episode explores the ethical, legal, and practical implications of virtual critical care in healthcare, highlighting recent cases and regulatory challenges. Hosts Sean and Terry discuss the boundaries of telehealth, the moral dilemmas faced by providers, and the importance of appropriate, compliant virtual care practices.

Key Topics

Ethical dilemmas in virtual critical care
Legal and malpractice considerations in telehealth
Impact of COVID-19 on virtual healthcare practices

Summary

This episode features a detailed discussion on recent healthcare compliance issues, focusing on Medicare Advantage overpayments, the importance of proactive audits, and the evolving role of data analytics in fraud detection. Experts Terry Fletcher and Sean Weiss share insights on regulatory updates, best practices, and the need for strategic compliance in healthcare organizations.

Key Topics

Medicare Advantage overpayment risks
The role of OIG alerts in compliance
Data analytics in fraud detection
Best practices for healthcare audits

Summary

In this episode of The Compliance Guy, Sean Weiss and Terry Fletcher discuss various compliance issues related to audits, medical necessity, and the importance of thorough documentation in healthcare. They engage in a role play to illustrate common pitfalls in audits, emphasizing the need for physicians to conduct appropriate examinations and maintain accurate records. The conversation also touches on the impact of electronic medical records (EMR) and artificial intelligence (AI) on healthcare practices, highlighting the risks of relying on outdated or incorrect information. The episode concludes with a call for healthcare providers to take responsibility for their documentation and patient care.

Takeaways

Audits often reveal common sense oversights in healthcare practices.
Physicians must understand the difference between hospital-based and private practice standards.
Medical necessity is crucial for justifying patient evaluations and management services.
Technicalities in documentation should not overshadow clinical responsibilities.
Inaccurate or outdated information in EMRs can lead to significant risks in patient care.
Providers should not rely on loopholes in guidelines to justify their actions.
The importance of a medically appropriate history and examination cannot be overstated.
Documentation should reflect current patient status, not historical data.
AI and EMR systems can exacerbate existing documentation issues if not managed properly.
Healthcare providers must prioritize accuracy and thoroughness in patient evaluations.

Summary

Join Sean Weiss as he discusses behavioral health coding, billing, and the current challenges faced by providers with expert Sonda Kunzi. Explore topics like reimbursement issues, telehealth, and regulatory complexities in behavioral health care.

Key Topics

Behavioral health reimbursement challenges
Telehealth regulations and compliance
Impact of COVID-19 on behavioral health services

Summary

This episode explores the complexities of virtual supervision under Medicare, emphasizing compliance, operational best practices, and the potential benefits when implemented correctly.

Key Takeaways

Virtual supervision is a payment, workflow, and compliance rule, not just a convenience.
Real-time audio-video technology is required for virtual direct supervision.
Separate telehealth policies from supervision policies to avoid confusion.
Organizations must verify service eligibility and supervision compliance before billing.
Immediate availability of the supervisor is a critical operational and documentation requirement.
Global surgery exclusions and state law overlays are key considerations.
Proper training, documentation, and auditing are essential for compliance.
When done right, virtual supervision enhances access, efficiency, and workforce flexibility.

Summary

In this episode, Terry Fletcher discusses common compliance pitfalls in healthcare, billing errors, fraud risks, and the importance of accurate documentation and risk management. He emphasizes the need for healthcare providers to stay informed and vigilant against fraud and billing mistakes.

Key Topics

Healthcare billing errors and compliance pitfalls
Fraud risks and detection in healthcare
CMS guidelines and billing codes
The impact of AI and data analysis on fraud prevention

Summary

This episode features a comprehensive discussion on healthcare compliance, audits, and payment integrity, with insights from industry experts on recent trends, challenges, and legal considerations in healthcare billing and review processes.

Key Topics

Prepayment reviews and quality reviews in healthcare
Legal considerations and due process in audits
CMS restructuring and payment models
Subjectivity and AI in healthcare reviews
ALJ hearings and LCD misapplications

Summary

In this episode, Sean Weiss and Terry Fletcher discuss the complexities and pitfalls of billing add-on code G2211 for E&M services, emphasizing the importance of medical necessity, proper documentation, and understanding payer policies.

Key Topics

G2211 coding and billing
Medical necessity and documentation
Pediatric billing considerations
Payer policies and reimbursement rates
Risks of improper billing and fraud

Summary

In this episode, Sean Weiss and Frank Cohen explore the realities of AI, its limitations, and its implications for healthcare and legal fields. They discuss how AI models work, the importance of human oversight, and the risks of overestimating AI capabilities.

Key Topics

How AI tokenizes words and predicts next tokens
The misconception that AI reasons or learns like humans
The importance of human oversight in AI applications
Risks of hallucinations and fake citations in AI outputs
The role of bias and subjectivity in AI decision-making

Summary

In this episode of The Compliance Guy, hosts Sean Weiss and Terry Fletcher explore the importance of internal audits, provider documentation, and maintaining objectivity in healthcare compliance. They discuss common pitfalls like over-familiarity with providers, the impact of personality on compliance, and the significance of external reviews to ensure practice integrity.

Key Topics

Internal audits and their role in healthcare compliance
The phenomenon of spousal concordance and over-familiarity
Common documentation errors and their legal implications
The importance of objective external reviews
The influence of personality and relationships on compliance behavior

Summary

This episode features a lively panel discussion on critical issues in healthcare compliance, including the use of cell phones for medical communication, prepayment reviews, and critical care documentation.

Experts Joe Rivet, ESQ, Scott Kraft, Jordan Johnson, Stephanie Allard, and David Duhaime share insights, practical advice, and regulatory updates to help providers navigate complex compliance challenges.

Key Topics

Use of cell phones and texting in healthcare
Prepayment review processes and challenges
Documentation and billing for critical care services

Summary

In this episode of the Compliance Guy podcast, host Sean Weiss interviews healthcare compliance expert Susan Wahlberg. They discuss the evolving landscape of healthcare regulation, focusing on the roles of the FTC, FDA, and OCR, and explore how compliance professionals can stay ahead in a rapidly changing environment.

Key Topics

Role of the FTC in healthcare data privacy and enforcement
Emerging FDA regulations on AI and medical devices
The importance of data mapping and vendor vetting in compliance
The impact of government enforcement on healthcare organizations

Here is a link to Susan's Website: www.susanwalberg.com

Here is a link to Susan's LinkedIn Profile: https://www.linkedin.com/in/susanwalbergjd/

Summary

In this episode, healthcare attorney and expert Dean Viskovich discusses the complexities of telehealth, medical necessity, and laboratory compliance, providing practical guidance for labs and billing companies navigating CMS and payer requirements.

Key Topics

Medical necessity and legal standards
Impact of recent court decisions on labs
Best practices for compliance and documentation

Here is a link to Dean's Website: https://deanviskovichpa.com/team/dean-m-viskovich/

Summary

In this episode, Sean and Terry Fletcher discuss the latest issues in healthcare compliance, focusing on problematic billing practices, the risks of retrospective diagnosis coding, and the influence of third-party payers like Optum. They explore how these practices threaten provider integrity and patient care, offering insights and advice for healthcare professionals navigating these challenges.

Key Topics

Healthcare billing and coding practices
Risks of retrospective diagnosis coding and claims manipulation
Impact of third-party payers on provider integrity
Uncovering the Truth Behind Healthcare Billing Fraud
How Payers Like Optum Are Influencing Medical Coding

Summary

In this engaging discussion, Sean Weiss and Terry Fletcher explore the recent CMS final rule that bans fax machines and snail mail in healthcare transactions. They analyze the implications for revenue cycle management, the move towards digital documentation, and the broader impact on healthcare modernization and value-based care.

Topics

CMS final rule banning fax and snail mail
Impact on revenue cycle management and documentation
Electronic signatures and digital transmission security
Broader implications for healthcare modernization and value-based care

Summary

This episode features a comprehensive discussion on current issues in healthcare compliance, including RadV audits, auto down coding, medical necessity, and the impact of AI in billing practices. Experts share insights on regulatory challenges, provider strategies, and the future of healthcare billing integrity

Topics

RadV audits and their impact on providers
Auto down coding and its implications
Medical necessity standards in Medicare and commercial payers
The role of AI in billing and coding accuracy
Legal and contractual considerations in healthcare billing

Summary

This episode features Sean Weiss and Terry Fletcher discussing recent issues with insurance payers, down coding policies, and the impact on healthcare providers. They analyze the implications of AI-driven denials, the importance of proper documentation, and advocate for provider advocacy and education.Key Topics

Insurance payer policies and down coding
Impact of AI and algorithms on medical billing
Importance of accurate documentation and provider advocacy

Summary

In this episode, Sean Weiss and Terry Fletcher explore the complexities of healthcare compliance, focusing on workflows, documentation, and audits in medical practices. They discuss real-world scenarios involving frequency audits, documentation cloning, and the importance of proactive compliance strategies to avoid regulatory risks.

Key Topics

Impact of workflow failures on compliance
Risks of documentation cloning and cut-and-paste
Strategies to improve patient follow-up and adherence
Understanding medical necessity and billing levels
Regulatory scrutiny from Medicare and commercial payers
Effective workflows are crucial for compliance and avoiding audits.
Cloning of medical records can lead to serious legal and financial risks.
Proactive follow-up with patients can prevent unnecessary visits and documentation issues.
Understanding and documenting medical necessity is key to justified billing.
Regular audits and leadership involvement are essential for a compliant practice.

Takeaways

Effective workflows are crucial for compliance and avoiding audits.
Cloning of medical records can lead to serious legal and financial risks.
Proactive follow-up with patients can prevent unnecessary visits and documentation issues.
Understanding and documenting medical necessity is key to justified billing.
Regular audits and leadership involvement are essential for a compliant practice.

Summary

This episode features a lively panel discussion on healthcare documentation, compliance risks, and best practices. The experts share insights on managing documentation delays, metadata analysis, contract oversight, and the impact of AI in healthcare record-keeping.

key topics

Risks of documentation modification

Metadata analysis in audits

Contract oversight and compliance

AI in healthcare documentation

Takeaways

Altering original medical records can escalate legal issues.

Metadata analysis is crucial in fraud detection.

Effective contract management prevents costly mistakes.

AI in documentation requires careful oversight.

Summary

This episode features a lively discussion on Olympic hockey, healthcare compliance, and the pitfalls of diagnostic coding. The hosts share insights on how practices often manipulate diagnoses for payment, the importance of proper documentation, and the impact of payer policies on clinical decisions.

Topics

Diagnostic coding manipulation
Healthcare audits and compliance
Impact of payer policies on clinical decisions

Summary

This episode features a deep discussion on HIPAA compliance, recent enforcement updates, and the implications of AI and third-party tools on patient data security. Experts Terry Fletcher and Sean Weiss explore how healthcare providers can stay compliant amidst evolving regulations and technological advancements.

Key Topics

HIPAA enforcement updates and penalties
Impact of AI and ambient scribes on patient privacy
Provider responsibilities and patient rights under HIPAA
Recent OCR enforcement actions and fines
Strategies for HIPAA compliance and risk management

Here is the latest episode of The Compliance Guy!

Summary

In this episode of The Compliance Guy, Sean M Weiss and Terry Fletcher discuss various topics related to compliance, telehealth, and revenue cycle management. They emphasize the importance of accurate documentation in medical records, the impact of government shutdowns on telehealth services, and the responsibilities of EMR companies in ensuring accurate data entry. The conversation highlights the consequences of inaccurate documentation and the need for providers to maintain compliance in their practices.

Takeaways

The government shutdown impacts telehealth services.
Compliance applies to various aspects of business and healthcare.
Inaccurate documentation can lead to serious consequences.
Every medical encounter must support the billed service level.
EMR systems can default to incorrect coding, causing issues.
Providers must ensure their documentation is accurate and up-to-date.
The responsibility for medical record accuracy lies with the provider.
EMR companies may have liability for errors in their systems.
Documentation should stand on its own without unnecessary coding.
Providers need to advocate for better EMR functionality.

Summary

The 2026 Compliance Roundtable discusses critical issues in healthcare compliance, focusing on prior authorizations, telehealth, clinical laboratories, and incident two billing provisions. Experts (Joe Rivet, Terry Fletcher, Scott Kraft, Stephanie Allard, Jordan Johnson, and David Duhaime) share insights on the challenges faced by providers, the impact of legislation, and the evolving landscape of healthcare regulations. The conversation highlights the need for reform and the importance of understanding the complexities of compliance in the healthcare industry.

Takeaways

Prior authorizations serve as a gatekeeper to control healthcare costs.
The burden of prior authorizations can create barriers to timely care.
Congress is considering reforms to the prior authorization process.
Medicare Advantage plans often complicate access to care compared to traditional Medicare.
Virtual supervision has changed the definition of direct supervision in healthcare.
Incident two billing provisions pose significant compliance risks for providers.
The error rate in incident two billing is alarmingly high.
PAMA cuts to laboratory services could negatively impact patient care.
AI in healthcare presents risks related to patient information security.
The importance of understanding the nuances of healthcare regulations is critical for compliance.

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss the implications of AI in healthcare, particularly focusing on AI scribes and the importance of patient consent. They explore the challenges and responsibilities healthcare providers face in ensuring patient privacy and compliance with regulations. The conversation highlights the need for transparency in AI usage and the potential risks associated with it, emphasizing the importance of patient safety and accountability in the evolving landscape of healthcare technology.

Takeaways

AI scribes are becoming a significant issue in healthcare.
Patients often rush through signing consents without understanding them.
There is a lack of clarity on what patients are agreeing to when they consent to AI usage.
Healthcare providers must ensure compliance with regulations regarding AI.
Patients should be informed about their rights to opt out of AI scribing.
The responsibility for AI outputs lies with the healthcare provider.
AI is rapidly changing the landscape of healthcare operations.
There is a need for better safeguards and regulations around AI in healthcare.
Patient safety must be prioritized over efficiency in healthcare practices.
Healthcare providers need to adopt a patient-centered approach in AI implementation.
Navigating AI in Healthcare: Consent and Compliance
The Rise of AI Scribes: What Patients Need to Know

Summary

In this episode, Sean M Weiss interviews Katy Talento, CEO of All Better Health, discussing her journey in healthcare policy reform, the challenges of navigating the healthcare system, and the importance of price transparency. Katy shares insights from her time in the White House, her approach to firing PBMs to reduce drug spending, and her optimistic outlook on future healthcare reforms.

Takeaways

All Better Health focuses on building health plans for self-funded employers.
Prior authorizations can be waived for urgent care needs.
Firing PBMs can significantly reduce drug spending for employers.
Price transparency is crucial for competitive healthcare pricing.
Katy Talento emphasizes the need for fearlessness in healthcare policy.
The current administration is showing some commitment to price transparency.
Healthcare legislation is complicated and often misunderstood by lawmakers.
Katy's experience in the White House provided unique insights into healthcare policy.
The importance of patient advocacy in navigating healthcare challenges.
Optimism exists for future healthcare reforms despite current challenges.

Website: https://allbetter.health/

About Katy Talento:

Katy is a licensed health benefits consultant, veteran health care reformer, epidemiologist and thought leader. As the top health advisor at the White House Domestic Policy Council, Katy spearheaded transformative policies to end secret health care prices across the United States, end predatory medical collections practices, lower prescription drug prices, guarantee health records access and interoperability for patients and their care teams, combat the opioid addiction crisis and eliminate domestic HIV/AIDS. She first developed her take-no-prisoners approach to waste and corruption as an oversight investigator and legislative director on Capitol Hill, born of love and duty toward the hardworking American taxpayers.

Katy has traveled the world, holding U.S. foreign aid programs accountable for results, as well as protecting the workforce of multinational energy companies from infectious disease threats. On the faculty of Georgetown University Medical School, Katy managed the school’s participation in a multi-site NIH study. She founded a mentorship program for junior high girls in inner city DC and even served two years as a Catholic nun! Katy earned her graduate degree in Epidemiology from Harvard School of Public Health and an undergraduate degree from the University of Virginia.

Based in northern Virginia, Katy quarterbacks AllBetter’s nationwide, custom-curated partnerships of advisors, actuaries, member services teams and analytics gurus to deliver on the AllBetter client promise: significant savings, more generous benefits, and happier employees.

Summary

In this episode of The Compliance Guy, Sean Weiss interviews Joe Rivet, a healthcare attorney with extensive experience in federal matters, including prior authorization processes and the No Surprises Act. They discuss the potential changes in legislation regarding prior authorizations, the challenges faced by physicians in getting necessary treatments approved, and the implications of recent Supreme Court rulings on healthcare legislation. Joe shares insights on navigating appeals, the importance of advocating for patients, and the complexities of the IDR process.

Takeaways

Prior authorization processes are being scrutinized for their impact on patient care.
The proposed 'Doctors Know Best' bill aims to empower physicians.
Advocating for patients is crucial, especially in off-label drug use cases.
The No Surprises Act has significant implications for healthcare providers and patients.
There is a lack of private right of action under the No Surprises Act.
The IDR process is complicated and often exploited by private companies.
Medical necessity determinations can be challenged, even after prior authorization approval.
Physicians should not accept denials without exhausting all options.
Recent Supreme Court rulings have clarified the limitations of private actions in healthcare disputes.
Transparency in enforcement actions is needed for better accountability in healthcare.

Summary

In this episode of The Compliance Guy Podcast, host Sean Weiss speaks with Evan Gottlob, a former federal prosecutor turned defense attorney, about the complexities of regulatory compliance in healthcare law. They discuss the decision-making process behind prosecutions, the impact of indictments on healthcare professionals, and the importance of protecting whistleblowers. Evan shares insights on civil investigative demands and the drivers behind False Claims Act cases, emphasizing the need for organizations to build a culture of compliance to prevent legal issues. The conversation highlights the challenges faced by healthcare providers and the legal landscape surrounding compliance and fraud.

Takeaways

Prosecutors must ensure they have a strong case before charging individuals.
Indictments can have devastating effects on healthcare professionals' careers.
The grand jury process is often biased towards the prosecution.
Complex white-collar cases can be easier to present due to more evidence.
Civil Investigative Demands (CIDs) can lead to criminal investigations.
Whistleblowers play a crucial role in exposing fraud in healthcare.
Organizations must take employee concerns seriously to prevent retaliation.
Building a culture of compliance is essential for healthcare organizations.
Legal representation is critical when facing investigations.
The healthcare industry is plagued by significant fraud and waste.

Summary

In this episode, Sean Weiss and Terry Fletcher discuss the critical importance of complete and accurate medical documentation in healthcare. They explore the consequences of incomplete records, the role of electronic medical records (EMRs), and the need for accountability among healthcare providers. The conversation emphasizes that clinicians must take responsibility for their documentation to ensure compliance and support medical necessity. The episode also touches on the complexities of medical coding and the importance of clear communication in clinical records.

Takeaways

Incomplete documentation can lead to compliance issues.
Providers must accept accountability for their documentation.
EMRs should not be blamed for incomplete records.
Documentation must support medical necessity and clinical judgment.
Auditors need complete records to defend against claims.
Assumptions in documentation can lead to errors.
Clear definitions in coding are essential for accurate billing.
Providers should not rely on templates to convey critical information.
Documentation standards change regularly and must be adhered to.
Healthcare professionals must work together to ensure complete records.

Summary

In this episode, Sean Weiss and Terry Fletcher discuss the new year and the importance of compliance in healthcare. They highlight the upcoming legislative changes affecting telehealth, the roles of medical students, and the challenges of documentation and accountability in healthcare practices. The conversation emphasizes the need for proper training, understanding of roles, and the importance of doing the right thing in healthcare to avoid risks and ensure compliance.

Takeaways

January 30th is a critical date for telehealth funding.
Medical students have limited roles compared to licensed providers.
Documentation must be accurate and compliant with regulations.
Providers must personally perform key components of services.
Using medical students for billing can lead to compliance issues.
Training and understanding roles are essential in healthcare.
Fraud and abuse can result in significant penalties.
Healthcare providers must be proactive in audits and compliance.
Integrity in healthcare is crucial, even when not being watched.
Proper billing practices are necessary to avoid legal repercussions.

Summary

In this episode, Sean Weiss discusses the complexities surrounding ancillary providers and their billing practices, particularly focusing on CMS and commercial payer rules. He explains the definitions and roles of ancillary staff, the intricacies of incident to billing, and the compliance requirements for split shared services. The conversation emphasizes the importance of understanding these regulations to ensure proper reimbursement and avoid potential pitfalls in healthcare billing.

Takeaways

Understanding the roles of ancillary staff is crucial for compliance.
CMS defines ancillary staff as non-independent billers.
Incident to billing allows non-physician services to be billed under a physician's NPI.
Direct supervision by a physician is required for incident to billing.
Split shared services have specific requirements for billing under a physician's NPI.
Documentation must capture substantive portions of services provided.
Regular audits of staff roles and job descriptions are necessary.
Understanding payer guidelines can help avoid billing denials.
Compliance gaps can lead to recoupments and legal issues.
Healthcare attorneys can assist with complex compliance issues.

Summary

In this episode, Sean M Weiss engages with Richa Kaul, CEO of Compliance with a Y, discussing the critical role of governance, risk, and compliance (GRC) in today's data-driven world. They explore the mission behind the organization, the importance of risk assessments, and the challenges posed by rapid advancements in AI technology. Richa emphasizes the need for ethical considerations in AI development and the necessity of human intervention in AI processes. The conversation highlights the balance between innovation and regulation, particularly in the context of data privacy and security.

Takeaways

Compliance with a Y focuses on protecting consumer data through enterprise security.
Risk assessments are crucial for both large and small organizations.
GRC stands for Governance, Risk, and Compliance, and is increasingly important.
AI technology is evolving rapidly, outpacing current regulations.
Ethical AI development requires human oversight and intervention.
Organizations must prioritize security over mere compliance.
The healthcare sector is a significant focus for Compliance with a Y.
AI can enhance risk visibility but should not replace human judgment.
Regulations need to adapt to the fast-paced changes in technology.
Integrity in business practices is essential for long-term success.

Summary

In this episode, Sean M Weiss discusses the critical role of compliance officers in healthcare organizations, emphasizing their responsibilities, best practices, and the importance of regulatory compliance. He highlights the need for a proactive approach to risk assessment, the do's and don'ts of compliance, and the necessity of independence and objectivity in the compliance role. The episode concludes with a call to action for compliance officers to leverage available resources and foster a culture of compliance within their organizations.

Takeaways

The compliance officer is crucial for organizational integrity.
Compliance programs must adhere to OIG's seven core elements.
Regular risk assessments are essential for identifying vulnerabilities.
Training and education are vital for compliance success.
Independence in the compliance role prevents bias and conflicts.
Separation between compliance and legal functions is necessary.
Empowering compliance officers can reduce enforcement risks.
Fostering a culture of compliance is a competitive advantage.
Ignoring red flags can lead to significant penalties.
Utilizing OIG and CMS resources enhances compliance effectiveness.

oig.hhs.gov/compliance/

cms.gov/medicare/compliance-and-audits

justice.gov/criminal/criminal-fraud/page/file/1562831/dl

Summary

In this episode of the Compliance Guy podcast, Sean M Weiss reflects on the challenges and lessons learned in 2025 regarding compliance in healthcare. He emphasizes the importance of building a robust culture of compliance to prepare for the upcoming year, 2026, which is expected to bring increased scrutiny from federal agencies. Weiss outlines essential steps for healthcare organizations to strengthen their compliance programs, including conducting risk assessments, integrating HIPAA requirements, implementing training programs, and engaging third-party auditors. He concludes with a call to action for organizations to proactively adapt to regulatory changes and foster a culture of compliance.

Takeaways

Building an effective compliance program is crucial.
2025 was a challenging year for compliance professionals.
Conducting a thorough compliance risk assessment is essential.
Strengthening HIPAA privacy rule compliance is necessary.
Implementing employee training programs is vital for compliance culture.
Engaging third-party auditors can provide objective evaluations.
Leadership oversight is critical for compliance success.
Monitoring regulatory developments is necessary for adaptation.
Cultivating a resilient compliance culture minimizes legal risks.
Proactive compliance enhances operational integrity and patient trust.

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss the complexities of compliance in healthcare, particularly as the year comes to a close. They explore the importance of understanding revenue cycle management, the disconnect between clinical and payer policies, and the necessity of reading contracts thoroughly. The conversation emphasizes the need for common sense in clinical practices and the critical role of compliance programs in healthcare settings.

Takeaways

The importance of understanding revenue cycle management as the year ends.
There is often a disconnect between clinical policies and payer policies.
Providers must read and understand their contracts before signing.
Medicare sets the standard for many insurance companies' policies.
Insurance companies prioritize profit over patient care.
Common sense is crucial in clinical practices and billing.
Services should only be billed once completed, not prematurely.
A written compliance plan is essential for healthcare practices.
Compliance programs should be dynamic and regularly updated.
Payer policies must align with clinical practices for effective compliance.

Summary

In this episode of the Compliance Guy podcast, Sean M Weiss interviews Dr. Raj Bothra, who shares his harrowing experience of being wrongfully accused of Medicare fraud and excessive narcotics distribution. Dr. Bothra discusses the complexities of the case, the role of the DOJ and FBI, and the injustices he faced during his trial. He emphasizes the need for judicial reform and advocates for awareness about the flaws in the legal system that can lead to wrongful accusations. The conversation highlights the importance of understanding the legal landscape for healthcare professionals and the impact of the opioid crisis on the judicial process.

Takeaways

The trial was pivotal in shaping legal defenses against the DOJ.
Dr. Bothra's background includes significant humanitarian work.
The charges against Dr. Bothra were based on flawed data.
The judicial system can be biased against defendants.
Dr. Bothra spent 1,300 days in prison without trial.
The opioid crisis influenced the prosecution's approach.
Expert testimonies were crucial in Dr. Bothra's acquittal.
The grand jury system needs reform to ensure fairness.
Dr. Bothra's story is a cautionary tale for healthcare professionals.
There is a pressing need for judicial reform to prevent future injustices.

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss the complexities surrounding Additional Documentation Requests (ADRs) from Medicare Advantage plans. They emphasize the importance of compliance, the legal obligations of providers, and the potential consequences of ignoring these requests. The conversation also touches on the ongoing investigations into Medicare Advantage fraud and the need for providers to navigate these challenges carefully while maintaining good relationships with payers.

Takeaways

Responding to ADRs is a legal obligation for providers.
Ignoring ADRs can lead to serious consequences.
Providers should negotiate terms if requests are unreasonable.
HIPAA allows disclosures for payment-related activities.
Payers are permitted to request specific documentation for audits.
Maintaining a good relationship with payers is crucial.
Providers can ask for clarification on ADR requests.
Documentation requests should be fulfilled within narrow parameters.
The OIG investigates Medicare Advantage plans for fraud.
Providers should utilize electronic means for submitting documentation.

Summary

In this episode, Sean M Weiss discusses the critical role of compliance officers in healthcare organizations, emphasizing their responsibilities, best practices, and the importance of maintaining objectivity and independence. He outlines the do's and don'ts of compliance, highlights essential resources for compliance officers, and stresses the need for separation between compliance, legal, and operations to ensure effective oversight and ethical conduct.

Takeaways

The compliance officer is pivotal in safeguarding organizational integrity.
Compliance officers must adhere to laws like the False Claims Act and HIPAA.
Regular risk assessments are crucial for identifying high-risk areas.
Establishing anonymous reporting mechanisms encourages whistleblowing.
Ignoring red flags can expose organizations to significant risks.
Objectivity and independence are essential for effective compliance.
Resources from OIG and CMS are vital for compliance programs.
Separation of compliance from legal and operations is necessary.
Fostering a culture of ethical conduct mitigates potential liabilities.
Compliance is a continuous process that requires vigilance and adaptation.

Summary

In this conversation, Terry Fletcher and Sean M Weiss discuss the recent announcement by ChatGPT regarding its decision to cease providing health and legal advice due to a significant error rate. They explore the implications of this decision, the ongoing debate about the accuracy of AI chatbots, and the potential consequences of AI errors in professional fields.

Takeaways

ChatGPT announced it will stop providing health or legal advice.
The error rate for ChatGPT is reported to be over 40%.
Debate exists about the accuracy of AI chatbots.
Significant hallucination rates in AI-generated content are concerning.
The decision to stop providing advice may be influenced by legal pressures.
AI's limitations in professional fields raise ethical questions.
Users should be cautious when relying on AI for critical information.
The conversation highlights the need for human oversight in AI applications.
Misinformation from AI can have serious consequences.
The future of AI in professional settings remains uncertain.

Summary

In this episode of The Compliance Guy podcast, Sean M Weiss engages in a detailed conversation with attorney Summer McKeivier about the complexities of healthcare law, particularly focusing on incident two billing, healthcare fraud prosecutions, and the challenges faced by providers in navigating compliance issues. They discuss the current trends in healthcare fraud, the role of medical directors and Medicare Administrative Contractors (MACs), and the implications of inexperienced prosecutors in healthcare cases. The conversation also highlights the impact of accusations on healthcare professionals and the importance of understanding medical necessity in the context of local coverage determinations. Throughout the discussion, both Sean and Summer share insights from their experiences in the field, emphasizing the need for knowledgeable representation in healthcare law.

Takeaways

Summer McKeivier is a leading attorney in healthcare law.
Incident two billing is a significant issue in healthcare compliance.
Wound care is currently a major focus for healthcare fraud investigations.
CMS's definition of medical necessity often differs from providers' perspectives.
Local Coverage Determinations (LCDs) do not have the effect of law.
Medical directors may lack the necessary expertise in specific healthcare areas.
Healthcare providers face challenges due to poorly written LCDs.
Overpayment disputes can escalate if not addressed properly.
Inexperienced prosecutors can lead to unjust accusations in healthcare cases.
Accusations can severely impact healthcare professionals' ability to practice.

Summary

In this episode of the Compliance Guy podcast, Sean M Weiss welcomes Don Self, a veteran in the medical billing industry, to discuss his extensive experience and insights. They explore Don's two recent books, touching on topics such as medical office management, evaluation and management services, and the importance of understanding ERISA. The conversation highlights the challenges faced by healthcare providers in documentation and billing, as well as the need for better practices in the industry. Personal anecdotes and reflections on mentorship add depth to the discussion, making it both informative and engaging.

Takeaways

Don Self has over 40 years of experience in the medical billing industry.
The importance of mentorship in professional growth is emphasized.
Don's books are accessible and filled with practical advice.
Evaluation and management services continue to challenge providers.
Documentation practices have become more complex and subjective.
Healthcare systems in other countries can offer valuable lessons.
Local coverage determinations are crucial for understanding payment policies.
ERISA provides significant protections for employees and providers.
Many providers are unaware of their rights under ERISA.
The conversation encourages proactive engagement with insurance carriers.

Summary

In this episode of The Compliance Guy podcast, Sean M Weiss interviews Steven Adler, co-chair of litigation at Mandelbaum Barrett PC, focusing on non-compete agreements and restrictive covenants in healthcare. They discuss the complexities of these agreements, the rights of patients, and the implications of a recent case involving Dr. Timothy Vogel, a pediatric neurosurgeon. The conversation highlights the importance of legal counsel in navigating employment agreements and the enforceability of non-compete clauses.

Takeaways

Non-competes are often negotiated and rarely go to trial.
Restrictive covenants can include non-solicitation and confidentiality clauses.
Patients have the right to choose their treating physician, even if a non-compete exists.
Courts generally respect the doctor-patient relationship in these cases.
The enforceability of non-compete agreements varies by state and circumstance.
Legal counsel is crucial when signing employment agreements in healthcare.
Many physicians mistakenly believe non-compete agreements are unenforceable.
The geographic scope of non-compete agreements must be reasonable.
Blue penciling allows courts to modify overly broad agreements.
The credibility of witnesses can significantly impact trial outcomes.

Summary

In this engaging conversation, Sean M Weiss and Terry Fletcher explore the evolving landscape of healthcare in 2025, emphasizing the importance of reflection on career paths, the integration of AI in healthcare, and the vast opportunities available within the industry. They discuss the significance of passion in one's career and the need for continuous learning and adaptation in a rapidly changing environment.

Takeaways

This is an interesting year for healthcare professionals.
The AMBA conference highlighted the importance of in-person networking.
Reflecting on career goals is essential, especially at year-end.
AI is a powerful tool but requires human oversight.
Healthcare offers diverse career paths beyond traditional roles.
Collaboration between billing and coding professionals is crucial.
Understanding compliance is vital for all healthcare roles.
Passion for the job can lead to greater job satisfaction.
Continuous learning is necessary to stay relevant in healthcare.
There are many resources available for career development in healthcare.

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss the current state of telehealth services amidst the ongoing government shutdown. They explore the changes in telehealth regulations since the public health emergency, the challenges faced by Medicare in reimbursing telehealth services, and the implications of the False Claims Act for healthcare providers. The conversation emphasizes the importance of compliance and the need for practices to adapt to the evolving landscape of telehealth.

Takeaways

Terry Fletcher celebrated her birthday during the episode.
The government shutdown has significant implications for telehealth services.
Telehealth regulations have changed since the public health emergency.
Only specific diagnoses are currently covered for telehealth under Medicare.
Practices must ensure compliance to avoid false claims.
The importance of having a telehealth facilitator in healthcare practices.
The future of telehealth services remains uncertain post-shutdown.
Providers must be transparent with patients regarding telehealth services.
The conversation highlights the risks of submitting false claims.
Sean M Weiss emphasizes the need for ethical practices in healthcare.

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss the critical aspects of Clinical Documentation Integrity (CDI) in healthcare. They explore the importance of compliance, the implications of audits, and the responsibilities of providers in maintaining accurate medical records. The conversation highlights the need for integrity in documentation before any improvements can be made, emphasizing that compliance is essential for both legal and ethical practice in healthcare.

Takeaways

Clinical Documentation Integrity (CDI) is crucial for accurate medical records.
Compliance must be prioritized before any improvements can be made.
Providers often overlook legal and compliance issues in documentation.
Audits reveal significant gaps in healthcare practices.
Education and training are essential for healthcare staff.
Providers must be aware of changing regulations and adapt accordingly.
Documentation should reflect the true nature of patient care.
Telehealth practices must comply with HIPAA regulations.
Ignoring compliance can lead to severe consequences for providers.
Healthcare professionals need to take accountability for their documentation.

I was joined by Terry, Stephanie, Scott, Paul and Christine for this all new episode to discuss a variety of issues including tied to Auditing, Coding, Compliance, and Documentation.

I was so good to be back after a 3-week break to spend time with the panel and with all of our listeners/viewers and friends!

Summary

In this conversation, Sean M Weiss and Walter Haydock discuss the implications of ISO IEC 42001 in the healthcare sector, focusing on AI governance, regulatory compliance, and the management of bias in AI systems. They explore the challenges faced by multi-site healthcare organizations, the importance of leadership in ethical AI use, and real-world examples of organizations implementing ISO 42001. The discussion also touches on the legislative landscape surrounding AI and the need for clear policies in healthcare AI applications.

Takeaways

ISO 42001 is a blueprint for managing AI risk.
Bias in AI is unavoidable but can be managed.
Leadership commitment is essential for effective AI governance.
ISO 42001 aids in compliance with regulations like HIPAA.
Multi-site healthcare systems face unique challenges in AI implementation.
Ethical AI use is crucial in telemedicine applications.
Real-world examples show the benefits of ISO 42001 certification.
Behavioral health can greatly benefit from AI governance.
Integrating ISO standards enhances overall AI governance.
Legislators need to improve their understanding of AI issues.

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Summary

In this episode, Sean M Weiss and Terry Fletcher discuss various trends and issues in healthcare auditing, coding, and documentation. They reflect on their recent experiences and the importance of accurate coding practices to avoid risks associated with incomplete documentation. The conversation also touches on behavioral change interventions and the challenges providers face in maintaining compliance with evolving regulations. The episode concludes with a teaser for the next discussion on shared visits.

Takeaways

Time flies, and boy, they were not kidding.
An abundance of macros and smart phrases can lead to issues.
Providers should only code for services actively managed during encounters.
Incomplete documentation invites risk and potential legal issues.
Behavioral change interventions require proper documentation and patient agreement.
It's not the volume of documentation, but the quality that matters.
Smart phrases and macros can lead to compliance problems if misused.
The current administration is intensifying scrutiny on healthcare practices.
Providers need to be aware of the risks associated with coding for unrelated diagnoses.
Next episode will focus on the complexities of shared visits.

Summary

In this episode, Sean and Terry discuss the critical role of hospitalists in patient care, emphasizing the importance of understanding their responsibilities and the challenges posed by overutilization and compliance issues. They highlight the necessity of medical necessity in documentation and the potential risks associated with billing practices that may violate regulations. The conversation underscores the need for proper protocols, audits, and a focus on patient care to ensure that hospitalists fulfill their roles effectively without contributing to unnecessary costs or compliance violations.

Takeaways

Hospitalists play a vital role in patient care within hospitals.
Overutilization of hospitalists can lead to compliance issues and denials.
Medical necessity is crucial for billing and documentation.
Providers should avoid creating unnecessary encounters for revenue generation.
Hospitalists are often not part of insurance programs, leading to out-of-network costs for patients.
Proper policies and procedures are essential for hospitalist practices.
Regular audits can help identify vulnerabilities in billing practices.
Understanding the roles of different providers is key to effective patient care.
Documentation should reflect actual patient interactions and medical necessity.
Healthcare organizations must prioritize compliance to avoid legal issues.

Summary

In this episode of the Compliance Guide podcast, Sean Weiss speaks with Jonathan Porter, a former prosecutor turned defense attorney, about the complexities of healthcare compliance and the legal landscape surrounding it. They discuss the transition from prosecution to defense, the power dynamics in legal practice, and the challenges faced by healthcare providers in navigating compliance issues.

The conversation highlights the importance of robust compliance programs, the intricacies of medical billing, and the role of metadata in legal cases. Jonathan shares insights on best practices for compliance and the increasing scrutiny on kickback investigations, emphasizing the need for healthcare providers to document their processes and decisions effectively.

Takeaways

Transitioning from prosecutor to defense attorney involves a significant shift in power dynamics.
Prosecutors often have more power and options than defense attorneys.
The healthcare compliance landscape is complex and requires thorough understanding.
Many younger prosecutors are focused on quick wins rather than collaboration.
Healthcare providers face challenges in understanding intricate billing codes and regulations.
Robust compliance programs are essential for healthcare organizations.
Documenting processes and decisions can protect against legal scrutiny.
Kickback investigations are increasing, necessitating careful documentation of relationships with pharmaceutical companies.
Metadata plays a crucial role in legal cases, providing insights into provider actions.
Open communication and transparency can mitigate risks of legal action.

Summary

In this episode, Sean and Terry discuss the alarming prevalence of embezzlement in medical practices, particularly focusing on the role of family dynamics and the importance of compliance and auditing. Terry shares a recent experience where she uncovered significant embezzlement in a client's practice, emphasizing the need for vigilance and proper oversight in financial practices. The conversation highlights the necessity of implementing robust auditing processes and being aware of the potential for fraud, especially in family-run medical offices.

Takeaways

Embezzlement in medical practices is alarmingly common.
Family members in administrative roles can pose a risk for fraud.
Regular audits are essential for financial oversight.
Providers must be proactive in monitoring their finances.
Desperation can lead individuals to commit fraud.
The first instance of theft often leads to more.
Healthcare practices need to treat patients with respect.
Compliance programs should be regularly reviewed and updated.
It's crucial to have clear processes for financial transactions.
Trust but verify: always keep an eye on financial practices.

Summary

In this episode, the panel discusses the evolving landscape of telehealth, the implications of AI-driven ambient scribes in medical documentation, and the challenges posed by payer downcoding of evaluation and management services. The conversation emphasizes the importance of compliance, understanding payer contracts, and the need for proactive measures to ensure quality patient care amidst regulatory changes.

Takeaways

Telehealth is becoming more prevalent and will not go away.
Providers must understand the implications of telehealth regulations in their states.
Ambient scribing technology is being integrated into healthcare but raises compliance concerns.
Providers are responsible for the accuracy of their documentation, regardless of AI assistance.
Payer downcoding is a significant issue that requires providers to track and appeal claims.
Understanding participation agreements is crucial for providers to navigate payer practices.
Regular audits are necessary to identify patterns of documentation issues.
Providers must engage in advocacy to address unfair practices by payers.
The healthcare industry must adapt to new technologies while ensuring compliance and quality care.
Education and training for providers on documentation practices are essential.

Summary

In this conversation, Sean and Terry discuss the latest updates in telehealth regulations, focusing on new Medicare codes, changes in billing practices, and the implications for healthcare providers. They emphasize the importance of understanding these changes to ensure compliance and effective patient care.

Takeaways

Telehealth services will revert to pre-COVID regulations after 2025.
New codes for chronic pain management have been introduced.
Behavioral health services will continue to be covered under telehealth.
Hospital outpatient visits now have specific billing requirements.
Providers must be aware of the limitations on telehealth services.
Documentation is crucial for billing outpatient services.
Telehealth regulations are evolving, and providers need to adapt.
The importance of reading updates thoroughly to catch key changes.
Changes in telehealth may affect patient access to care.
Healthcare providers should prepare for the upcoming regulatory landscape.

Link to MLN Booklet https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf

Summary

In this engaging conversation, Sean and Terry discuss the challenges and importance of audits in medical practices, the resistance to change within healthcare, and the critical role of compliance and implementation of recommendations. They share personal anecdotes and insights from their experiences, emphasizing the need for meaningful change and the consequences of ignoring audit findings.

Takeaways

Audits are essential for compliance and improving patient care.
Many practices fail to implement audit recommendations effectively.
Resistance to change is a common issue in healthcare settings.
Change is necessary for growth and improvement in medical practices.
Practices often do audits just to fulfill requirements, not to improve.
Ignoring audit findings can lead to financial penalties and legal issues.
Training and educating staff is crucial for successful implementation of changes.
Consultants should be credible and knowledgeable about the specific practice area.
Meaningful change must be validated and monitored through audits.
Practices need to be proactive in addressing audit findings to avoid negative consequences.

Summary

In this conversation, the panel discusses various challenges in the healthcare industry, focusing on the roles of students in medical practices, the complexities of Medicaid, and the implications of proposed CMS regulations on skin substitutes. They emphasize the importance of compliance, accurate documentation, and the need for providers to be aware of the evolving landscape of healthcare regulations and billing practices.

Takeaways

Students cannot perform or do any work that is billable and reimbursable.
Documentation is key to halting audits and investigations.
Medicaid faces challenges with enrollment and funding.
Providers must understand the billing rules for students and graduates.
AI can lead to cloning in documentation if not used carefully.
Vendors must be held accountable for their products and claims.
The EMR is a tool that requires proper management and understanding.
Medicaid managed care plans can be poorly managed and lead to issues.
Providers need to be cautious of schemes in billing practices.
Skin substitutes are becoming a focal point for compliance and billing scrutiny.

Summary

In this episode, Sean and Terry discuss the critical importance of accurate and specific documentation in healthcare, particularly in the context of E&M services and audits. They explore the challenges faced by providers in maintaining detailed records, the implications of using generic phrases, and the role of defense operatives in ensuring compliance. The conversation emphasizes the need for patient-centric documentation practices to enhance care quality and protect against audits.

Takeaways

Documentation is essential for compliance and patient care.
E&M service documentation must be specific and detailed.
Generic phrases in documentation can lead to audit issues.
Providers should avoid lazy documentation practices.
Smart phrases should be used judiciously and tailored to each patient.
Patient records must reflect individual care, not just generic templates.
The financial implications of documentation practices are significant.
Auditors look for substance over volume in medical records.
Healthcare providers must prioritize patient-centered documentation.
Understanding payer guidelines is crucial for accurate billing.

Summary

In this episode of Terry Tuesday, Sean and Terry discuss the challenges and insights from recent audits in emergency rooms, focusing on overutilization of services, critical care documentation, and the importance of accurate medical records. They highlight the need for compliance in healthcare practices and the implications of poor documentation on patient care and billing.

Takeaways

Terry recently completed a large paper audit with significant findings.
Emergency rooms often overutilize diagnostics and labs for simple complaints.
There is a lack of understanding of medical necessity in ER documentation.
Critical care documentation is often misapplied in ER settings.
Standard orders for tests can lead to unnecessary costs and audits.
Providers must analyze and incorporate data from external sources in their documentation.
Overutilization can lead to targeted probes and audits by payers.
Healthcare providers need to be aware of their billing patterns and compliance.
Documentation must reflect the medical necessity of services rendered.
Providers on salary still need to be accountable for their documentation.

Summary

In this episode, Sean and Terry discuss the complexities surrounding the G2211 add-on code in healthcare billing. They reflect on personal experiences, the importance of understanding coding regulations, and the implications of team-based care. The conversation highlights the challenges faced by healthcare providers in navigating compliance and the potential misuse of coding practices. They emphasize the need for proper education and adherence to guidelines to avoid pitfalls in billing practices.

Takeaways

The G2211 code is often misused and misunderstood.
Team-based care is essential for appropriate billing of G2211.
Providers must have a longitudinal relationship with patients to use G2211.
Urgent care facilities should not use the G2211 code.
Misuse of G2211 can lead to increased scrutiny from regulators.
Education on coding guidelines is crucial for healthcare providers.
The complexity of patient care should dictate billing practices.
Providers should avoid automatic billing for G2211 without proper review.
Regulatory compliance is becoming stricter under the current administration.
Healthcare providers must be aware of the risks associated with coding practices.

You Don't Want To Miss This One!

Summary

In this episode, Sean and Terry discuss the critical importance of proper documentation in healthcare, particularly focusing on the discrepancies that arise when dealing with cash patients versus insured patients. They emphasize that documentation should be consistent and thorough, regardless of the patient's financial status, to mitigate compliance risks and protect both providers and patients. The conversation also touches on the broader implications of healthcare practices, including the influence of insurance companies and pharmaceutical companies on treatment options.

Takeaways

Documentation should be universal across all patient types.
Cash patients often receive inadequate documentation.
Proper documentation protects against medical liability risks.
Providers must document services regardless of insurance coverage.
Documentation is essential for continuity of care.
Inadequate records can harm patient care and outcomes.
Compliance risks increase with poor documentation practices.
Providers are responsible for documentation even after retirement.
Audits can go back six years, regardless of provider status.
Be proactive in documentation to prepare for audits.

Summary

The conversation delves into the recent healthcare cuts, particularly focusing on the $1.1 trillion in cuts to Medicaid, which are expected to have significant impacts on both rural and urban healthcare systems. The panel discusses the implications of these cuts, including the potential closure of rural hospitals, the challenges faced by urban healthcare facilities, and the ongoing issues surrounding Medicaid eligibility, particularly for undocumented immigrants. The discussion also highlights the lack of coverage for long-term care under Medicare, the importance of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), and the need for civil dialogue in addressing these complex issues. The panelists emphasize the importance of understanding the broader implications of healthcare legislation and the necessity of addressing fraud, waste, and abuse within Medicaid.Takeaways

The recent healthcare bill includes significant cuts to Medicaid, impacting rural hospitals.
Urban hospitals are also facing challenges due to Medicaid cuts.
Eligibility for Medicaid is a contentious issue, especially regarding undocumented immigrants.
Long-term care is not covered by Medicare, leading to reliance on Medicaid.
FQHCs and RHCs are crucial for underserved populations but face funding challenges.
State-specific Medicaid programs can vary significantly in their effectiveness.
Fraud and abuse in Medicaid are ongoing concerns that need addressing.
The provider exodus is a growing issue, particularly in rural areas.
Civil dialogue is essential when discussing controversial healthcare topics.
Understanding the implications of healthcare legislation is crucial for all stakeholders.

Summary

In this conversation, Sean Weiss and Terry Fletcher discuss the complexities of accountability in healthcare billing and coding. They explore the challenges providers face in ensuring compliance, the role of coders, and the importance of accurate documentation. The discussion highlights the need for clear communication and responsibility among all parties involved in the billing process, emphasizing that while providers have ultimate responsibility, everyone in the chain must be held accountable for their actions.

Takeaways

Providers must ensure accuracy in claims submitted to insurance companies.
The buck stops with the provider, regardless of third-party involvement.
Coders should not make clinical decisions without proper credentials.
There is a significant issue with billing compliance in healthcare.
Providers need to educate their staff regularly on coding and billing guidelines.
The importance of maintaining meticulous documentation cannot be overstated.
Everyone involved in the billing process shares responsibility for compliance.
Bad advice from consultants or attorneys can lead to serious consequences.
The healthcare billing process is often a vicious cycle of blame.
Providers should be proactive in understanding their billing practices.

Summary

In this episode, the hosts discuss various pressing issues in healthcare, including the recent increase in CMS investigations into Medicare risk adjustment data, the challenges faced by providers in complying with insurance requests, and the implications of Medicaid eligibility changes. They also delve into the role of GLP-1 medications in weight loss and the importance of patient advocacy in navigating healthcare decisions. The conversation emphasizes the need for healthcare professionals to engage in meaningful dialogue with insurers and to advocate for their patients' needs.

Takeaways

The increase in CMS investigators for Medicare risk adjustment data is significant.
Providers have the right to push back against unrealistic insurance requests.
Medicaid is a state program designed for low-income individuals and specific groups.
Work requirements for Medicaid eligibility are being proposed, affecting millions.
GLP-1 medications are becoming popular for weight loss but come with high costs.
Patients should advocate for themselves and ask questions about their treatment plans.
Insurance companies often request excessive documentation, creating administrative burdens.
The healthcare system is facing challenges with compliance and documentation accuracy.
Understanding the implications of HCC coding is crucial for providers.
The long-term effects of new medications are still largely unknown.

Summary

In this episode of the Compliance Guy podcast, Sean and Terry discuss the critical importance of medical necessity in healthcare, particularly in relation to patient preparation and documentation. They explore the challenges faced by providers and support staff in ensuring that patient records are complete and accurate, emphasizing the legal and ethical implications of inadequate documentation. The conversation highlights the collective responsibility of healthcare professionals in delivering quality patient care and the potential consequences of failing to meet documentation standards.

Takeaways

Medical necessity is the foundation of healthcare billing.
Proper patient preparation is essential for effective visits.
Inadequate documentation can lead to legal issues.
Staff play a crucial role in ensuring provider readiness.
Follow-up visits must have clear medical necessity.
Documentation should reflect the true nature of care provided.
Healthcare compliance is a shared responsibility.
Errors in billing can result in significant penalties.
Patient welfare should guide clinical decisions.
Proactive measures can prevent documentation issues.

Summary

In this episode of the Compliance Guy podcast, Sean interviews attorney Andrew Feldman, who specializes in federal healthcare fraud cases. They discuss Andrew's recent trial victory, the impact of COVID-19 on healthcare fraud, and the legal challenges surrounding COVID testing and medical necessity. The conversation also touches on prosecutorial challenges, ethical considerations in healthcare law, and future trends in healthcare fraud and compliance.

Takeaways

Andrew Feldman is a talented attorney specializing in healthcare fraud.
Recent trial victories highlight the importance of effective legal defense.
Cross-examination can significantly impact trial outcomes.
COVID-19 has changed the landscape of healthcare fraud investigations.
Labs are under increased scrutiny from federal payer programs.
The government prioritizes certain healthcare fraud cases based on data mining.
Medical necessity is a complex issue in healthcare fraud cases.
Prosecutors face challenges in understanding the nuances of healthcare law.
Ethical considerations are crucial in prosecuting healthcare fraud cases.
Future trends indicate ongoing scrutiny in healthcare compliance and fraud.

Here is a link to the case discussed on this episode: Feldman Firm Obtains Complete Acquittal in 65 Million Dollar Health Care Fraud and Kickback Trial – Andrew Feldman Attorney At Law

Summary

In this episode, Sean and Terry discuss various challenges in healthcare compliance, including the importance of networking, the role of third-party auditors, and the necessity of due diligence in verifying information. They delve into Medicare and Medicaid regulations, telehealth compliance, and the consequences of ignoring audit findings. The episode concludes with a celebration of their podcast's achievements and contributions to the field.

Takeaways

Networking is crucial for healthcare professionals.
Due diligence is essential in verifying compliance information.
Third-party auditors can sometimes provide inaccurate information.
Medicare and Medicaid regulations can be complex and interrelated.
Telehealth regulations require providers to be licensed in both states.
Ignoring audit findings can lead to larger financial repercussions.
Healthcare providers must understand both national and state policies.
Consultants can help navigate complex compliance issues.
The podcast has achieved recognition as a top regulatory compliance podcast.
Collaboration and sharing knowledge is vital in the healthcare industry.

Summary

In this episode of the Compliance Guy Podcast, the hosts discuss various compliance issues in healthcare, including coding practices, the implications of audits, and the evolving role of artificial intelligence in documentation. They emphasize the importance of proper coding, the risks associated with unauthorized alterations, and the need for a robust compliance culture. Insights from the recent HCCA conference highlight the ongoing scrutiny of telehealth services and the challenges posed by new technologies.

Takeaways

Unauthorized coding changes can lead to significant legal risks.
Providers must be aware of their coding responsibilities.
AI in healthcare should be used as a tool, not a substitute.
Telehealth regulations are constantly changing and need close attention.
Compliance programs must be regularly updated to reflect current practices.
Skin substitutes are under increased scrutiny from auditors.
Documentation must be thorough to avoid compliance issues.
Providers should engage in discussions about coding decisions.
The culture of compliance is essential for healthcare organizations.
AI can introduce risks if not properly managed.

Summary

In this episode, Sean and Terry discuss the increasing prevalence of audits in healthcare, emphasizing the importance of being prepared and knowledgeable about compliance. They explore the challenges posed by third-party audit requests, the necessity of verifying the accuracy of cited policies, and the strategies for responding effectively to audit inquiries. The conversation highlights the need for vigilance and thoroughness in documentation and coding practices to navigate the complexities of healthcare audits successfully.

Takeaways

Audits are inevitable in healthcare; preparation is key.
Challenge audit requests and verify their accuracy.
Documentation must be thorough and compliant with guidelines.
Third-party auditors may misinterpret or misrepresent policies.
Request extensions to ensure complete and accurate records.
Clinical summaries can provide context for audits.
Always check the validity of cited references in audit requests.
Understanding the rules is crucial for compliance.
Independent audits can help validate coding practices.
Proactive communication with auditors can lead to favorable outcomes.

Summary

In this episode of the Compliance Guy, Sean and Terry discuss the importance of being vigilant in healthcare compliance, particularly regarding Evaluation and Management (E&M) services. They emphasize the need for accurate documentation, understanding the risks involved in patient management, and relying on authoritative sources like the AMA for guidance. The conversation highlights the potential dangers of using proprietary tools that may misrepresent E&M guidelines and the importance of maintaining integrity in healthcare practices.

Takeaways

The importance of being vigilant in healthcare compliance.
Accurate documentation is key to compliance.
Understanding the risks involved in patient management is crucial.
Relying on authoritative sources like the AMA is essential.
Proprietary tools may misrepresent E&M guidelines.
Navigating risks in patient management requires careful consideration.
Healthcare professionals should maintain integrity in their practices.
Feedback from listeners is invaluable for improvement.
Continuous education on compliance is necessary for healthcare professionals.
Building a circle of trusted resources is vital for success.

Summary

In this episode, Sean and Terry discuss the recent passing of Pope Francis and its impact on the world. They then transition into the complexities of healthcare audits, including SIU, CERT, TPE, UPIC, and ZPIC audits. The conversation emphasizes the importance of understanding audit types, the necessity of compliance, and the proactive measures healthcare providers should take to mitigate risks. They also highlight the significance of creating a culture of compliance within organizations and the evolving landscape of administrative law regarding audits.

Takeaways

Healthcare providers are facing increased scrutiny from various audit types.
Understanding the nature of audits is crucial for compliance.
Not all audits require attorney-client privilege, but some do.
Proactive measures can mitigate financial and legal risks.
Creating a culture of compliance is essential for healthcare organizations.
Auditors should provide detailed support for their findings.
Engaging with experienced professionals can help navigate audits.
Administrative law judges are becoming more insightful and supportive.
Providers should be prepared to appeal audit findings effectively.

Summary

In this episode, Sean and Terry discuss the complexities and challenges surrounding annual well visits in healthcare compliance. They emphasize the importance of physician involvement and the risks associated with allowing non-physician providers to conduct these visits without adequate supervision. The conversation highlights the potential consequences of inadequate patient assessments and the need for proper workflows to ensure quality care. They also touch on the role of medical assistants and the implications of billing practices in the context of compliance and patient safety.

Takeaways

Just because you can, doesn't mean you should.

Annual well visits require thorough physician review.

Inadequate assessments can lead to serious patient risks.

Medical assistants should not make clinical determinations.

Physician involvement is crucial in patient care workflows.

Quality control is essential for healthcare compliance.

Audits and inquiries are increasing in healthcare.

Preventive services must be properly documented and reviewed.

Common sense should guide healthcare practices.

Healthcare providers must take responsibility for patient outcomes.

Summary

In this episode, Sean and Terry discuss the critical importance of accurate claims submission in healthcare, particularly regarding the representation of patient identity and biological information. They explore the implications of inaccurate documentation on medical necessity, reimbursement, and patient safety, while also addressing the sensitivity surrounding these topics. The conversation emphasizes the need for providers to balance empathy with the responsibility of maintaining accurate medical records to avoid legal and financial repercussions.

Takeaways

Accurate claims submission is essential for reimbursement.
Sensitivity in documentation must not compromise accuracy.
Medical necessity is determined by biological information.
Inaccurate records can lead to healthcare fraud charges.
Providers must adhere to legal and regulatory standards.
Patient safety relies on complete and accurate medical records.
Insurance companies require precise diagnoses for reimbursement.
The healthcare system is affected by statistical inaccuracies.
Providers face financial consequences for inaccurate claims.
Open discussions about sensitive topics are necessary for progress.

Summary

In this episode, Sean and Terry discuss the importance of maintaining high standards of medical record documentation, regardless of whether patients are cash pay or insured. They emphasize that documentation integrity is crucial for all patients and should not be compromised based on financial status. The conversation also touches on recent telehealth updates and the implications of documentation in legal contexts.

Takeaways

Medical record compliance is essential for all patients, regardless of payment method.
Telehealth services have been extended, highlighting ongoing changes in healthcare delivery.
Documentation integrity is critical in avoiding legal issues and ensuring patient safety.
Providers should not differentiate the quality of care based on a patient's insurance status.
Federal standards exist for documentation that apply universally to all patients.
Medical records must support diagnosis and treatment justification, irrespective of payment type.
Providers should treat every document as a potential legal document.
The integrity of medical records is vital for continuity of care among providers.
Documentation should be accurate, complete, and timely to avoid confusion.
Healthcare professionals must prioritize patient care over financial considerations.

Summary

In this episode of the Compliance Guy Monday Auditing, Coding, and Compliance Roundtable, the panel discusses various topics including updates on telehealth regulations, challenges in behavioral health documentation, privacy concerns under HIPAA, security risks associated with remote work, the complexities of split shared services, and the implications of United Healthcare's contract requirements for access to electronic medical records. The conversation emphasizes the importance of compliance, accurate documentation, and the need for robust security measures in healthcare practices.

Takeaways

Telehealth guidelines have been extended until September 2025.
Behavioral health documentation must reflect specific patient goals and progress.
Privacy concerns are heightened with the accessibility of behavioral health records.
Remote work poses significant security risks for patient information.
Split shared services require clear documentation of who provided care.
UHC's contract demands raise questions about patient consent and privacy.
Healthcare providers must ensure compliance with HIPAA regulations.
Documentation should accurately reflect the services provided to avoid audits.
The practice of medicine is non-standardized, complicating compliance efforts.
Insurance companies' access to medical records can lead to potential misuse.

Summary

In this episode, Sean and Terry discuss the complexities and challenges surrounding upcoding in medical billing and auditing. They explore the implications of upcoding, the importance of accurate documentation, and the consequences of non-compliance. The conversation also touches on prescription drug management and the nuances of E&M coding, emphasizing the need for healthcare providers to adhere to regulations and ensure that billing practices reflect the services rendered. The episode concludes with a reminder of the importance of compliance in the healthcare industry.

Takeaways

Upcoding is a significant issue in healthcare billing.
Accurate documentation is crucial to avoid legal issues.
Providers must ensure that billing reflects actual services rendered.
Prescription drug management requires clear connections to services provided.
Incident to services can complicate billing practices.
Healthcare providers should avoid adding incidental services to visits.
The risk of upcoding can lead to severe consequences for practices.
Regular audits can help identify and correct billing issues.
Education on coding practices is essential for compliance.
Healthcare professionals must stay informed about regulations and guidelines.

Summary

The conversation delves into the evolving role of artificial intelligence (AI) in healthcare, particularly its implications for compliance, documentation, and evaluation and management services. The speakers discuss the benefits and challenges of AI, emphasizing the need for providers to understand its limitations and the importance of maintaining accurate documentation.

They also explore the complexities of billing for evaluation and management services, highlighting the risks associated with improper documentation and the scrutiny from insurance companies.

Takeaways

AI is significantly impacting healthcare, especially in diagnostics.
Providers must ensure they understand AI's limitations and capabilities.
Compliance and documentation are critical when using AI tools.
There are many pitfalls in AI that providers need to be aware of.
Patients have the right to opt out of AI-assisted documentation.
The importance of accurate documentation cannot be overstated.
Modifiers like 25 and 59 are often misused in billing.
Commercial payers are becoming more aggressive in audits.
Public comments can lead to better regulatory outcomes.
Documentation manipulation is a serious concern in healthcare.

Summary

In this conversation, Sean and Andrew Livingston explore the transformative role of artificial intelligence (AI) in healthcare. They discuss the potential benefits and challenges of AI, including its applications in diagnostics, mental health, and the importance of data privacy and regulation. Andrew shares insights on AI hallucinations, the need for transparency in AI decision-making, and the tools available for leveraging AI in writing and content creation. The discussion emphasizes the balance between innovation and regulation in the rapidly evolving landscape of AI in healthcare.

Takeaways

AI is not a solution for everything and should amplify doctors' abilities.
Hallucinations in AI can lead to misinformation and require careful validation.
AI can help personalize healthcare by analyzing individual data.
The role of AI in diagnostics is significant, especially in early cancer detection.
Mental health applications of AI can fill gaps in care due to professional shortages.
Data privacy and security are paramount when using AI in healthcare.
Over-regulation of AI could stifle innovation and drive talent away.
Transparency in AI decision-making is essential for trust and accountability.
AI can serve as a second set of eyes for healthcare professionals.
The future of AI in healthcare requires a balance between innovation and regulation.

Summary

In this episode, Sean Weiss and Terry Fletcher discuss the complexities of healthcare compliance, emphasizing the importance of understanding various regulations, authoritative documentation, and the necessity of thorough preparation for audits and investigations. They highlight the challenges faced by medical practices in navigating compliance issues and the critical role of state regulations in healthcare. The conversation underscores the need for healthcare professionals to dig deeper than just relying on CPT codes and to be well-informed about the various guidelines and policies that govern their practices.

Takeaways

Healthcare professionals often lack understanding of compliance requirements.
CPT codes are just one part of a larger compliance framework.
State regulations can supersede federal guidelines in healthcare.
Authoritative documentation is crucial for defending practices.
Audits are becoming increasingly common in healthcare.
Relying solely on CPT can lead to compliance issues.
Healthcare providers must be prepared for inquiries from payers.
Understanding acronyms like E&M and CMS is essential for providers.
Consultants play a vital role in navigating complex regulations.
Continuous education and awareness are necessary for compliance.

Summary

In this episode, Sean and Terry discuss the evolving landscape of healthcare compliance, particularly focusing on HIPAA protections and the implications of the Cures Act. They explore the changes in regulations post-COVID, the importance of safeguarding mental health information, and the need for practices to stay updated with compliance policies. The conversation emphasizes the complexities of navigating healthcare regulations and the necessity for clear communication and understanding within the industry.

Takeaways

Terry and Sean both experienced health issues recently, leading to a brief hiatus.
There has been a noticeable change in HIPAA protections since COVID, with some practices not updating their policies.
Certain medical records, especially in behavioral health, require extra protections under HIPAA.
The Office of Civil Rights oversees HIPAA violations, not just Medicare.
Explicit consent is required to disclose mental health information under HIPAA.
The 21st Century Cures Act has implications for patient access to medical records.
There are limitations on disclosing information that could lead to a patient being jailed.
Practices need to ensure their staff is aware of updated compliance policies.
HIPAA protections extend beyond the office and into patient interactions in public spaces.
The healthcare industry is highly regulated, and changes in administration can impact compliance policies.

Summary

The conversation explores the evolving landscape of telehealth, focusing on recent regulatory changes, challenges faced by Congress in legislating telehealth, and the implications for patient care. The panel discusses the importance of documentation, access to services, and the need for guardrails to ensure quality care. They also highlight the historical context of telehealth and its restructuring during the COVID-19 pandemic, emphasizing the need for clarity in its implementation moving forward. The conversation delves into the complexities of healthcare compliance, focusing on the challenges of time documentation, the implications of macro time statements, and the necessity for effective communication between departments to ensure compliance and quality patient care. The speakers emphasize the importance of understanding the nuances of documentation and the need for a collaborative approach to workflow processes in healthcare settings.

Takeaways

Telehealth regulations are changing, impacting patient access.
Congress is struggling to address telehealth legislation effectively.
Quality of telehealth documentation is often inadequate.
Access to telehealth services remains a significant issue.
Telehealth has been a part of healthcare for decades.
The pandemic accelerated the adoption of telehealth services.
Patients often prefer in-person visits for social interaction.
There is confusion about telehealth benefits and coverage.
Specialty care access has improved through telehealth.
Guardrails are necessary to prevent abuse of telehealth services. Accessibility to healthcare services is crucial for all patients, especially seniors.
Time documentation in healthcare can lead to significant challenges and misunderstandings.
Macro time statements can degrade the quality of medical documentation.
Providers should focus on medical necessity rather than just time spent with patients.
Compliance and workflow processes must be integrated to avoid issues in healthcare delivery.
Departments within healthcare organizations need to communicate effectively to ensure compliance.
Auditing practices should be mindful of the nuances in time documentation.
Healthcare providers should avoid using canned statements that do not reflect actual patient care.
Collaboration among departments can lead to better compliance and patient outcomes.
Healthcare organizations should consider hiring compliance consultants for a comprehensive review.

Summary

In this conversation, the panel discusses the complexities and challenges faced by external auditors in the healthcare industry. They explore the importance of maintaining integrity and ethical standards while navigating client relationships, compliance issues, and the business side of medicine. The discussion highlights the need for clear communication and understanding between auditors and healthcare providers to ensure proper documentation and adherence to regulations. The conversation delves into various aspects of healthcare compliance, focusing on HCC chart reviews, the integrity of medical records, and the complexities of transitional care management (TCM). The participants discuss the importance of understanding medical necessity, the role of digital e-visits, and the risks associated with vendor relationships in healthcare. They emphasize the need for accurate documentation, the challenges faced by providers, and the importance of compliance in billing practices.

Takeaways

External auditors play a crucial role in healthcare compliance.
Clients often want validation rather than objective feedback.
Maintaining integrity is essential in consulting roles.
Documentation must support billing to avoid compliance issues.
Providers need to understand the business side of medicine.
Ethical standards should not be compromised for profit.
Communication is key in client-auditor relationships.
Preventative services should not incur out-of-pocket costs for patients.
Auditors must navigate gray areas in compliance guidance.
The importance of philosophical alignment in consulting engagements. HCC chart reviews are crucial for identifying missing information.
Metadata manipulation in medical records can lead to compliance issues.
Transitional Care Management (TCM) is essential for patient support post-discharge.
Providers often misunderstand the billing process for TCM services.
Medical necessity must be clearly documented and justified.
Digital e-visits offer a new avenue for patient-provider communication.
Vendors can create compliance risks if not properly vetted.
Healthcare providers need to be aware of the implications of coding errors.
Consultants play a vital role in ensuring compliance and proper documentation.
Coders must actively correct and verify the accuracy of medical records.

Summary

In this episode, Sean and Terry discuss the complexities of billing for imaging services, focusing on the distinctions between professional and technical components. They explore compliance issues, the importance of proper documentation, and the challenges faced by healthcare providers in navigating billing practices. The conversation also touches on patient interactions and the ethical considerations in medical billing, emphasizing the need for transparency and accuracy in reporting services rendered.

Takeaways

Understanding the difference between professional and technical components is crucial for accurate billing.
Billing globally means including both technical and professional components in the fee.
Documentation must reflect formal interpretations to justify billing for imaging services.
Modifiers like 26 and TC are essential for distinguishing between professional and technical billing.
Certain imaging services require specific certifications for billing.
Billing practices can vary significantly between different specialties and settings.
Providers must be cautious not to double bill for services rendered by other providers.
Patient interactions can complicate billing, especially when documentation is unclear.
It's important to engage in constructive dialogue about billing practices and compliance.
Healthcare billing often operates in shades of gray, requiring careful consideration of regulations.

Summary

In this episode, Sean and Terry discuss various aspects of E&M audits, focusing on compliance, documentation, and the importance of accurate patient records. They share personal anecdotes and insights into the challenges faced by healthcare providers in maintaining proper documentation and the implications of upcoding. The conversation emphasizes the need for thoroughness in patient care and the potential pitfalls of inadequate documentation.

Takeaways

E&M audits are crucial for compliance in healthcare.
Accurate documentation is essential to avoid upcoding.
Independent historians play a significant role in patient history.
Providers must review and sign off on clinical staff documentation.
Using templates should not replace personalized patient care.
Documentation must reflect the actual patient encounter.
EKGs require proper interpretation and documentation to be valid.
Healthcare providers should avoid generic notes in patient records.
Communication between providers is key to effective patient care.
Incomplete documentation can lead to legal and financial repercussions.

Summary

This round table discussion focuses on critical aspects of healthcare compliance, particularly around deductibles, copays, telehealth, and billing practices. The panelists emphasize the importance of understanding patient financial responsibilities, the need for modernized billing processes, and the legal implications of waiving deductibles. They also discuss the nuances of telehealth services and the risks associated with blanket orders in laboratory testing. In this conversation, the speakers discuss critical aspects of healthcare compliance, focusing on medical necessity, standing orders, genetic testing, and telehealth codes. They emphasize the importance of ensuring that medical services are justified and appropriately billed to avoid legal repercussions. The discussion also highlights the evolving landscape of telehealth and the need for healthcare providers to stay informed about regulations and best practices.

Takeaways

Patients are increasingly burdened by high deductibles and copays.
Practices must ensure they collect patient financial responsibilities upfront.
Consultants can provide valuable insights into managing patient costs effectively.
Telehealth services must adhere to strict compliance guidelines.
Routine waiving of deductibles can lead to legal issues for providers.
Modernizing billing processes is essential for patient satisfaction.
Preventive services should be prioritized to maximize reimbursement.
Blanket orders for lab tests are not compliant with regulations.
Providers must clearly communicate costs to patients before services are rendered.
Maintaining compliance is crucial for the sustainability of healthcare practices. Medical necessity is crucial for appropriate patient care.
Standing orders can lead to unnecessary tests and costs.
Patients may face increased financial responsibilities due to blanket orders.
Genetic testing must be medically indicated, not patient-requested.
Healthcare providers should be aware of the legal implications of their orders.
Telehealth codes are still in flux and require careful navigation.
Consultants can help practices optimize their billing and compliance processes.
Regular audits can uncover missed opportunities for reimbursement.
Laboratory services must be treated as medical services with proper documentation.
Staying informed about changes in healthcare regulations is essential.

Summary

In this episode, Sean discusses the complexities of vaccine injury law with attorneys Jon Groth and Jubaile Abila. They explore the differences between various compensation programs, particularly focusing on the COVID-19 vaccine and the challenges faced by individuals seeking compensation for vaccine-related injuries.

The conversation delves into legislative efforts, the impact of biological factors on vaccine reactions, and the future outlook for vaccine injury claims. The attorneys share insights on the legal landscape and the importance of public awareness regarding vaccine safety and compensation options.

Takeaways

The COVID vaccine is currently not part of the National Vaccine Injury Compensation Program (NVICP). Individuals injured by the COVID vaccine must file claims under the Countermeasures Injury Compensation Program (CICP).

There is a significant lack of attorneys willing to take on COVID vaccine injury cases due to the complexities involved.

Legislative efforts are underway to potentially include COVID vaccines in the NVICP.

The timeline for filing claims is critical, as many may miss the statute of limitations.

Biological factors may influence individual reactions to vaccines, raising concerns for specific populations.

The UK has a more established compensation program for COVID vaccine injuries compared to the US.

Public awareness and education about vaccine injury compensation programs are lacking.

The attorneys emphasize the importance of clinical evidence in proving vaccine-related injuries.

Future political movements may influence the landscape of vaccine injury claims.

Summary

In this conversation, Sean and Kenneth Polite discuss Kenneth's transition from the head of the criminal division at the DOJ to a partner at Sidley, a global law firm. They explore the importance of compliance in healthcare, the role of data in investigations, and the implications of AI in the industry. Kenneth shares insights on the focus of the DOJ on private equity in healthcare and the potential benefits of the recent overturning of Chevron for providers. The discussion emphasizes the need for proactive compliance measures and the evolving landscape of regulatory frameworks.

Takeaways

Kenneth Polite transitioned from public service to private practice at Sidley.
The importance of building a culture of compliance in organizations.
Regular reviews of compliance programs are essential to mitigate risks.
Data is increasingly driving investigations and prosecutions.
AI poses risks in healthcare that require careful management.
The DOJ is focusing on private equity's role in healthcare.
The overturning of Chevron may benefit healthcare providers.
Proactive compliance measures can prevent legal issues.
Cyber fraud is a growing concern in the healthcare industry.
The DOJ's discretionary authority can lead to better outcomes for providers.

Summary

In this episode, Sean and Terry discuss the recent withdrawal of the United States from the World Health Organization, the implications of this decision on healthcare policy, and the political landscape surrounding healthcare administration. They explore the effectiveness of global health organizations, critique the previous administration's handling of health crises, and emphasize the importance of independent agencies in healthcare. The conversation also highlights listener engagement and feedback on previous episodes, concluding with a look ahead to future topics.

Takeaways

The withdrawal from the WHO is seen as a positive step.
Independent agencies are crucial for effective healthcare management.
The new administration is expected to prioritize healthcare issues.
Criticism of the WHO's handling of the COVID-19 pandemic is prevalent.
Healthcare policies should focus on American interests.
Listener feedback is valuable for shaping future episodes.
The political landscape is shifting with the new administration.
Transparency in healthcare organizations is essential.
The importance of fiscal responsibility in healthcare spending.
Engagement with listeners enhances the podcast experience.

Summary

In this episode, Sean and Terry discuss the complexities surrounding audio-only telehealth services, particularly in the context of evolving regulations and compliance challenges. They emphasize the importance of understanding the regulatory landscape, the need for proactive measures in healthcare practices, and the potential risks associated with audio-only services. The conversation highlights the ambiguity in current guidelines and the necessity for healthcare providers to navigate these challenges carefully to ensure patient safety and compliance.

Summary

In this episode of the Compliance Guy program, Sean and Terry discuss the importance of understanding compliance and auditing in the healthcare industry as they enter 2025. They emphasize the significance of metadata and audit trails in electronic medical records, the need for documentation integrity, and the challenges that healthcare providers will face in the coming year. The conversation highlights the necessity for providers to stay informed and proactive in their compliance efforts to avoid potential pitfalls and ensure proper practices.

Takeaways

Understanding your tools is crucial for compliance.
Metadata serves as an essential audit trail in healthcare.
Documentation integrity is vital for patient safety.
Providers must be aware of the compliance landscape in 2025.
Healthcare fraud is a growing concern that needs attention.
Audit trails can reveal critical information about patient care.
It's important to educate clients about compliance risks.
Being proactive in compliance can prevent serious issues.
The healthcare industry is facing increased scrutiny from regulators.
Providers should not underestimate the importance of accurate documentation.

Summary

In this episode, the panel discusses the complexities and challenges surrounding telehealth services, particularly focusing on the regulations, compliance issues, and the evolving landscape of audio-only services. They explore the implications of recent legislative changes, the importance of understanding payer policies, and the need for careful navigation of telehealth guidelines to ensure compliance and effective patient care. The conversation also highlights the specific considerations for behavioral health services and the role of advanced beneficiary notices in the context of Medicare. In this conversation, the panel discusses the complexities of compliance in telehealth, emphasizing the importance of understanding the nuances between different insurance plans. They highlight the necessity of conducting internal audits to ensure adherence to regulations, especially with the Office of Inspector General's increased focus on audits in 2025. The discussion also covers the critical aspects of incident to services, stressing the need for proper supervision and documentation. The panel concludes with insights on optimizing revenue through better compliance practices.

Takeaways

Telehealth regulations are constantly evolving and require careful navigation.
Audio-only services have specific guidelines that must be followed to ensure compliance.
Behavioral health services have exceptions that differ from general telehealth policies.
Payer policies can vary significantly, necessitating thorough research by providers.
Advanced Beneficiary Notices (ABNs) are not applicable for non-covered services.
Patients may prefer audio-only visits for convenience, but compliance must be maintained.
The abuse of audio-only services has led to stricter regulations and scrutiny.
Providers must stay informed about the latest coding and billing practices for telehealth.
Transparency in healthcare is often not prioritized by patients; they focus on out-of-pocket costs.
The future of telehealth services remains uncertain as new regulations are anticipated. Understanding compliance nuances is crucial for telehealth services.
Patients must take accountability for their care and coverage.
Regular internal audits are essential for compliance and risk management.
The OIG's focus on audits will significantly impact providers in 2025.
Incident to services require direct supervision and established relationships.
Billing data can reveal compliance issues beyond documentation quality.
Providers must be aware of state-specific regulations regarding telehealth.
The quality of medical records is deteriorating due to over-reliance on templates.
Proper training and understanding of billing practices are vital for staff.
Optimizing existing services can lead to increased revenue without adding new services.

Summary

In this episode, Sean welcomes back Jose Vela Jr., a retired military officer and former federal prosecutor, to discuss his transition into healthcare law. They explore Jose's military career, his experiences as a prosecutor, and the complexities of healthcare fraud cases. The conversation delves into the impact of indictments on healthcare professionals and the importance of understanding the socio-economic factors affecting healthcare delivery. Jose shares insights on the legal landscape and the need for prosecutors to engage with the communities they serve. In this conversation, Jose Vela Jr. discusses various themes surrounding healthcare fraud, the political landscape affecting the justice department, and the implications of pardons in the current political climate. He emphasizes the importance of accountability in crime, the challenges posed by private equity in healthcare, and the need for a balanced approach to healthcare costs and job creation. The discussion also touches on the future regulatory expectations for 2025 and the impact of political changes on healthcare enforcement.

Takeaways

Understanding the socio-economic factors is crucial in healthcare.
Indictments can severely impact a healthcare professional's career.
Prosecutors often lack insight into the healthcare environment.
Healthcare fraud cases require a nuanced understanding.
Indictments should not be published without context.
Prosecutors need to engage with the communities they serve.
There are many cases that never reach indictment.
Transparency from the DOJ is essential for public trust. Healthcare fraud cases are on the rise, particularly in Texas.
Prosecutors must adhere to strict guidelines regarding public statements.
Most criminal cases are resolved without going to trial.
The narrative of weaponization of the justice system is prevalent in politics.
Pardons are a controversial but legal aspect of presidential power.
Job creation in the U.S. is a pressing issue that needs attention.
Regulatory changes in 2025 will depend on new leadership in key departments.
Private equity's involvement in healthcare can lead to increased costs for consumers.
Healthcare costs are rising, impacting patients and their families.
A balanced approach is necessary to ensure quality healthcare while managing costs.

Summary

In this episode, Sean and Terry discuss the recent CMS final rule and its implications for healthcare practices, focusing on telehealth regulations, direct supervision requirements, and updates in behavioral health services. They also delve into the G2211 add-on complexity code, emphasizing the importance of understanding the nuances of these regulations to ensure compliance and optimal patient care.

Takeaways

This is the last hashtag Terry Tuesday for 2024.
We have spent quite a bit of time taking a look at the CMS final rule.
Direct supervision means immediately available.
Audio only is not sufficient for direct supervision.
Behavioral health has gotten a huge leap in virtual care.
You need to know that your commercial plans also update their language.
The perfect example when UnitedHealthcare last year said, we're not going to pay for audio only anymore.
You have to be careful because it's something you have to say, OK, this is why I did it.
It's a gift. It is an add-on gift that says we respect and understand.
I would still caution our audience to not use this as a blanket add-on code.

Summary

The conversation delves into significant healthcare issues, including the targeted assassination of a healthcare CEO, the ongoing challenges and expansion of telehealth services, and the implications of new Medicare regulations. The panel discusses the importance of compliance, the impact of the new administration on healthcare policies, and the need for proactive measures in navigating the evolving landscape of healthcare. The discussion emphasizes the necessity of understanding the rules and regulations governing telehealth and Medicare, as well as the importance of maintaining a strong advocacy for healthcare professionals and patients alike.

Takeaways

Murdering an individual is never justified, regardless of circumstances.
Telehealth services are expanding and are here to stay.
Compliance in healthcare is an ongoing process, not a one-time task.
Healthcare policies are subject to change and require constant attention.
The new administration may bring significant changes to healthcare regulations.
Understanding Medicare's rules is crucial for healthcare providers.
Proactive measures are essential in navigating healthcare compliance.
Healthcare professionals must advocate for their rights and the rights of their patients.
Telehealth must be accessible to all, regardless of location.
The importance of having a clear policy in place for telehealth services.

Summary

In this episode, Sean and Terry discuss the current state of healthcare regulations, focusing on HIPAA compliance and government oversight. They provide a critical analysis of the effectiveness of HIPAA audits and the contradictions within healthcare regulations. The conversation emphasizes the need for accountability in government and healthcare, highlighting the challenges faced by providers and the implications for patient protection.

Takeaways

Government oversight in healthcare is crucial but often ineffective.
HIPAA audits are not improving compliance as intended.
There is a significant discrepancy in how providers and entities are treated under the law.
The Office of Civil Rights has a limited budget for audits, impacting effectiveness.
Healthcare organizations often fail to implement proper safeguards for patient information.
The government should be held accountable for its inefficiencies.
Providers face intimidation from regulatory agencies, impacting patient care.
The public must hold elected officials accountable for their actions.
Healthcare regulations should prioritize patient protection over provider penalties.

Summary

In this conversation, Sean discusses the critical issue of healthcare fraud, emphasizing the roles of the Department of Justice and the Office of the Inspector General. He outlines various laws and regulations, shares alarming statistics about fraud losses, and highlights emerging challenges in the healthcare landscape. Sean also explores the impact of technology on fraud detection and prevention, provides real-world case studies, and offers actionable recommendations for healthcare providers to combat fraud effectively.

Takeaways

The DOJ and OIG are crucial in combating healthcare fraud.
Healthcare fraud includes various deceptive practices.
Fraud costs the U.S. healthcare system billions annually.
Whistleblower claims are increasing in healthcare fraud cases.
Telehealth has created new vulnerabilities for fraud.
AI and technology are essential tools in fraud detection.
Regular training and education are vital for healthcare staff.
Collaboration among stakeholders is necessary to combat fraud.
Regulatory frameworks must adapt to new challenges.
A proactive approach is needed to protect healthcare integrity.

Summary

In this conversation, Sean and Terry discuss the implications of artificial intelligence (AI) in healthcare, emphasizing its role as a tool rather than a replacement for human oversight. They explore the potential benefits and risks associated with AI in clinical documentation, the importance of maintaining patient privacy, and the legal ramifications of relying on AI for medical decision-making. The discussion highlights the need for careful implementation and monitoring of AI technologies in healthcare settings.

Takeaways

AI is a tool that requires human interaction.
The accuracy of AI in healthcare is still under scrutiny.
Providers must ensure the integrity of AI-generated documentation.
AI can improve clinical documentation but has limitations.
Human oversight is essential to prevent errors in AI usage.
Legal implications arise from the misuse of AI in healthcare.
Patient privacy must be protected when using AI tools.
AI can enhance efficiency but should not replace medical judgment.
The healthcare industry must vet AI tools thoroughly.
AI's biases can affect its performance in clinical settings.

Summary

The conversation delves into the complexities and changes surrounding telehealth services, particularly in light of the 2025 Medicare physician fee schedule final rule. Key topics include the confusion regarding telehealth reimbursement post-public health emergency, the implications of new regulations, compliance challenges, malpractice concerns, and the importance of equitable access to telehealth services. The discussion emphasizes the need for healthcare providers to adapt to these changes and ensure compliance to avoid legal repercussions.

Takeaways

Telehealth reimbursement will change significantly after January 1, 2025.
Providers must return to originating sites for many telehealth services.
Compliance with telehealth regulations is critical to avoid malpractice issues.
Many practices are unprepared for the upcoming changes in telehealth policy.
Patients may feel pressured to use telehealth services even when they prefer in-person visits.
The lack of clarity from CMS has led to confusion among providers.
Telehealth services must be accessible to all patients, including those with disabilities.
Providers need to ensure they are using HIPAA-compliant platforms for telehealth.
The importance of having effective policies in place for telehealth services cannot be overstated.
Congressional intervention is uncertain, leaving many providers in a difficult position.

Summary

In this episode, Sean and Terry discuss the critical role of support staff in healthcare, and the necessity of listening to compliance experts to avoid legal pitfalls. They emphasize the need for collaboration and communication within healthcare practices to ensure compliance and effective billing practices.

Takeaways

Support staff play a crucial role in healthcare compliance.
Listening to compliance experts can prevent legal issues.
Healthcare providers must trust their support staff.
Collaboration is key in healthcare practices.
Ignoring staff advice can lead to serious consequences.
Healthcare professionals should be aware of billing regulations.
Open forums for policy suggestions can empower healthcare professionals.
Maintaining communication can enhance workplace relationships.

Summary

In this episode, Sean and Terry discuss the implications of the recent Medicare final rule, particularly focusing on the challenges facing telehealth services. They explore the political dynamics surrounding healthcare access, the importance of equitable access to telehealth, and the need for legislative action to address these issues. The conversation emphasizes the critical role of Congress in reforming the Medicare system and ensuring that all patients have access to necessary healthcare services, especially in light of the upcoming election.

Takeaways

The Medicare final rule has significant implications for telehealth access.
85% of Medicare patients may lose access to telehealth services.
Equity in healthcare means access for everyone, not just a select few.
Congress must take action to fix the Medicare system.
The current political climate is affecting healthcare access and reform.
Telehealth regulations are reverting to pre-COVID limitations.
Healthcare is becoming increasingly unsustainable without reform.
Politicians often prioritize re-election over effective governance.
Voting is essential for making one's voice heard in democracy.
The healthcare system needs urgent attention and reform.

Summary

In this episode of the Compliance Guy Podcast, Sean engages with Dean Viskovich, a healthcare attorney with extensive experience in lab-related compliance and reimbursement. They discuss the challenges faced by healthcare providers in the wake of post-pandemic audits, the importance of documentation, and proactive measures that can be taken to navigate the complexities of compliance in the healthcare industry. Dean shares insights on the evolving landscape of reimbursement and the implications of COVID-19 on healthcare practices, emphasizing the need for thorough documentation and strong relationships with ordering providers.

Takeaways

The healthcare industry is facing increased scrutiny from payers post-pandemic.
Understanding reimbursement processes is crucial for healthcare providers.
Documentation is key to supporting medical necessity in claims.
Proactive measures can help mitigate risks associated with audits.
The landscape of telehealth has changed significantly due to the pandemic.
Maintaining good relationships with ordering providers is essential for compliance.
The post-pandemic audit landscape is broader than just healthcare.
Healthcare providers must be prepared for audits as a matter of course.
The importance of understanding state-specific regulations in compliance efforts.
Collaboration between compliance experts can enhance audit defense strategies.

Summary

In this episode, Sean and Terry discuss the challenges faced by consultants in the healthcare industry, particularly regarding collaboration requests and the importance of maintaining credibility. They share personal experiences with scams and the necessity of due diligence when engaging with potential partners. The conversation also touches on the significance of networking and building trust within the consulting community.

Takeaways

Building your business has to do with credibility.
You have to protect yourself.
If something sounds too good to be true, it probably is.
Your reputation can never unring a bell.
Navigating scams is crucial for consultants.
Networking with trusted individuals is essential.

SummaryIn this episode, Sean discusses the complexities of compliance in healthcare with Dr. Muhammad Ali Rafai, who faced a criminal indictment for healthcare fraud. The conversation covers the emotional toll of the indictment, the audit process, trial preparation, expert testimonies, and the eventual acquittal. Dr. Rifai shares insights on the challenges faced by private physicians and the importance of compliance, while also reflecting on the lessons learned from his experience.

Takeaways

The emotional impact of being criminally indicted is profound.
Indictments do not equate to guilt; they are merely accusations.
The audit process can lead to severe consequences for physicians.
Having a knowledgeable attorney is crucial in legal battles.
Expert testimonies can significantly influence trial outcomes.
The importance of compliance in healthcare cannot be overstated.
Private physicians are often easy targets for government investigations.
The role of the jury is critical in determining the outcome of a trial.
Cross-examination can reveal significant flaws in the prosecution's case.
Maintaining a strong support system is essential during legal challenges.

Summary

In this episode, Sean and Terry discuss the critical importance of compliance in healthcare, focusing on the need for consequences for non-compliance, the implementation of financial penalties, and the role of documentation in ensuring patient safety. They emphasize the necessity of creating a culture of compliance within medical practices and the importance of having a living, breathing compliance program that is actively enforced.

Takeaways

Consequences are essential in compliance programs.
Financial penalties can deter non-compliance behavior.
A culture of compliance must be established in organizations.
Documentation quality directly impacts patient safety.
Auditing and monitoring are crucial for compliance effectiveness.
Compliance programs should be flexible yet strict.
Education is key to improving compliance among providers.
Non-compliance can lead to serious patient safety issues.
Providers must adhere to compliance policies universally.
Regular updates to compliance programs are necessary.

Summary

The conversation delves into the complexities of Medicare Advantage plans, highlighting concerns about their effectiveness and the implications of recent changes in coding. The panel discusses the challenges faced by patients under these plans, the deceptive marketing tactics used, and the potential shift towards remote patient monitoring as a solution for chronic condition management. The discussion emphasizes the importance of understanding the differences between Medicare Advantage and traditional Medicare, particularly in terms of patient access to care and the quality of services provided. In this conversation, the panel discusses the complexities of medical necessity in remote patient monitoring (RPM) and the challenges faced by healthcare providers in navigating federal and state regulations. They emphasize the importance of understanding medical necessity, adhering to payer policies, and the implications of compliance in healthcare. The discussion highlights the disconnect between providers and regulatory guidelines, the need for clear communication, and the consequences of non-compliance.

Takeaways

Medicare Advantage has a checkered history with inflated coding data.
CVS's financial issues are linked to Aetna's Medicare Advantage business.
Medicare Advantage plans are facing scrutiny for pre-authorization practices.
The shift to Medicare Advantage may not benefit all retirees.
Medicare Part B offers more direct access to care than Medicare Advantage.
Deceptive marketing tactics are prevalent in Medicare Advantage advertising.
Patients need to be educated about their Medicare options.
Changes in coding have significant implications for Medicare Advantage payments.
Concierge medicine is emerging as a trend within Medicare Advantage.
Remote Patient Monitoring (RPM) is gaining traction for chronic condition management. Practices need to fully grasp medical necessity for RPM.
There are still deficiencies in guidance from CMS and HHS.
Medical necessity is often lost in ambiguous regulations.
Providers must understand the implications of their actions.
State laws can trump federal guidelines in healthcare.
Telehealth consent requirements vary by state.
Healthcare compliance is complex and multifaceted.
Providers should seek clarity on regulations from their administrators.
Ignorance of regulations can lead to serious consequences.
It's essential to follow the specific guidelines of your MAC.

Summary

Eric Rubenstein and Ron Chapman join The Compliance Guy to discuss the implications of a recent dismissal of a False Claims Act case based on the appointment clause.

The guys explore the historical context of key tam cases, the role of relators, and the complexities surrounding the appointment clause. The conversation delves into the differences between dismissals with and without prejudice, the potential for Supreme Court involvement, and the impact of venue shopping on key tam cases.

The episode concludes with a discussion on judicial appointments and their political implications.

Takeaways

Qui Tams are a significant part of healthcare fraud enforcement.
The appointment clause raises questions about the authority of relators.
Dismissals with prejudice are nearly final and limit future actions.
The Supreme Court may be interested in conflicting rulings on key tam cases.
Venue shopping can dilute the strength of a case.
Judges may make decisions that align with their career interests.
The appointment of special counsels has constitutional implications.
Relators can receive a larger share if the government does not intervene.
Resource limitations often lead to the government declining key tam cases.
Judicial decisions can reflect broader political agendas.

00:00 Introduction to Key Tam Cases and the Appointment Clause

07:03 Exploring the Appointment Clause and Its Implications

14:03 Dismissal with Prejudice vs. Without Prejudice

16:19 The Future of Key Tam Cases in the Supreme Court

24:13 The Impact of Venue Shopping on Key Tam Cases

30:29 Judicial Appointments and Political Implications

Summary

In this episode, Sean and Terry discuss the intersection of sports and healthcare, particularly focusing on the implications of sports injuries on mental health. They delve into the nuances of preventative medicine visits, the complexities of evaluation and management services, and the importance of medical necessity in billing practices. The conversation highlights the challenges healthcare providers face in navigating these areas while ensuring compliance and quality patient care.

Takeaways

The connection between sports injuries and mental health is significant.
Preventative medicine visits can include additional work if abnormalities are found.
Medical necessity is crucial in determining billing practices.
Providers must ensure that services billed are significantly separate from preventative services.
The guidelines for evaluation and management services have changed, adding complexity.
Subjectivity in medical appropriateness can lead to confusion in billing.
Patients often bring up additional concerns during preventative visits.
Providers should be cautious about billing for services that may not be necessary.
Documentation is key to supporting claims for additional services.
Understanding payer expectations is essential for compliance.

Summary

In this conversation, Sean and his guests discuss various pressing issues in healthcare, focusing on the implications of HIPAA violations, the challenges of patient privacy, and the recent controversies surrounding the Epic EMR system. They delve into the complexities of unauthorized access to patient information, the role of AI in healthcare compliance, and the legal ramifications of the recent overturning of the Chevron deference. The discussion highlights the importance of statistical sampling in overpayment estimations and the evolving landscape of healthcare legislation, particularly in light of the False Claims Act.

Takeaways

Epic EMR's interoperability issues have led to legal challenges.
HIPAA compliance is critical in protecting patient information.
Unauthorized access to medical records is a growing concern.
AI tools in healthcare require careful human oversight.
Zero paid claims must be considered in overpayment estimations.
The Chevron deference ruling will impact regulatory interpretations.
The False Claims Act's provisions are under legal scrutiny.
Veterans' support is crucial, especially in times of need.
Healthcare professionals must prioritize patient privacy and compliance.
The Epic EMR Controversy Explained
The Future of the False Claims Act
"Epic has not particularly been a company that plays well in the sandbox."
"You can't just think that signing a waiver will protect you."

Chapters

Introduction and Context Setting 02:54

The Epic EMR Controversy 07:53

HIPAA Violations and Patient Privacy 14:59

Unauthorized Access and Compliance Challenges 20:02

The Impact of AI on Healthcare Compliance 24:56

Statistical Sampling and Overpayment Estimation 30:07

The Future of Healthcare Regulations 36:09

Closing Thoughts and Call to Action

Summary

In this conversation, Sean and Nicole Thorn discuss the increasing challenges healthcare providers face regarding compliance, particularly in light of rising audit risks and overpayment demands. They explore the complexities of healthcare law, the role of attorneys in navigating disputes, and the importance of proactive compliance strategies. The discussion also touches on the impact of AI in healthcare and the necessity for providers to adapt to these changes while maintaining a culture of compliance.

Takeaways

Healthcare providers are facing a significant increase in audit risks.
The complexity of healthcare law requires specialized legal expertise.
Overpayment demands from payers are becoming more aggressive and frequent.
Proactive compliance strategies can mitigate risks and improve outcomes.
AI is being increasingly utilized by payers to identify potential issues.
Effective communication with payers is crucial for dispute resolution.
Providers must be prepared to defend their billing practices against audits.
The cost of compliance is rising due to increased regulatory scrutiny.
Understanding the nuances of payer agreements is essential for providers.
A culture of compliance can help providers navigate the challenging healthcare landscape.

Summary

In this episode, Sean and Terry discuss the current state of the healthcare industry, focusing on the business of medicine, the impact of external factors on healthcare operations, and the alarming rise in healthcare bankruptcies. They delve into the role of private equity in healthcare, the importance of compliance, and the need for healthcare organizations to prepare for future challenges. The conversation emphasizes the necessity for healthcare leaders to be proactive in their operations and compliance strategies to ensure sustainability and success in a rapidly changing environment.

Takeaways

Healthcare organizations are facing significant operational challenges.
The No Surprise Act has impacted private practices' profitability.
Healthcare bankruptcies have surged, with a 60% increase year over year.
Private equity firms often lack experience in the healthcare sector.
Compliance is crucial for navigating the complexities of healthcare regulations.
Organizations must prepare for potential future crises and disruptions.
Inflation continues to outpace reimbursement rates for healthcare providers.
Engagement with professional organizations is vital for advocacy and support.
Healthcare leaders need to prioritize sustainability and operational efficiency.
A robust compliance program is essential for long-term success in healthcare.

Summary

In this episode, Sean and David discuss the importance of compliance education in healthcare, highlighting the diverse educational sources available, particularly through the Practice Management Institute (PMI). They explore the various certifications offered by PMI, the significance of personalized education, and the impact of recent changes in healthcare, including the shift to value-based care and the effects of the COVID-19 pandemic. The conversation emphasizes the need for continuous learning and adaptation in the ever-evolving healthcare landscape.

Takeaways

Compliance education is crucial for healthcare professionals.
Diverse educational sources can enhance professional development.
PMI offers a range of valuable certifications.
Personalized education experiences foster better learning outcomes.
The CMOM program has evolved to meet current healthcare needs.
COVID-19 has significantly impacted healthcare operations.
Value-based care is becoming increasingly important in healthcare.
Understanding compliance is essential for practice management.
Networking and relationships in the industry can lead to growth.
Continuous learning is necessary to keep up with industry changes.

Summary

In this episode, Sean and Terry Fletcher discuss the complexities of prior authorization in healthcare, emphasizing its critical role in the reimbursement process. They explore the misconceptions surrounding prior authorization, the disconnect between healthcare providers and payers, and the challenges posed by Medicare Advantage plans. The conversation highlights the importance of compliance, medical necessity, and the legal aspects of prior authorization, providing insights for healthcare professionals navigating this intricate system.

Takeaways

Prior authorization is essential but does not guarantee payment.
There is significant misinformation about prior authorization processes.
The volume of prior authorization requests has been increasing annually.
Medicare Advantage plans often complicate the reimbursement process.
Providers must understand their insurance coverage limitations.
Patients often believe all services requested by doctors are covered.
Compliance in prior authorization is crucial for healthcare organizations.
Medical necessity must be documented alongside prior authorization requests.
The process for obtaining prior authorization can vary significantly by payer.
Healthcare providers need to be proactive in managing prior authorizations.

Summary

In this episode, the panel discusses the critical importance of honesty in healthcare compliance, the challenges posed by audits, and the responsibilities of providers in navigating vendor relationships. They explore the implications of using AI in clinical documentation, the escalation of compliance issues to law enforcement, and the risks associated with outsourcing, particularly in emergency departments. The conversation emphasizes the need for thorough vetting of vendors and maintaining a culture of compliance within healthcare organizations.

Takeaways

Healthcare professionals must prioritize honesty in compliance matters.
Audits are becoming more frequent and complex, requiring vigilance.
Providers should not rely solely on vendors for compliance; they must understand their responsibilities.
AI tools in documentation require careful oversight to ensure accuracy.
Escalation to law enforcement can occur for compliance failures, not just billing issues.
Outsourcing can lead to significant compliance risks if not managed properly.
Providers must validate vendor claims and ensure they align with regulations.
Documentation practices must be tailored to the specific requirements of each service line.
A culture of compliance must be fostered from the top down in healthcare organizations.
Ignoring compliance issues can lead to costly repercussions down the line.

Summary

In this conversation, Sean and Terry discuss the critical importance of conducting audits in healthcare practices, emphasizing the need for both internal and external reviews to ensure compliance and accuracy in coding and billing. They highlight real-world examples of practices that have suffered due to a lack of audits and the biases that can occur in internal reviews. The discussion also touches on the role of compliance in healthcare and the upcoming topic of prior authorizations.

Takeaways

Many practices have never conducted an audit of their coding and billing.
Internal audits can be biased and may not capture all issues.
External audits provide an objective perspective on compliance.
Providers often make assumptions about documentation that can lead to errors.
The Department of Justice emphasizes independence in auditing practices.
Training and education are crucial for coding staff.
Practices can lose significant revenue due to improper billing.
Compliance plans should include prior authorization processes.
Auditing is essential for identifying fraud and ensuring compliance.
Investing in audits can save practices money in the long run.

Summary

In this episode, Sean and Terry discuss various topics related to healthcare compliance. They start by sharing their recent experiences, including Sean's trip to Alaska. Then, they dive into the theme of the episode, which is when things are as clear as mud in the healthcare community. They discuss the challenges of finding clear guidelines and regulations for certain situations, such as timely completion of medical records and coding for patient visits without symptoms. They emphasize the importance of creating internal policies and best practices to navigate these ambiguous situations.

Takeaways

Finding clear guidelines and regulations in the healthcare community can be challenging.
Creating internal policies and best practices is crucial to navigate ambiguous situations.
Timely completion of medical records is important for credibility and believability.
Referring a patient to a specialist is considered minimal to low risk, not moderate.
Prescription drug management is only a part of the overall medical decision-making process.
Coding for patient visits without symptoms requires careful documentation and consideration of the appropriate codes.
Having internal policies can help mitigate fines and refunds during audits.
Being proactive and compliant is essential in the ever-changing healthcare landscape.

Summary

The conversation revolves around the topic of padding medical bills and the importance of clear communication with patients regarding their financial responsibilities. The speakers discuss instances where unnecessary charges are added to the bill, such as billing for lifestyle medicine codes during a visit for a finger fracture or adding charges for services that were not provided. They emphasize the need for providers to stay in their lane and let the billing office handle financial matters. The conversation also touches on the No Surprise Act and the importance of notifying patients about potential changes in billing during procedures. Overall, the speakers stress the importance of running a compliant practice and ensuring patients are not surprised by their financial responsibilities. The conversation covers various topics related to compliance and healthcare, including personal anecdotes, the importance of commenting on proposals, the need for a collective voice in healthcare, the impact of fee schedule reductions, the complexities of telehealth, the role of contracts in telehealth, and the significance of having an effective compliance program. The main takeaways include the importance of staying informed and engaged in healthcare policy, the need for healthcare professionals to advocate for themselves and their patients, the value of having a strong compliance program, and the potential consequences of non-compliance.

Program Takeaways

Providers should avoid adding unnecessary charges to medical bills, such as billing for services that were not provided or adding charges for unrelated conditions.
Clear communication with patients regarding their financial responsibilities is crucial to avoid surprises and maintain a good patient-provider relationship.
Providers should let the billing office handle financial matters and stay focused on providing medical care.
Understanding and adhering to the rules and regulations set by insurance companies and government programs is essential to avoid compliance issues.
Providers should have a waiver of liability or an advanced beneficiary notification in place for procedures that may convert from preventive to therapeutic or diagnostic services.
Running a compliant practice includes educating providers on coding guidelines and ensuring proper documentation to support billed services. Stay informed and engaged in healthcare policy
Advocate for yourself and your patients
Have a strong compliance program
Understand the potential consequences of non-compliance

In this episode, Sean and Terry discuss the recent incident where Sean accidentally went live with colorful language during a recording. They also dive into the proposed changes to the telehealth services and fee structure for 2025. Terry explains the challenges and limitations of telehealth services, especially when it comes to billing and coding. They highlight the importance of understanding the regulations and requirements for telehealth services, as well as the need for clear guidelines and definitions from CMS. They also touch on the financial constraints and budget issues that impact physician reimbursement.

Takeaways

Understanding the regulations and requirements for telehealth services is crucial for healthcare providers.
Clear guidelines and definitions from CMS are needed to ensure proper billing and coding for telehealth services.
The financial constraints and budget issues in healthcare impact physician reimbursement.
Physicians and healthcare providers should stay informed and provide feedback on proposed changes to the fee structure and telehealth services.
The shortage of healthcare providers and the need for fair compensation are pressing issues that need to be addressed.

This is a controversial topic depending on which side of the yellow line you stand on... The question is does all work with a consultant require attorney client privilege... This is a great discussion for those of you looking to engage in coding and billing audits.

This was a great live show! Sean was joined by Terry, Christine, and Paul to discuss Medical Decision-Making for levels of EM service when Rx Management is involved.

There was a lot to unpack in this episode so don't miss this one!

Terry and Sean take on the importance of words in the medical record. There is no slowing of the audit trend so providers better buckle up!

In this episode Terry and Sean take on what it means to flat-line with your coding and how to avoid unnecessary scrutiny!

This one is a head-scratcher for The Compliance Guy for so many reasons... Not going to give it away but this is a really good episode you are gonna want to catch!

We had a great program on Monday with Terry Fletcher CPC CEMC CCC CCS CCS-P CMC ACS-CA SCP-CA PACS QMPM Christine Hall Stephanie Allard, CPC, CEMA, RHIT Scott Kraft and John Paul Spencer and their take on some hard-hitting issues:

Practices wanting to use RNs or MAs to do post of visits after 90-global surgery
Medical necessity for E/M services and the fact that a face-to-face visit has occurred in the office not being the only required component to be able to bill.

And so much more!

Terry Fletcher CPC CEMC CCC CCS CCS-P CMC ACS-CA SCP-CA PACS QMPM and #TheComplianceGuy, addressed critical issues in the latest #TerryTuesday episode. In this episode, we delved into current events affecting our country, marking a significant departure from our usual content.

Listeners can fast forward to the 15-minute mark for an insightful discussion on Untied Healthcare and Aetna's decision to stop covering the G2211. The reason? Misinterpretation of the concept of a longitudinal relationship by the majority and over-utilization of the code. Other payors are sure to follow!

A heartfelt thank you to all the #linkedin family, friends, followers, and listeners for your continuous support and engagement. Join us as we navigate through the world of #COMPLIANCE.

Peace and Love!

Sean

Sean sat down with Dana McMahon, Chief Compliance Officer for Stryker to discuss all the great things she and her team are doing to ensure a culture of compliance and to lead Stryker into the future. Beyond that Dana is the Global President for Stryker Women's Network (see bio below)!

This is one great discussion you do not want to miss!

Bio

Dana serves as Chief Compliance Officer for Stryker and is responsible for overseeing the global compliance, privacy, and enterprise risk programs and functions. Under her leadership, the Compliance function has been focused on driving value for Stryker by partnering across the businesses to enable growth and manage risk. Dana also currently serves as the global president for Stryker Women’s Network, which seeks to improve Stryker’s results by fostering an open and inclusive culture, with a focus on attracting, developing, and retaining talented women.

Dana has more than 20 years of experience in the life sciences industry. She joined Stryker in 2017 as Chief Legal Counsel, leading a global legal team advising on regulatory and quality, manufacturing and supply, technology and cybersecurity, commercial and government contracting, and privacy. Prior to Stryker, she served as Assistant General Counsel at Novo Nordisk, where during her 14-year career she held several positions of escalating responsibility within the legal team, overseeing support to the commercial, clinical, medical affairs, R&D, compliance, and government affairs organizations. Dana has worked extensively on matters related to product development and commercialization, market access and reimbursement, and compliance and risk management. Previously, Dana worked in private practice at O’Melveny in New York City.

Dana received her law degree from New York University School of Law and her bachelor’s degree from Hamilton College.

Terry and Sean sat down to discuss credentialing vs contracting. What are the main differences, how do you handle various aspects of each and the pitfalls to avoid.

The full panel was back this week taking on an array of topics impacting healthcare organizations across the country! Join Stephanie, Paul, Scott, Christine and Terry as they discuss and debate HCC Coding Issues, No Charging Physicians and others who refer to the practice and so much more...

This episode Terry and Sean take on adding services to your revenue mix and the costs for doing so if "Medical Necessity" is not met. There is a ton to unpack in the episode.

Sean also blogged about this topic on LinkedIn Monday, July 1, 2024... take a look at that blog!

Terry and Sean are back at it once again taking on the big issues impacting healthcare providers! It's all about risk mitigation and creating a culture of compliance!

The Monday Roundtable is back with all new segments and compliance centered topics. Join Sean, Terry, Christine, Scott, Paul and Stephanie as they tackle the biggest issues in healthcare.

Don't let the title fool you... this is not just another incident-to podcast. This episode focuses on the employee/employment requirement(s) and how organizations continue to make significant mistakes.

Terry, Christine, Stephanie, Paul, and Scott were all back for this new episode of the Monday Roundtable. It was quite the discussion on various payor guidelines regarding G2211, The Anatomy of CPT Codes, Split/Shared Services, EMR as a Tool, and so much more...

Brian Lobley brings over 20 years of experience leading healthcare businesses, operations, and strategy. Prior to joining tango, he served as the executive vice president, chief operating officer, and president of Health Markets at Independence Health Group, the parent company of Independence Blue Cross, LLC. He was responsible for leading Commercial, Consumer, and Medicare lines of business and the company’s group pharmacy business and Operations, Business Technology Services, Informatics, and Innovation departments. He provided oversight for the company’s subsidiaries: AmeriHealth New Jersey, and AmeriHealth Administrators.

He has also served on numerous boards across non-profit and for-profit sectors.

Brian earned his Bachelor of Science in Industrial Engineering at Lehigh University.

https://tangocare.com/

In this episode Sean and Terry take on Addendums, Corrections, and Late Entries, and when you can make them, when you shouldn't, and when clinical summaries are a better options.

Sean and Terry are back with an all new #TerryTuesday episode that you are not going to want to miss!

The full panel! Scott Kraft, John Paul Spencer, Terry Fletcher CPC CEMC CCC CCS CCS-P CMC ACS-CA SCP-CA PACS QMPM, Stephanie Allard, CPC, CEMA, RHIT and Christine Hall CHC was back with all new topics!

Weight loss drugs and all the confusion on medical necessity
Physician disclaimers and the misnomers
Developing the next generation of coders, and the difficulties practices are having retaining experienced coders in this economy

Bryan Meek of Brennan, Manna, and Diamond joins Sean to discuss last weeks final rule issued by the Federal Trade Commission and what it means at this point, where things are headed and how to navigate through all the noise.

Don't miss this episode!

Sean and Terry are at it again, taking on the most perplexing and head-scratching auditing, coding and compliance topics and bringing a sense of sanity to insane situations!

Most of the all star team was back for this one and it was an outstanding discussion of the G2211, Medical Necessity vs. Correct Coding, SNF Visits and Medical Necessity, and so much more!

Sean and Terry are back at it with another great episode focusing on the most challenging issues facing healthcare providers and their organizations.

The all star panel is back together again with an all new episode.

Clean Claims
Misapplication of Diagnosis Codes
Change Healthcare Debacle

Terry and Sean take on Medicare's IPPE and AWV and all the misinformation and dos and don'ts! Hear directly from a Medicare Auditor on her thoughts and opinions on direct supervision / incident-to regarding these services.

The Panel takes on the most pressing issues facing healthcare providers today!

Medicare Physician Fee Schedule Update
G0136 - SD0H HCPCSII Code Dos and Don'ts
TPE Targeting Level II and IV EM Services

It was such a treat to have Christine Hall of Stirling Global Solutions (https://www.stirlingglobalsolutions.com/) join The Compliance Guy Podcast to discuss compliance and coding issues surrounding Chronic Care Management (CCM), Providers Failing to Issue Voluntary Refunds, and so much more!

In this episode Terry and Sean take on the updated Compliance Program Guidance from the OIG and more specifically the section dealing with quality and substandard care leading to prosecution. Don't miss this one!

Join Sean, Stephanie, Scott, Christine, and Terry as they take on:

Collaboration Agreements
CERT Studies and error rate

Terry and Sean take on providers who render services but choose to bill for a higher level of service than what was actually performed or what they are able to support with their documentation. Oh, but there is more... so much more!

The panel is back for a much-needed discussion on two critical topics that are generating a ton of issues for providers. We'll be addressing G2211, a code that requires specific requirements and documentation components to support it, and Incident-to, a provisional billing service that continues to wreak havoc on providers. Unfortunately, self-proclaimed "experts" in the area are leading providers and others to poor outcomes. Join Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM, Christine Hall CHC, John Paul Spencer, and Scott Kraft, along with me, as we take on these two critical topics.

Dan Cohen of PainScript joined Sean to discuss their innovative solution for managing opioid prescriptions. As the focus on prescriber compliance intensifies, Dan and his team have developed a HIPAA-compliant app that connects physicians with their chronic pain and SUD patients daily. Through real-time data and daily digital care, patients are more engaged in their health, improving treatment plan and medication adherence. Join us for this fascinating discussion with a true pioneer in the industry.

Terry joined Sean to discuss some of the more obscure aspects of HIPAA and what practices should be doing to cover their assets!

What do you do when a State Medicaid program and their contractor fail to comply with their own published guidance... you call The Compliance Guy! Listen to this episode and hear an unbelievable story of incompetence and what happens when folks dig their heels in to deep and lose in the end.

Paul Spencer Joins Sean to discuss all the details of this case.

Sean and Terry take on the risks associated with not following audit results whether internal or external results. Don't miss this one!

The team was back and took on when it does and does not make sense to employ remote workers as well as the do's and don'ts. The team also took on AI and the inherent risks associated with EHRs deploying this technology into their systems.

Before you say, "not again" keep in mind these are the problem child of providers and the government. The provisional services continue to create problems and until the ambiguous aspects of these services are more clearly defined we will have to continue threading the needle to keep you compliant.

The entire cast is back this week taking on the most complex and challenging issues tied to medical auditing, coding, and compliance...

In this episode Sean takes on effective leadership and what it takes to lead a team. While Sean is known as "The Compliance Guy" he started his professional career in practice management back in the mid-90s amid all the consolidation and acquisitions by the health systems "Physician Services" Groups. Take a listen... you just may be surprised at what a regulatory compliance professional knows about Practice Management.

The one and only Clint Pulver returns to The Compliance Guy to provide an update on his upcoming 2024 speaking tour, his new documentary (Finding Hill on YouTube), The Master Class Program, and so many more unbelievable amazing things Clint and his team are undertaking!

Clint Pulver is a professional keynote speaker, author, musician, pilot, and workforce expert. Known as the leading authority on employee retention, Clint has transformed how corporations like Keller Williams, AT&T, and Hewlett Packard create lasting loyalty through his work and research as the Undercover Millennial. He has been featured by BusinessQ Magazine as a "Top 40 Under 40," and, as a professional drummer, he has appeared in feature films and on America's Got Talent. In 2020, Clint won an Emmy Award for his short film Be a Mr. Jensen, which tells the story of how a single moment in time-and one particular mentor-can change the course of a life.

In the first Legal with Liles/Parker episode of 2024, Robert and Ashley sit down with Sean to discuss Compliance Risks in 2024! The list is long and distinguished...

Terry and Sean take on Cloning, Cut and Paste and Clinical Plagiarism... It is not as clear cut as you would think it is! Don't miss this one because the end-results could cost you dearly!

The All Star Panel was back taking on the latest in auditing, coding and compliance challenges for healthcare professionals.

Katie Deming, MD sits down with Sean to discuss engaging with those diagnosed with cancer. Dr. Deming, host of the Born to Heal Podcast and a #tedxspeaker, provides insightful and invaluable advice on communication. Don't miss this opportunity to change your outlook on how we engage with those diagnosed with cancer...

There is no doubt the machines are taking over! Terry and Sean explore how AI both helps and hurts providers of medical services and what they need to do to ensure they don't find themselves in a trap!

The All Star Panel is back for the first roundtable discussion of 2024 and what a great discussion it was.

Topics Include:

G2211 - The New Add-on for Evaluation and Management Codes... The Dos and Don'ts
Medical Students - What they can and cannot provide as a services and the PATH Guidelines...
Laboratory Compliance - The world of lab services has been absolutely turned on its head over the past 24 months and there is no end in sight...

David sits down with Sean to discuss avoiding 2024 pitfalls with provider enrollment, credentialing, and contracting in addition to so much more.

David is one of the most celebrated healthcare professionals and for good reason. Don't miss this one!

Zetter Consulting Website: https://zetter.com/

NSCHBC Website: https://nschbc.org/

In this final episode of season 6 and the overall final episode of 2023 Terry joins sean to take on the critical nature of having a non-retaliation policy for your organization! You can't have a compliance program without one of these!

In this final roundtable discussion of 2023 the all star cast was back to address:

CPT Coding Changes for 2024
Impact of a transmittal change by CMS for chemo and Rheumatology Infusion Drugs
The impact of medical necessity
Documentation standards
The impact bad behavior has on a case at trial

CMS is at it once again with a new HCPCSII Code that will only lead to confusion and potential long-term audits and claw backs! Take a listen as Sean and Terry break down this one...

Terry, Scott, Paul, and Christine joined Sean for a great discussion...

Topics include: 1. Holding on to overpayments when a refund, corrected claim, and/or self-disclosure should be made; 2. How to teach audit results... painting the wrong picture; 3. Wound care; 4. Critical mistakes providers make that lead to charges of healthcare fraud and/or false claims act violations... There is so much to explore!

Split/Shared Services is the theme of this episode and you do not want to miss this in-depth discussion!

The Allstar team was back together to discuss the latest changes to the AMA CPT Manual, Risk to Providers who Clone medical records, and so much more!

Terry and Sean take on 2024 changes from AMA/CMS regarding telehealth!

This episode is all about compliance... So much to unpack in so little time!

Terry, Christine, and Stephanie joined Sean to discuss a variety of pressing topics impacting compliance and operations.
Topics for Discussion:
- Billing for bundled or non-covered services “hoping” to get paid and then writing it off if you don’t.
- trying to bill to insurance an injection code when it’s on the list of “likely self administered” because the patient doesn’t want to self Inject.
- not verifying patient's insurance coverage, getting denials and then billing the patient-
So much to discuss!

This is a very special episode of The Compliance Guy #TerryTuesday... There is some signing, and somethings that we refer to as "Don't Do That... It's Stupid!

Join Stephanie, Terry, Christine, Scott, and Paul as they sit down with Sean to discuss a variety of coding and compliance topics including:

Traveling overseas and needing medical attention... who is going to pay for it?
Modifier 25 CMS/AMA Joint Definitional Change...

In this episode, Sean and Terry take on Revenue Cycle Management and the role of compliance in operations.

You favorite dynamic duo is back and at it again! In this episode Sean and Terry take on the different types of audits... This episode is a must for every type of healthcare organization!

The entire crew (Christine, Terry, Scott, Paul, and Stephanie) is back for an outstanding roundtable discussion that is wide-ranging and full of great content!

Orders for tests and how the EMR impacts how specific tests are displayed in a note and the impact given for credit for towards data and MDM.
Cyber Security Attacks on healthcare providers (CMS Warning) and how to be diligent in your efforts!
The impact of private equity money and the latest claims of price gouging by the government against anesthesia groups!
What it means to be the subject of an investigation, the impact on your professional and personal life and that of the people surrounding you!
Being convicted of a healthcare crime and whether it leads to OIG Exclusion even if you are cooperating with the DOJ.

Don't miss this one!

Terry and Sean take on can I do this because the doctor down the street does it... and what happens when you don't stay in your lane!

We had a great line-up of topics on this episode:

Orders for tests and how the EMR impacts how specific tests are displayed in a note and the impact given for credit for towards data and MDM.
Cyber Security Attacks on healthcare providers (CMS Warning) and how to be diligent in your efforts!
The impact of private equity money and the latest claims of price gouging by the government against anesthesia groups!
What it means to be the subject of an investigation, the impact on your professional and personal life and that of the people surrounding you!
Being convicted of a healthcare crime and whether it leads to OIG Exclusion even if you are cooperating with the DOJ.

Sean was joined by Dr. Carolyn Ward, Director of Clinical Strategy for Particle Health to discuss challenges with interoperability and other dynamic challenges facing healthcare professionals...

About Dr. Ward:

Carolyn Ward is a dynamic and driven internal medicine physician with a passion for physician empowerment and data-driven decision making. With over eight years of experience in healthcare, including as Chief Resident at Rutgers Robert Wood Johnson Medical School, she has established herself as a leader in the field. As the Director of Clinical Strategy at Particle Health, Carolyn has taken her experience to the next level. She is responsible for developing the clinical product roadmap for the organization, ensuring that providers and patients are represented throughout the research and development process.
Carolyn's mission is to enable simple and secure access to actionable patient data through Particle's modern API platform. She believes that the health data system must be more cohesive to prevent digital friction and to promote positive patient outcomes. Carolyn is an ideal fit for podcasts targeting audiences of C-suite executives and founders for health tech companies, physicians, and women in tech. She can offer unique insights on topics such as healthcare interoperability, AI in health data management, digital health innovation, and value based care innovation. Her knowledge, experience, and her passion make her an outstanding guest for any podcast looking to explore the challenges facing the industry and the opportunities for innovation.

On this episode, Sean was joined by Dr. Brian Fengler of EvidenceCare to discuss the state of healthcare and what he as an Emergency Room Physician has see as opportunities to gain access to evidence based care information to assist in the treatment of patients at bedside faster and more accurately.

About Dr. Fengler: (https://evidence.care/)

Dr. Brian Fengler is the co-founder and Chief Medical Officer of EvidenceCare. During his career as an emergency medicine physician, Brian saw and experienced a provider struggle to access evidence-based content quickly and at the bedside. Looking to fill this gap, Brian founded EvidenceCare in 2014.

After finishing his residency at the University of Virginia Health System in 2008, Brian moved to Nashville where he began his practice in the emergency department of St. Thomas Health System. He was also a founding physician and managing director of Physicians Urgent Care and a partner-owner of Middle Tennessee Emergency Partners physician group. During these ventures, he served as an assistant professor of emergency medicine for the University of Tennessee/St. Thomas residency program. In 2016, Dr. Fengler left the daily practice of medicine to focus full-time on his work at EvidenceCare.

Terry and Sean take on the giant headache of split/shared and incident-to services. This one gets a bit heated for legitimate reasons.

You're gonna love this one!

The entire team is back for this episode! There was a lot to discuss with so many issues coming to light in the areas of coding, billing, documentation, and compliance. Don't miss one minute of this one!

What is a compliance plan and how to build one that is effective and meets OIG and DOJ requirements!

This was an epic episode that you do not want to miss. Scott, Terry, Stephanie and Christine joined Sean to discuss the False Claims Act, Anti-Kickback Statute, Template issues, and so much more!

Terry and Sean take on Telehealth access. Clients are getting letters about not having Telehealth available for disabled patients, which is required under the Federal Disabilities Act. Physicians telling patients they don't have in-person options for care, ONLY Telehealth is not okay.

The panel was back at it with a great breakdown of the Medicare Physician Fee Schedule Rule Changes for 2024... as always it was a lively discussion about the proposed rule changes and their impact on providers.

Topics Included:

Split/shared services – the definition of substantive portion will remain the same as it is now through 12/31/2024... Time will not be the controlling factor. HX, EX, and MDM can be used to make this determination of the substantive portion.
Extend flexibilities for certain assessments furnished via audio-only communication, through the end of CY 2024. If finalized, opioid treatment programs (OTPs) would be allowed to bill Medicare when video is not available, using technology permitted by the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Administration (SAMHSA). This extension would equalize telehealth flexibilities across providers of care and negate potential service disruptions due to the end of the COVID-19 public health emergency (PHE).
CMS proposes several additions to covered telehealth services under the MPFS, as well as an extension of several telehealth provisions from the Consolidated Appropriations Act (CAA) of 2023. Proposed changes include the add-on of health and well-being coaching services on a temporary basis (specific diagnoses and licensure/certifications will apply), as well as a refined process to review requests to add services to the Medicare Telehealth Services List. Telehealth provisions extended through December 31, 2024, will include:

• The temporary expansion of the scope of sites where telehealth is furnished from, to include any location in the U.S. where a beneficiary may reside; for Medicare and MA patients, but States would also have to agree to comply.

• A change in definition of telehealth providers to include qualified audiologists, speech-language pathologists, occupational therapists, and physical therapists; They are already on the Temp list through 2024

• Continued payment for telehealth services provided by federally qualified health centers (FQHCs) and rural health centers (RHCs); limited to BH services

• Delaying requirements for beneficiaries to meet with practitioners six months before initiating mental health telehealth services; Unless they have a narcotic prescription then they would not qualify if a new patient after Nov 2023

• Allowing physicians in teaching environments to use video and audio communications when a resident is furnishing Medicare telehealth services; and But the supervising provider would have to be somewhere in the inpatient hospital setting and available if needed.

• Continued payment and coverage of telehealth services that are included on the Medicare Telehealth Services List.

There is a proposed reduction to the 2024 conversion factor that would reduce provider reimbursement. CMS is urging Congress to create a permanent fix for this issue but as it stands now, the proposed rate reduction stands. CMS is also proposing significant increases in payment for primary care and other kinds of direct patient care with the HCPCS add on G2211.
The proposed rule includes a new benefit category wherein family therapists, marriage therapists, and mental health counselors would be able to bill Medicare (Physician supervision necessary). Additionally, CMS proposes changes in payment and coding to account for resources utilized in the delivery of care involving a multidisciplinary clinical team and other staff members.
The Proposed Rule has significant implications for other virtual care and care management services, including Remote Physiologic Monitoring (“RPM”) and Remote Therapeutic Monitoring (“RTM”) services. Below is a summary of key provisions in the Proposed Rule relating to RPM, RTM, and other virtual care management services, along with opportunities and challenges for stakeholders in the space.

This is a systemic problem facing the industry and the MACs, OIG, DOJ and others who audit and investigate are hyper aggressive when it comes to recoveries! Learn the regulations and your obligations to refund money you are not entitled to!

The panel was back for a great discussion on today's most pressing issues facing healthcare professionals:

Providers changing records and documentation after notice of an audit...
Denials by CIGNA and other plans for unspecified diagnosis. What is a "valid" diagnoses, vs. "covered" diagnoses...
United Healthcare's continued woes...

Sean and Terry take on some spicy issues (literally and figuratively) in this episode. Not knowing the coding rules can land you in some hot water and lead to significant claw backs and/or overpayment demands. Don't miss this outstanding episode with one of the industries foremost coding and billing SMEs!

The all star panel was back for another outstanding episode. There was a lot of debate in this one and the fact is all of the positions laid out were solid and accurate. Providers need to be proactive in their compliance when it comes to accurate coding but when things aren't perfect it takes a team to create a solid defense. Do not miss this one as it was hands-down one of the best debates of the season!

The one and only Ronald Chapman II of the Chapman Law Group joins Sean to discuss their latest (5 in 12 months) of acquittals for Dr. Loey Kousa. Sean and Ron lay out what went right for the defense and why the prosecution's case failed. If you are a provider charged with a crime in healthcare or an attorney looking for strategies to ensure a level playing field and due process for your client then this episode is a must!

Sean and Terry take on the world of Pre-ops and provide clarification of the different types of visits and what is required to satisfy billing of these services.

Sean and Terry are back and taking on Stark from a practical standpoint in this episode of The Compliance Guy.

The panel is back for this outstanding discussion on when it's appropriate to make changes to CPT Code Selection(s) and when it is not!

Just because you go paid doesn't mean you billed it right... just because you got paid doesn't mean you get to keep it... just because you got paid once doesn't mean you will be paid again! Terry and Sean tackle an issue that we know is prevalent in all medical groups.

The all star panel was back live to discuss the latest in healthcare billing, coding, compliance, and documentation issues and strategies. On the topic list for this episode was the impact of cyber-terrorism on healthcare facilities and the false sense of security physicians have by relying on their EMR Templates. Truly a great discussion!

This episode was mind boggling to yours truly! Just when you think you understand a Medicare process you realize you really need brilliant health care attorneys like Ashley Morgan and Robert Liles to help you make sense of things! Don't miss this one

Sean was joined by Hassan Abdallah of ATLAH to take on a wide-range of topics directly impacting healthcare compliance, audits, private equity, and so much more!

About Hassan F. Abdallah

Hassan F. Abdallah is a proven and recognized professional in the field of organizational

compliance with extensive experience in designing and managing compliance based solution

systems. Throughout his career he has worked and consulted exclusively with some of the top

healthcare institutions in the country, assisting them in navigating and understanding regulatory

requirements through a strategic and analytical view.

Mr. Abdallah is a co-founder and former Board Member of the SAFE Substance Abuse

Coalition. SAFE is a grassroots organization that aims to lead and support local communities in

dispelling myths and stigmas about substance abuse and drug addiction. In his two years as

Executive Director, SAFE had become a leader in substance abuse prevention and education in

the Dearborn and Dearborn Heights communities.

As he progressed throughout his professional career, Mr. Abdallah climbed the corporate ranks

throughout two different organizations achieving great success in the field of regulatory

compliance. In previous positions, Hassan F. Abdallah served as the Chief Compliance Officer

of Health Alliance Plan (HAP) becoming the youngest C-suite executive in the company’s

history. In that capacity, he managed compliance activities in the broad range of U.S. regulatory

obligations including Consumer Privacy, Consumer Protection, CMS, and HIPAA; as well as

global regulatory obligations such as EU General Data Protection Regulation, and Consumer

Data Protection.

Prior to joining HAP, Hassan

Terry is back in the hot seat to discuss facility vs pro-fee coding... lots to unpack in the episode!

The entire gang is back for this one... Terry, Christine, Stephanie, Scott and Paul teamed up with Sean to discuss:

AI and the impact on healthcare...
Q3014 Site of Service Fee Differential...
Patient Centered Care...
Statistically Valid Random Sample (SVRS) when and how can it be used...

Sean takes on the question "should we fear the “Bots” or should we openly embrace them"? You be the judge. What risk(s) do we face during an audit if it’s determined the documentation is cloned. What potential med-mal issues could be hiding around the corner?

Sean was joined by Ashley Morgan and Robert Liles of Liles/Parker to discuss Medicare Part C Appeals and how different the process is from traditional Medicare Part A and B Appeals...

Once again, this was such an incredible episode with two of the best attorneys in the administrative process!

About Ashley Morgan:

Ashley Morgan is a Partner at Liles Parker. She focuses her practice on regulatory health care compliance matters, fraud and abuse, and reimbursement issues. Ms. Morgan represents health care providers across the country in connection with a wide variety of health law issues including coverage disputes, documentation concerns, compliance, medical board complaints, and exclusion / termination issues. She has worked with an assortment of providers including dentists, home health companies, hospice agencies, pain management practices, primary care and specialty physicians, mental health professionals, physical therapists, and licensed acupuncturists. Ms. Morgan is one of only a small percentage of health lawyers who has also trained and passed the certification examination requirements to become designated as a "Certified Professional Coder."

About Robert Liles:

Mr. Liles first began working in hospital management after receiving both an M.B.A. and an M.S. in Health Care Administration. After graduating from law school, he was hired as an Assistant United States Attorney (AUSA) in the Southern District of Texas (SDTX) where he primarily handled False Claims Act cases. He was later promoted to Chief, Financial Litigation Unit.

Shortly after the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Mr. Liles was asked to serve as our country's first National Health Care Fraud Coordinator.He was detailed to Washington, DC and was later promoted to the position ofDeputy Director, Legal Programs, for the Executive Office for U.S. Attorneys (EOUSA), a component of the United States Department of Justice (DOJ). While at EOUSA, he advised Federal prosecutors around the country on civil and criminal fraud statutes, schemes, investigative tools, privacy concerns, and compliance issues.

Sean was joined by Elliot Golding of McDermott Will & Emery to discuss all things HIPAA Privacy and Security, Information Blocking, and a few more critical aspects of cybersecurity! This episode is a must for all medical practices, hospitals and health systems to ensure your compliance with the ever-changing landscape!

Elliot is Sean's go-to when it comes to Data Privacy and Cybersecurity!

About Elliot Golding:

Elliot Golding (CIPP/US) is a partner in McDermott Will & Emery's Data Privacy and Cybersecurity Practice. Elliot provides business-oriented privacy and cybersecurity advice to a wide range of clients, with a focus on health care/life sciences, technology (including "digital health"), ecommerce, financial, and other sectors that frequently handle personal information. His practical approach helps clients balance legal risk with business needs, particularly relating to innovative issues such as “digital health” technologies, the Internet of Things, data monetization, online advertising technology, big data and Artificial Intelligence/Machine Learning tools (particularly in the health research context). He has extensive experience helping clients navigate the patchwork of evolving legal standards and best practices, including:
--Federal laws, such as HIPAA/HITECH, Information Blocking and Interoperability Rules, 42 CFR Part 2, GLBA, COPPA, health research rules, marketing rules (TCPA, CANSPAM, etc.),
--US state laws, such as CCPA (and for coming laws in CA, CO, VA, CT, and UH), CMIA, CalFIPA, laws governing sensitive health and financial information, and state laws governing security and breach notification
--industry standards (such as DAA/NAI self-regulatory principles, PCI-DSS, and security standards (such as NIST and ISO).
Elliot has also handled hundreds of breaches and security incidents through all aspects of investigation, notification, remediation and engagement with regulators.
He has received awards for his expertise from numerous publications, including Bloomberg and Global Data Review. Elliot also chairs several American Bar Association committees including the Privacy, Security and Emerging Technology Division; E-Privacy Law Committee, and Biotechnology, Healthcare Technology, and Medical Device Committee.

Terry and Sean take on the question of why... why are auditors, billers, coders, and providers still doing things that expired with the end of the PHE!

Jerrod Bailey is the CEO of Medplace, Joined me to discuss technology in healthcare, advancements in #artificialintelligence and how he and his company are filling a vital gap in the #litigation, #peerreview and #clinicalreview spaces.

Bio:

Jerrod is the CEO of Medplace, an app built for healthcare, legal, and insurance industries to streamline their case and peer review processes. He holds over 20 years of experience in venture-backed technology companies and specializes in healthcare technology development and human-centered user experience design. Jerrod has helped launch over 100 technology start-ups, including corporate new ventures with American Express, Intel, and other notable names.

Charity of the Month: The Tafida Raqeeb Foundation https://tr-foundation.org/

Around 6000 children are diagnosed with serious brain injury in the UK every year which result in devastating effects on the child and their family. Children rarely receive the rehabilitation they require, predominantly due to the lack of available support. There is a limited number of specialist rehabilitation beds for children and young people in the UK. Acceptance to relevant services come with strict pre-requisites and waiting times can be lengthy. Private treatment is very expensive. All in all, many children have little access to rehabilitation and do not reach their full potential. Delivering support for these children and their families is the sole aim of the foundation.

Terry and Sean take on the new "Graduate Physician Program" and what this means... This is a very interesting topic that we got to explore. The discussion then shifts to DME Audit Targets...

Charity of the Month: The Tafida Raqeeb Foundation https://tr-foundation.org/

Around 6000 children are diagnosed with serious brain injury in the UK every year which result in devastating effects on the child and their family. Children rarely receive the rehabilitation they require, predominantly due to the lack of available support. There is a limited number of specialist rehabilitation beds for children and young people in the UK. Acceptance to relevant services come with strict pre-requisites and waiting times can be lengthy. Private treatment is very expensive. All in all, many children have little access to rehabilitation and do not reach their full potential. Delivering support for these children and their families is the sole aim of the foundation.

In this episode Sean takes on the routine waiver of copayments and/or deductibles and why it's a really bad idea... There are many Administrative, Civil, and/or Criminal issues/penalties one faces for violating the False Claims Act, Health Care Fraud Statute, and/or the Anti-Kickback Statute(s) (Federal and State)...

Charity of the Month: The Tafida Raqeeb Foundation https://tr-foundation.org/

Around 6000 children are diagnosed with serious brain injury in the UK every year which result in devastating effects on the child and their family. Children rarely receive the rehabilitation they require, predominantly due to the lack of available support. There is a limited number of specialist rehabilitation beds for children and young people in the UK. Acceptance to relevant services come with strict pre-requisites and waiting times can be lengthy. Private treatment is very expensive. All in all, many children have little access to rehabilitation and do not reach their full potential. Delivering support for these children and their families is the sole aim of the foundation.

Terry and Sean are back at it in this episode... the focus was on payor contracting vs. credentialing. Lots to unpack in this episode that you are not going to want to miss!

Charity of the Month: The Tafida Raqeeb Foundation https://tr-foundation.org/

Around 6000 children are diagnosed with serious brain injury in the UK every year which result in devastating effects on the child and their family. Children rarely receive the rehabilitation they require, predominantly due to the lack of available support. There is a limited number of specialist rehabilitation beds for children and young people in the UK. Acceptance to relevant services come with strict pre-requisites and waiting times can be lengthy. Private treatment is very expensive. All in all, many children have little access to rehabilitation and do not reach their full potential. Delivering support for these children and their families is the sole aim of the foundation.

Hands-down, one of the best Monday Roundtables to-date! The full panel was back for a lively discussion on the following:

Mayo Clinic
AdQuic Process
The end of the PHE and Telehealth Services
Cigna and their Modifier 25 Policy, and so much more!

Charity of the Month: The Tafida Raqeeb Foundationhttps://tr-foundation.org/

Around 6000 children are diagnosed with serious brain injury in the UK every year which result in devastating effects on the child and their family. Children rarely receive the rehabilitation they require, predominantly due to the lack of available support. There is a limited number of specialist rehabilitation beds for children and young people in the UK. Acceptance to relevant services come with strict pre-requisites and waiting times can be lengthy. Private treatment is very expensive. All in all, many children have little access to rehabilitation and do not reach their full potential. Delivering support for these children and their families is the sole aim of the foundation.

Sean is joined by attorney's Amanda Waesch and Joshua La Bouef of Brennan Manna and Diamond breakdown the latest legislation signed into law by Governor Ron DeSantis on Personal Injury and Auto Accident and what many are calling a pure disgrace! Listen and you determine...

Charity of the Month - The Tafida Raqeeb Foundation was formally launched on 22 March 2022 in London, United Kingdom. The Foundation believes that every child deserves a chance to live after any suffering from any form of neurological condition. Every year over 300,000 children attend A&E in the UK with a head injury. Website: www.tr-foundation.org

This episode is hands-down one of Sean's favorites to date... This episode exposes the Medicare Administrative Appeals Process for what it really is... Smoke and mirrors! The fact is, even if you prevail at the ALJ level there is a significant chance you can still lose the case based on an AdQIC referring the case to the Departmental Appeals Board (DAB)!

Sean is definitely in a rare and irritated mood, which makes this episode that much more enjoyable!

Charity of the Month - The Tafida Raqeeb Foundation was formally launched on 22 March 2022 in London, United Kingdom. The Foundation believes that every child deserves a chance to live after any suffering from any form of neurological condition. Every year over 300,000 children attend A&E in the UK with a head injury. Website: www.tr-foundation.org

For the first time in 25-years the Office of Inspector General is updating the Compliance Program Guidance (CPG) for the entire healthcare industry! No more are the days of searching and reading the Federal Register... What will be the new delivery method? Tune in to find out!

Jenna K. Godlewski - Jenna focuses solely on health care law and assists medical practices across the country on reimbursement, regulatory, and compliance matters. She helps clients reduce exposure, develop corrective action plans, and successfully appeal Medicare, Medicaid, and other federal payor recoupment claims. Another primary focus of her practice is handling CMS enrollment issues, payment suspensions, and revocation/exclusion appeals. Since joining the firm, she has also had the opportunity to assist clients with developing and restructuring their internal compliance programs.Jenna served for three years as a prosecutor for the City of Chicago where she handled over 100 cases at a time from filing through resolution. This experience has been beneficial in her current work of representing her clients in Administrative Law Judge hearings to appeal Medicare overpayments and in supporting her colleagues on healthcare litigation matters.Please take a look at our Charity of the Month - The Tafida Raqeeb Foundation was formally launched on 22 March 2022 in London, United Kingdom. The Foundation believes that every child deserves a chance to live after any suffering from any form of neurological condition. Every year over 300,000 children attend A&E in the UK with a head injury.Website: www.tr-foundation.org

In this final episode of Season 5, Terry and Sean sit down to discuss concierge medicine and health coaches... when, where and how these services come into play and the pitfalls with providing them.

The entire #allstar panel (Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I Stephanie Allard, CPC, CEMA, RHIT Scott Kraft and John Paul Spencer) are back and armed with a ton of new information to discuss and offer solutions for!

coding and #compliance are the focus and the topics will include:

A breakdown of #telehealthservices now that the #publichealthemergency is over May 11th (or is it for these services...)
Handling #diagnosis code Denials...
Split/Shared Services; these will lead to #audits and #overpayment demands...
Cut and Paste (#cloning) in the #inpatient setting... is there a smart-phrase that can help mitigate risk?
5. #cigna and the #modifier25 conundrum...

Terry joined Sean to discuss all the intricacies and pitfalls of the three-midnight- rule... Didn't know there was one, well there is. The dynamic duo also took on the two-midnight-rule just to cover all of the bases!

Sean was joined by Colin Callahan of Flannery Georgalis, LLC and Jeana Singleton of Brennan Manna Diamond to discuss issues impacting #healthcareprofessionals in the #coding, #auditing, #compliance, #documentation, and #leagal areas of healthcare!
Todays Topics Include:
The intersection of prevention and prosecution/enforcement
How preventative measures help defense
Recent DOJ guidelines (self-referrals, cooperation by entities, etc.)
The value of active compliance program
Self-reporting of issues
Telehealth
Expiration of the PHE
Telehealth and lab marketing
Proposed DEA rules
and so much more!

Terry and Sean take on the coding and compliance surrounding Urgent Care Centers and Retail Clinics and all of the "gotchas"... There are a lot of hidden gems in this one.

The all star panel of Terry Fletcher, Stephanie Allard, Scott Kraft and Paul Spencer are back to take on Auditor vs. Coder! Sounds contentious but the fact is, this was a dynamic discussion with a ton of thoughtful dialogue!

Robert Liles and Ashley Morgan join Sean to discuss the power of UPICs and their reach and affirmative actions! This was a brilliant discussion. Don't miss this one!

Terry and Sean are at it again with another hard-hitting topic impacting health care operations... identifying a problem but not wanting to issue a refund! This one gets interesting.

Sean was joined by Terry, Scott, Stephanie, Paul as they took on the biggest issues in healthcare!
Topics Included:
1. RPM and RTM services, the difference between them and the difference between RPM and CCM and why these services are such a high priority target for CMS, OIG and commercial insurance (hint: telehealth!
2. HIPAA - enforcement is on the rise and things you do every day without knowing may be causing you a reportable event...
3. Bio Fire - what are these services, how were they used during the PHE and why are so many insurance companies coming after providers now...
4. What to do with a payer that is jerking you around but they only make up 5% or less of your payer population... and so much more!

Terry and Sean sat down to discuss the impact of prescription drug management and the impact on the overall level of EM Service. Take a listen, you might be surprised by this discussion!

Sean was joined by John Paul Spencer Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM Stephanie Allard, CPC, CEMA, RHIT and Scott Kraft to discuss all of the big events impacting #healthcareoperations!

So much to discuss including:

ChatGPT and its impact on #physician documentation
Sub-regulatory guidance and the False Claims Act
E/M Visits when the patient is not part of the visit
Cigna and Claims Rejections

Don't miss this one!!!

Assistant Attorney General and the head of the Criminal Division at the Department of Justice, Kenneth Polite sits down for a candid discussion with Sean to explore a variety of topics including:

Why compliance programs are so important to DOJ...
The benefit of Compliance Certifications
Proffers where corporate attorneys are driving the responses vs the compliance officer of the organization...
Regulatory changes for telehealth services
The Ryan-Haight Act, what is it and its impact on prescribing narcotics...
Telemedicine fraud since the PHE... and
The Criminal Division’s Corporate Enforcement Policy (CEP)

This is a discussion you cannot afford to miss!

Terry and Sean discuss the critical importance of completing medical records and closing them within the time requirements established by state and federal requirements. What are the potential penalties for non-compliance and how do you argue technical violations...

In this episode, Sean is joined by Ashley Morgan (Partner) and Robert Liles (Founding Member), of Liles / Parker, LLC to discuss Medicare Suspensions and Revocations, what are they, how are they different and how do you get them reversed. There is a great discussion about UPICs, OIG, DOJ, and Medical Boards. There is so much to unpack in this great issue!

Don't miss this one.

On March 15th Sean put out a blog post on Cigna and their new demand for documentation when an EM and minor procedure is performed on the same day with the modifier 25 appended. Don't miss this one!

In this episode Sean breaks down the False Claims Act and the Health Care Fraud Statute. This is a very detailed breakdown of both laws with some insight to the proposed language change to the Medicare Voluntary Refund (60-Day Rule).

Terry and Sean sit down to discuss the latest investigation and prosecutions tied to telehealth services performed by providers engaging in contractual arrangements with 3rd party telefraud companies to perform medical necessity reviews for DME prescribed by other providers! You do not want to miss this one!

In this episode Sean is joined by the all star cast of subject matter experts to discuss topics impacting healthcare operations and compliance!

It's all about under-coding.

The full cast of #characters is back for another #allstart panel discussion on #thecomplianceguy!

This is a show you are not going to want to miss:

Computer Assisted Coding (CAC) - What is it and the reasons why providers are facing potential #falseclaimsact allegations!
The routine waiver of co-payments and/or deductibles - What the OIG and DOJ have to say about it, and why it's illegal!
Coding certifications - The state of coding and what's transpiring that puts the industry at significant risk!

Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM Stephanie Allard, CPC, CEMA, RHIT John Paul Spencer and Scott Kraft (from Hawaii) will be joining me.

Robert Liles, ESQ. sat down with Sean to discuss an array of topics impacting and potentially impacting health care providers and professionals in the near future! There is so much to unpack in this episode...

Jordan Johnson sits down with Sean to discuss the FTC proposal regarding Noncompete Agreements, Hospital CEO Salaries vs. Nurses and so much more!

Terry joins Sean to discuss Incident-to and all the headaches that comes with billing this provisional service.

Once again the all star panel of subject matter experts (Terry, Christine, Scott, Paul, and Stephanie) join Sean to discuss some of the most pressing issues impacting the healthcare industry!

Medicare ABN vs. Commercial Payer Waiver of Liability
EM Services - How and when time drives pre 2021 services
The ins and outs of psych services
Mergers and take-overs in healthcare and the potential impact

Terry joins Sean to discuss the end of the PHE and the little known gotchas waiting on the other side. Don't miss this vital information to ensure you are in compliance come May, 2023!

Sean was joined by his all star cast of characters to discuss HIPAA Breaches and OIG Compliance. There is also a discuss about catching a hacker who recently tried to pull a scam on Sean! A great episode you do not want to miss.

Terry and Sean discuss the audio only telehealth services and the implications for getting it wrong if you do not document these time based services correctly.

Sean was joined by the all star cast of characters (Terry, Stephanie, Scott, and Paul) to discuss the latest in coding and compliance headaches impacting health care providers! Topics included:

CMS conference call on the end of the public health emergency.
What is a medically appropriate history and examination for EM Services...
Coding for Psychotherapy Services and then the complexity of adding an EM Service.
Split/Shared Services and CMS' inconsistencies.

Jordan and Sean explore the intersection of compliance and the business of medicine. Lots going on in this episode regarding the end of the pandemic and its impact on operations, the continued issues with the independent dispute resolution and much more.

Terry and Sean take on Time Based Coding... This is a lively discussion about high-risk service and how to mitigate risk!

The all star cast of characters is back again to discuss bad decisions made by physicians and what can be done to ensure the train doesn't derail! Great discussions and great interaction with the viewers from the live stream!

Don't miss this one!

Sean and Jordan sit down to discuss the end of the Public Health Emergency (PHE), what that means for the waivers and flexibilities afforded during the PHE and the Good Rx FTC Settlement!

This episode is a little salty so take it with a grain of salt!

The one and only Clint Pulver sat down with Sean to discuss effective leadership and what it takes to become an effective leader! Clint shares his insights into what makes an effective leader and how to keep your team engaged!

Don't miss this awesome interview with a true leader and a great person!

Sean and Terry sit down to discuss Addendums, Late Entries, and Corrections... This one is a must listen to since so many, make lots of mistakes on when and how to address these things!

The all star panel is back for another bite at the apple! Great discussion on incident-to, inference when it comes to medical documentation to support billing of ancillary services, split/shared services, and much more!

Jared Walker, CEO of Dollar For joins Sean to discuss the world of medical debt and hospital charity care. This is an episode that whether you are a hospital C-Suite or consumer of health care services at a hospital you are not going to want to miss. Jared exposed the dark-side of medical debt and how to detect the schemes and scams some try to get over on the unsuspecting.

Don't miss this one!

Visit Dollar For at: www.dollarfor.org

Dollar For is the official charity of The Compliance Guy Podcast for the month of February! Let's Crush Medical Debt!!!

Jordan sits down with Sean to discuss some of the more interesting, political and hairbrained issues impacting healthcare operations and compliance efforts!

Topics include:

ChatGPT - is this Artificial Intelligence (AI) really here? How is it and will it impact billing, coding, compliance, clinical care, documentation, and operations? Who’s afraid of ChatGPT? AI in healthcare could save $360B (mmm-online.com)
Rural Healthcare - The continued shortage, hospitals shutting down and equity in healthcare.
Digital Healthcare - Envelop Please

Rural Hospital Crisis - Magnolia Tribune

https://ontheflyingbridge.wordpress.com/2023/01/22/digital-health-in-2023-envelope-please/

What this could mean:

ChatGPT passes MBA exam given by a Wharton professor (nbcnews.com)

In this episode Sean is joined by the full All Star Panel (Christine Hall, Paul Spencer, Scott Kraft, Stephanie Allard, and Terry Fletcher)! Topics include:

Changes to the United Health Care Appeal Process
Rendering Telehealth Service over state lines
Behavioral Health and the increased interest in auditing these services and why
The Reasonable, Necessary Standard established by CMS

Such a dynamic discussion!

Terry joins Sean to discuss Chronic Care Management (CCM) Services, what they are, how they are billed, and what documentation is required to support them. But, what happens when you get it all wrong or don't have documentation to support the billing and reimbursement of these services?

Jordan Johnson sits down with Sean to discuss the ins and outs of the FTC Proposed Rule on Non-Competes for Employees. This is a full breakdown of the proposed rule. The conversation then shifts to physician shortages by specialty and what should and can be done about it.

Below are the 2 links from the show:

Percentage Change in the Number of Active Physicians by Specialty, 2016-2021 | AAMC

Non-Compete Clause Rulemaking | Federal Trade Commission (ftc.gov)

Terry joins Sean to discuss training and education, or lack thereof at the payers and why they are not being held accountable! If you don't like humor skip the first 12 minutes but if you enjoy humor and fun stories listen to the who episode!

Monday's Roundtable on the compliance guy podcast will be a lively discussion about #payeraudits and what to do when the "letter" arrives!

Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I John Paul Spencer Stephanie Allard, CPC, CEMA, RHIT Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM and Scott Kraft will provide insight into why:

Having great #yelpreviews won't protect you against being audited...
Steps to take when #adr letter, audit #letters are received...
Missing #deadlines and why that leads to #recoupments...
Why size doesn't matter...

There is so much to unpack in this one!!! Don't miss this #allstar panel at 12pm EDT / Monday, January 16, 2023!

In this episode Jordan Johnson sits down with Sean to discuss operational concerns in physician practices driving them to abandon their practice and join large groups, hospital networks, and integrated delivery health systems. The discussion the transitions to the impact of nurse strikes and what it will take to get them aligned with their employers. This episode is a bit charged but hey, someone has to stand-up for America's Elite!

Terry joins Sean for a discussion on what it means to stay in your lane and not create liability situation for your clients or yourself. This episode gets a bit salty so buckle up and enjoy the ride!

This was one of the best episodes of our Monday Roundtable! Sean was joined by Stephanie Allard, Terry Fletcher, Scott Kraft, and Paul Spencer. Topics included:

Dealing with Commercial Payor Demand for Refund of Overpayments, when they say they did a statistically valid random sampling that led to an extrapolated overpayment.
The No Surprises Act and the change to how the process works based on CMS sneaking in a change prior to Christmas after making promises they would not change.
How to deal with "clinical plagiarism" in 2023 with the changes to EM Guidelines.
The impact of terms like Fraud, Waste, Abuse when speaking to providers.

You Do Not Want To Miss This One!

Salvador Hernandez, Senior Compliance and Ethics Advisor at Husch Blackwell joins Sean to discuss the state of compliance... Topics of discussion include:

The DOJ Corporate Crime and Compliance Initiative: Where are We Now, One Year Later? (a high-level survey)
Disclosure to the Government—the why, how and when (discussion of the DOJ’s expectations, the pros and cons of disclosing)
Compliance Officer Certifications—A good or a bad thing? (capitalizing on the significant recent discussion of this topic)
Compliance via Compensation (discussion of DOJ’s focus on the compensation as a means of incentivizing and disincentivizing behavior)
Conducting Internal Investigations (a primer on conducting successful internal investigations)

As a former senior executive with the Federal Bureau of Investigation (FBI)

Sal began his career inside government with 25 years at the FBI, where he rose through the ranks, via numerous assignments, from Special Agent to executive-level positions at FBI Headquarters in Washington, DC, the U.S. Embassy in Mexico City, and the FBI’s Los Angeles Field Office. At FBI Headquarters, as Deputy Assistant Director in the Criminal Investigative Division, he had oversight responsibility for the FBI’s Financial Crimes and Public Corruption Programs. In Los Angeles, he held the title of Assistant Director and served as the office’s chief executive, with responsibility for the work of more than 1,300 FBI employees charged with carrying out the FBI’s criminal, counterterrorism and national foreign-intelligence responsibilities in Southern California. Sal followed his FBI career with a career in the private sector where, first as Security Director, and then as Vice President of Compliance and Ethics, he expanded the security and investigations programs and established and led the legal and regulatory compliance efforts at Enterprise Holdings, Inc., the world’s largest vehicle rental, leasing and sales company.

Sal is uniquely suited to collaborate closely with attorney teams and clients to strategize at all stages of investigative and compliance-program work. He has experience building compliance structures for clients and is equally adept at program review, risk assessment, crisis response and mitigation.

phone: 314.345.6193 fax: 314.480.1505

email: sal.hernandez@huschblackwell.com

Ronald Chapman II, Esq. LLM of Chapman Law Group | Health Care Attorneys sits down with Sean to discuss his full trial acquittal in United States vs. Lesley Pompy, MD.

You do not want to miss this one because what happened to Dr. Pompy can happen to you!

This is the very first episode of the newest segment on The Compliance Guy... It is not J2, it's J-Squared with Jordan Johnson, Healthcare Data Analytics Expert! Such a great first episode and the topics will not disappoint:

Omnibus bill includes relief from Medicare cuts, extensions of rural and telehealth programs

1.7 trillion dollar package and what it means for healthcare

· Telehealth provisions

· Medicaid coverage

· No mention of prior auth

Prior auth bill

· Go live January 2026

· API utilization

Access to care and what will need to be tackled

· Fewer physicians in specialties

· Fellows and residency going to urban areas

Hospital closures

631 rural hospitals at risk of closure by state (beckershospitalreview.com)

More rural hospitals will close in 2023 - Poynter

Rural hospital closures affect operations of surrounding hospitals (medicalxpress.com)

Terry Fletcher joins Sean for the very first #TerryTuesday episode of 2023 to discuss the Medicare Fee Schedule Change and What it Really Means! As they say... watch out for the ole bait and switch! While Congress indicates a slight bump was given to the conversion factor the reality is, it was still an overall decrease. Terry and Sean explain it all in this episode.

The All Star Panel was back together for an outstanding first roundtable of the year! Sean was Joined by Terry, Christine, Scott, and Paul to discuss 2023 EM Services for the Inpatient setting, Split/Shared Services, Corporate Compliance Programs, HIPAA, and much more!

In this episode Sean takes on H.R. 8800 (The Supporting Medicare providers Act of 2022)... Medicare Providers are facing a potential cut in reimbursement of up to 8.4%. However, if your contracts are paid at a % of Medicare your commercial contracts may be taking up to the same 8.4% cut.

H.R. 8800 was referred to the Subcommittee on Health back on September 14, 2022, but there’s been crickets ever since… the question is why and whether Congress (who by the way does not have to worry about healthcare in the same way civilians do) realizes that if these cuts hold up, there will be a mass exodus from the Medicare System. Providers will either retire early or shut their doors to Medicare and any insurance company that follows suit with reducing provider fees. The industry is already facing a crisis with respect to a shortage in physicians, couple that with what COVID-19 did to the industry with mandatory shutdowns and closures of surgery rooms and ASCs for elective surgeries and now a looming cut based on a reduction to the conversion factor and a PAYGO Sequestration cut, and you have a situation that the industry and patients may never recover from.

H.R. 8800 introduced by Congressmen Bera and Bucshon looks to amend title XVIII of the Social Security Act to extend certain increases in payments for physicians’ services under the Medicare program through 2023. “It is the sense of Congress that the Secretary of Health and Human Services, the House of Representatives, and the Senate should commit to take administrative and legislative actions to—

(1) ensure financial stability and predictability in the Medicare physician payment system;

(2) promote and reward value-based care innovation; and

(3) safeguard timely access to high-quality care by advancing health equity and reducing disparities”.

In this final #TerryTuesday episode, Sean and Terry tackle the OIG Report on improper payments for Co-Surgeons and assistants at surgery! Such an important topic to round out the year!

It is that time of the year where we begin to wrap-up our current efforts and prepare for the year that awaits us!

This is the FINAL #thecomplianceguy podcast of 2022 and we are going out in style!

Join John Paul Spencer Stephanie Allard, CPC, CEMA, RHIT Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I and Scott Kraft in a #coding and #compliance roundtable discussion on what #compliance and #audit professionals can realistically be doing to get ready for the changes coming January 1st.

Reviewing #EMR’s and how #data information is displayed, which can hurt leveling an encounter if there is a lack of detail.
Places #coders and #auditors need to look when auditing #inpatient notes in 2023 and why....
Preparing for an audit and what to do when you receive an ADR or CERT audits... What do you send and how do you ensure you are not wrung-up for non-compliance:
A. can they send original records
B. Can they make addendums before they send out the records (yes they’ve already been billed)
C. The didn’t meet the deadline request so can they just send a letter saying they are too busy to comply but will try and send next year (wait what?)…

Don't Miss This One!!!

Sean and Terry take on the HHS-OIG Report on Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic... The report makes you questions who's on these committees and why we spend so much of the taxpayer money that we do on reports that can be written by an 8-year-old! Since he stayed in a Holiday Inn Express recently, Sean shares with you his clinical insights on a couple of conditions that reading this report will help with! Don't miss this one! Here is a link to the report... Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic OEI-02-22-00150 11-30-2022 (hhs.gov) Don't forget to check us out at www.thecomplianceguy.com or visit Terry at www.terryfletcher.net

In this Episode the entire All-Star Panel is back together to discuss the latest most pressing coding and compliance issues healthcare organizations are facing! The panel takes on Computer Assisted Coding (CAC) and the problems that come with this technology as well as the significant differences between office, inpatient and facility coding when it comes to EM Guidelines.

Such a great episode! Don't Miss This One!

Shay Eskew joins #thecomplianceguy tomorrow at 11am right here on #linkedinlive for an insightful discussion on life, surviving, healthcare and so much more. PLEASE DO NOT MISS THIS ONE!!!

Shay is the CSO of CirclesX – a technology company & the Chief People Officer of Shay Eskew – Motivational Speaking and Consulting. He is an All-American & top 1% All World ranked #ironman triathlete, burn #survivor with scars over 65% of his body and a sought out international motivational #speaker.

Despite being told he’d never compete in sports again at the age of 8, Shay is living testament to “Anything is Possible”: 45x IRONMAN finisher, 4x member of Team USA, and has competed in 12 triathlon world championships in 9 countries on 5 continents, including the IRONMAN World Championships in Kona, and most recently in Nice, France in 2019 – all of this despite not being able to sweat on 1/3 of his body due to his scars.

His mantra has always been to not merely be a “finisher” but to be a “competitor.”

Shay is a healthcare disrupter, RCM strategist, Board Advisor, 6 Continent and 45x IRONMAN finisher, Medicare + Medicare Advantage Recovery, 5x Dad, Best Selling Author and Motivational Speaker

His Book: What the fire ignited – How life’s worst helped me achieve my best - the trials and tribulations he was forced to face while recovering from his burns and reclaiming his life as an athlete. (https://lnkd.in/dQm6DrWP)

The all star cast of characters is back as they join Sean to discuss 2023 em services and the impact changes have and will have on your coding and compliance!

Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I / Scott Kraft Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM / Stephanie Allard, CPC, CEMA, RHIT / John Paul Spencer will join me to discuss how the AMA has added so much new instructional guidance in 2023 CPT® guidance (the green stuff) beyond the codes themselves.

Many (most) coders or providers assigning codes, or worse the EMRs with NPL may not educate themselves on these priceless updates, especially if using an encoder or CACS.

The panel will focus on Medicare because they are disagreeing on the AMA's position for #prolongedservices, also multiple same day #hospital visits for the same condition, when a patient goes from the ER or office to Inpatient.

For more information on our cast visit them here:

www.doctors-management.com

www.terryfletcher.net

www.stirlingglobalsolutions.com

www.namas.co

Terry joins Sean to discuss a variety of coding and compliance related topics including the critical importance of following instructions and complying with published guidance. The conversation also addresses the Clean Claims Payment (42 CFR 447.45), Christmas Trees and being a farmer... Enjoy!

For more information on Terry and her service offerings visit her at www.terryfletcher.net

In this episode Collin Callahan of Flannery Georgalis joins Sean to discuss what a prosecutor / defense counsel looks for in an expert, why expert reports are so critical, the dos and don’ts of SMEs and their reports, Daubert Motions vs Motion in Limine, and more... There are even some tributes to Runaway Jury and a Few Good Men! Don't miss this outstanding episode with one of Sean's favorite guests!

In this episode Sean hits on a Daubert Motion, which is a type of motion which seeks to exclude the presentation of an expert's testimony to a jury. Daubert motions are named for the Supreme Court case, Daubert v. Merrell Dow Pharm., Inc. (509 U.S. 579 (1993)). Rules 702 and 703 of the Federal Rules of Evidence govern the admission of scientific evidence in federal court. The rules allow expert witnesses greater leniency in their testimony because it is presumed that the expert will have a reliable basis in knowledge and expertise in their field. The court in Daubert required that trial judges act as a gatekeeper and determine the scientific validity of scientific evidence before admitting it.

So much to address in 15 minutes. Don't miss this one if you are or planning to be an expert in a trial.

Terry joins Sean to discuss Compliance Programs and Obligations for participating with all insurance companies... The difference between compliance plans and compliance programs, why compliance fails in smaller practices and how things like the No Surprise Act impact your efforts!

There's also a discussion about a pink comfy, Tom doing laundry and making coffee, and so many other things to keep you entertained.

On this Monday roundtable discussion Sean is joined by Terry Fletcher, Christine Hall, Paul Spencer and Scott Kraft to discuss coding and compliance issues plaguing hospitals and physician practices. The panel addresses providers creating and signing notes prior to ever seeing the patient, cloning, clinical plagiarism, impact of not having a compliance plan, and so much more.

Dawn Carter, Director of Product Strategy of Centauri Health Solutions joined Sean to discuss Risk Adjustment Audits and the ins and outs of these often times annoying administrative requirements if you participate with an MA Plan... This was such an interesting discussion and we believe you will think so too!

Links to articles from the show:

Article 1: Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,’ Part 1: The Risk-Score Game - https://www.healthaffairs.org/do/10.1377/forefront.20210927.6239/full/

Article 2: Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,’ Part 2: Building On The ACO Model - https://www.healthaffairs.org/do/10.1377/forefront.20210928.795755/full/

Article 3: Halvorsen/Crane rebuttals: https://www.healthaffairs.org/do/10.1377/forefront.20220106.907235and https://www.healthaffairs.org/do/10.1377/forefront.20220203.915914/

Article 4: Gilfillan and Berwick rebuttal to Halvorsen and Crane: The Emperor Still Has No Clothes: A Response To Halvorson And Crane - https://www.healthaffairs.org/do/10.1377/forefront.20220602.413644

Article 5: Kang/Duncan/Hunh response: Making The Right Diagnosis: A Response To Berwick And Gilfillan - https://www.healthaffairs.org/do/10.1377/forefront.20220706.909897/

About Dawn Carter:

Her career in healthcare spans 28 years, which most recently includes extensive experience in developing revenue integrity and quality software solutions, with a focus on encounter management, risk adjustment, and social determinants of health solutions for Medicare Advantage, Medicaid and Commercial health plans, as well as providing risk adjustment strategic advisory services for these markets. Prior to that, her experience spans all domains of health care including health plan and provider systems administration, finance, compliance and healthcare applications development inclusive of EDI and X12 and HL7 development. Her experience also includes multiple teaching engagements in medical administration, billing and coding. Dawn holds a Bachelor’s degree in Business Administration, and she holds the American Association of Professional Coders CPC (Certified Professional Coder), CRC (Certified Risk Adjustment Coder), and CPMA (Certified Professional Medical Auditor) credentials. She is also a Certified Scrum Product Owner (CSPO). Dawn is a passionate and prolific industry speaker, author, blogger and subject matter expert in claims, EDI management, and risk adjustment.

Terry joins Sean to discuss the ins and outs of Medicare Advantage (MA) and what you really need to know about these plans. Why is the OIG investigating MA plans and what are they finding. Don't miss this one!

Sean was joined by an all star panel of guests including Christine Hall, Paul Spencer, Terry Fletcher and Scott Kraft to discuss "Scary Scenarios" they've each dealt with over the past week and what you need to know to avoid the same costly mistakes as others... Don't miss this one as it's an absolute fright!

In this episode I am joined by Stephen Soloway MD FACP FACR to discuss his new book "Medical Politics" This dynamic book shows you through a Non-Fictional lens health care's landscape and all that is wrong with it!

You can find the book on Amazon (https://lnkd.in/gP4UrfWh), at Target or at Barns & Nobel Book Store or wherever books are sold!

In this episode of the Daily Dose Sean discusses and reads the Foreword of Dr. Stephen Soloway's new book "Medical Politics" This dynamic book takes you through a Non-Fictional lens of health care's landscape and all that is wrong with it!

Terry Fletcher joins Sean on this #TerryTuesday Episode of The Compliance Guy to discuss Time Based Coding, Las Vegas, The Steelers and other fun facts! Don't miss this one as Sean and Terry hit their stride!

Terry Fletcher joins Sean to discuss the PHE and its impact on the healthcare industry! No matter what side of the isle you sit on this should not be a political issue but rather a business and compliance issue and that is what Sean and Terry focus on!

Don't miss this one!

On this roundtable Sean is joined by Terry Fletcher, Karen George, Stephanie Allard, Christine Hall, and Paul spencer for a discussion on the following:

Information Blocking Rule
No Surprises Act / Independent Dispute Resolution
Preparing for a Payor and/or Contractor Audit
MDD Audits and their impact on HCCs

This is part 2 of the series on using the Gap Analysis to develop and implement an effective compliance program in your organization... Do not miss this episode because Sean delivers the punchline!

In this episode Sean takes on the critical aspects tied to GAP analysis and what they are, how to perform one and how it impacts your ability to build an effective compliance program, which leads to demonstrating a "Culture of Compliance"!

Don't miss this one!

This is an awesome episode with my very good friend Terry Fletcher. Take a listen as our answer(s) may shock you!

After a week of being off for Conferences Sean is back with an all new episode... Today's focus is delivering audit results to providers in the most effective and efficient way!

Terry joins Sean to discuss a variety of topics including ablations, bilateral services and other nuanced issues impacting health care organizations. Don't miss this one!

Terry Fletcher, Christine Hall, Scott Kraft and Paul Spencer joined the Coding and Compliance Roundtable to discuss a host of critical topics including:

Evaluation and Management Services - What does it mean to take a clinically relevant history and examination
Telehealth Services - The Challenge Continues
Incident-to Services - Can a Physician bill Incident to another physician and can a non-credentialed NP, CNS or PA bill incident to a credentialed physician - MAKE SURE TO LISTEN TO THIS SEGMENT ALL THE WAY TO THE END TO ENSURE YOU DO NOT MISINTERPRET ANYTHING!

Sean was joined by Scott Kraft, Christine Hall, Paul Spencer, Stephanie Allard and Terry Fletcher to discuss all of the latest in the world of coding and compliance.

In this episode Sean and Terry tackle "Split Visits" not to be confused with "Split-shared Visits"... E/M Services on the same date as a preventive service have and continue to cause a lot of confusion for coders and billers. Hangout with us for a bit and let us clear up the confusion.

In this episode Sean takes on Templated Compliance Plans and the Do's and Don'ts! Taking the time to understand how compliance templates work for and against you is critical to establishing an effective program. The key takeaway from this podcast should be, “Don’t Be Lazy” if using a template… spend the time and effort on the front end to save you money, and your sanity on the back end.

What do you do when you receive "The Letter"? Everyone gets at least one from a payer/investigator/contractor that makes your belly gurgle and sends you searching for the Imodium AD! Take a listen to this episode for the Do's and Don'ts and how best to respond to the dreaded letter!

In this episode I take on the lack of auditing standards in healthcare and push for standardization... There is no doubt we work in one of the most regulated and complex industries and at times it leads to a misinterpretation of Acts, Guidelines, Laws, Regulations and Statutes, and because of the complexities we deal with, it also leads to folks to taking shortcuts that in the long-run lead to critical problems.

Take a listen and let me know if I have convinced you for why we need standards.

In this episode Sean and Terry provide a comprehensive list of acronyms in healthcare from the obvious to the obscure. There is also talk of The Show Friends, Sean's beard, and much more. There is also, a complete list of Sean and Terry's Acronyms available on LinkedIn on Sean's feed.

In this 20 minute episode I discuss the dos and don'ts of handling an onsite investigation/audit and steps to take prior to something like that ever happening.

In this episode I take on provider legibility. I know you are on an EMR but take a listen to this 13 minute episode to find out how a technical violation results in significant demands for refund by payors. I break down how payors try to use sampling and extrapolation without actually using the words but findings other synonyms to try to make it look less like they are doing something they should not be doing...

In this episode Sean and Terry take on non-compliant providers and the liability it creates for "anyone" who knowingly submits claims in violation of the False Claims Act... Sean also gets to practice his Latin, which is quite entertaining!

In this quick 15 minute episode Sean discusses the 2022 FCA increases for penalties and discusses the False Claims act and qui tam lawsuits.

Joining Sean is special guests Attorney Colin Callahan of Flannery / Georgalis and Eric Rubenstein, Ret. OIG Agent of Advize Healthcare. The roundtable discussion will be Private Equity (PE) and the pitfalls of engaging both as the investor and as the portfolio company.

There is ton to explore and we are sure you will walk away with a better understanding of how best to engage with PE!

Don't forget to visit us at www.thecomplianceguy.com

In this episode Sean takes on the Eliminating Kickbacks in Recovery Act of 2018 (EKRA), the little known law passed in 2018... Congress enacted EKRA, a law to fight patient brokering and recovery profiteering. The law prohibits accepting or paying kickbacks for referrals to recovery homes, clinical treatment facilities, or laboratories. EKRA combats opioid related fraud.

Give me 20 minutes and I will give you EKRA tied up in a nice bow!

Don't forget to visit us at www.thecomplianceguy.com

In this episode Sean and Terry take on HIPAA and OSHA in a Post Pandemic Work World... The do's and don'ts and all the in-betweens. The wheels on the bus while they do go round and round, start to come off in this one and you don't want to miss it!

In this episode of The Compliance Guy Monday Coding and Compliance Roundtable, you missed an outstanding panel discussion with Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I Stephanie Allard, CPC, CEMA, RHIT John Paul Spencer and Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM!

Tremendous interaction by the viewers and out standing topics:

Macro statements and their impact on documentation
Surgical Package and how it differs payer to payer
Adding ancillary services without understanding federal/state guidelines
Proper use of Modifier 22

In this 15 minute episode Sean tackles the issues with routine waiver of copays and/or deductibles, professional courtesy, and the potential implications with the FCA, Health Care Fraud Statute, Anti-Kickback Statute, and Stark Law.

Sean addresses the Special Fraud Alert from OIG on why it's illegal for "charged-based" providers, practitioners and suppliers to Routinely Waive Copayment and Deductibles!

https://oig.hhs.gov/documents/special-fraud-alerts/876/121994.html

In 16 minutes Sean breaks down the 2010 Affordable Care Act (ACA) and its mandate on establishing a compliance program (Core Elements). The breakdown includes:

Mandatory Compliance and Enforcement
The implementation of the 60-Day Rule and how it actually works
The Relator (qui tam) Bar and Effective Changes under ACA

In this episode, Sean and Terry take on questions from listeners and subscribers...

Topics:

Telehealth
Documentation Requirements for Telehealth
Use of Locum Tenens
Independent Dispute Resolution (IDR - Surprise Bills)

The Compliance Guy Coding and Compliance Roundtable this week was simply put, Awesome! Guests Stephanie Allard, CPC, CEMA, RHIT Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I John Paul Spencer and Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM provided outstanding insight on a variety of topics and the engagement from the audience was fantastic!

Topics Include:

Laboratory services - the issues between ordering physicians and labs...
The use of templates for procedures and how they do not always support the service or drug codes being billed and
The use of "smart" EMR's that are intended to code for a provider and why a human (certified coder) still needs to review documentation to determine medical necessity if the providers are not changing what the system auto selects for them...
HIPAA and OSHA Compliance in the Remote workspace for Healthcare Professionals. OSHA is now knocking on doors of employees homes and they are being told that their "work space" is not compliant.
Internal audits vs. external audits. What is better for medical practices?

Don't miss these subject matter experts as we discuss and debate all that is coding and compliance!

Colin Callahan of Flannery Georgalis, LLC sat down with Sean on Friday, August 12, 2022 to discuss the Ruan ruling by the Supreme Court. This ruling has and will continue to impact the litigation landscape significantly for matters tied to the Substance Control Act (SCA)!

High profile cases have already been impacted and several that are pending decisions by Prosecutors to dismiss or move forward on hang in the balance!

This is a critical discussion for physician providers attorneys complianceofficers administrators and healthcare professionals

Don't miss this one on LinkedIn Live! You can also find it on your favorite streaming platform (facebook twitter youtube stitcher) and immediately following the live program it will be available on your favorite podcast platform!

Steve Gallion, CEO of Medtrainer sits down to discuss all things compliance with Sean on this episode! The discussion covers the current landscape, ramped-up enforcement actions, and a bit about economics! Such an outstanding discussion with one of the industry's thought leaders! Don't miss this one!

About Steve Gallion

Chief Executive Officer

Steve’s passion for people and eye for market opportunities have led him to build several companies over the past 15 years that have brought benefit to healthcare. Today Steve is directly responsible for company vision and empowerment of the executive team to fulfill MedTrainer’s mission. Academically Steve holds multiple degrees from the University of California Riverside in Business Economics as well as his Juris Doctorate from California Southern Law. In his free time, Steve is active with his two children, enjoys outdoors, loves to read, has a passion for cooking, an affection for travel as well as doing his best to limit time in the gym while still being an active doughnut connoisseur. Steve loves building companies, loves technology, loves people, believes in inclusive leadership, and has a passion for enjoying the journey along each path he ventures down.

Visit their company here: www.medtrainer.com

Sean sat down with Scott Kraft, Senior Compliance Auditor for DoctorsManagement, LLC to discuss strategic defense litigation services and how those played a key role in the outcome of the United States v. Rajendra Bothra, et. al case on June 28th, 2022!

Here are some of the headlines in what is one of the Nation's largest heath care fraud cases.

"How 4 doctors beat the feds in botched $500 million pill mill case" (https://www.freep.com/story/news/local/michigan/macomb/2022/06/30/doctors-opioid-scheme-birmingham-bothra/7778004001/)

United States v. Bothra: (https://casetext.com/case/united-states-v-bothra-1)

"Michigan Physician Rajendra Bothra Acquitted in Prescription Drug Fraud Case After More Than 3 Years in Prison" (https://americankahani.com/community/michigan-physician-rajendra-bothra-acquitted-in-prescription-drug-fraud-case-after-more-than-3-years-in-prison/)

"4 Michigan doctors acquitted of charges in prescription drug scheme" (https://www.clickondetroit.com/news/2022/06/29/4-michigan-doctors-acquitted-of-charges-in-prescription-drug-scheme/)

Dr. Maheu joins Sean on this episode to discuss telehealth in behavioral health and the impact it is having on patient care. This is such an important episode for so many reasons especially coming out of the pandemic of the past 2 years! Do not miss this episode with one of the industry's leading voices on this topic!

About Marlene M. Maheu, PhD

Dr. Marlene Maheu started publically addressing telehealth in 1994 when she was invited to Chair a subcommittee at the American Psychological Association (APA) to examine Internet issues. Her early work was based on a self-funded, consumer-based behavioral health magazine dedicated to bringing behavioral information to the consumer public on the World Wide Web. Her interest in the legal and ethical aspects of using technology fueled her research, which led to invitations from no less than 7 established publishers in 1997 after speaking at the APA’s annual meeting. Those invitations launched her subsequent focus on professional writing and training about a legal and ethical risk management related to clinical interventions mediated through technology.

As the Executive Director of Telebehavioral Health Institute, Dr. Maheu has served on a dozen professional association committees to assist with developing telehealth standards, guidelines, and other consensus documents. She has published 43 book chapters and journal articles as well as 5 professional books related to telehealth practice. Dr. Maheu is a consultant, researcher, author, and trainer who has served more than 55,000 professionals from 109+ countries.

Learn more about her organization here: https://telehealth.org/marlenemaheu/

On this episode of TCG - The #TerryTuesday episode Karen N. George of Buchalter Law Firm joins Sean and Terry Fletcher to discuss payer contracting and all the ins and outs to ensure success!

Such a great episode!

About Karen N. George:

Karen George is an attorney at Buchalter in the Los Angeles office and is a member of firm’s Health Care Practice group. Karen specializes in managed care contracting and routinely represents healthcare providers in large exposure reimbursement disputes and litigation against payors. Karen regularly handles out-of-network reimbursement disputes, coverage disputes, coordination of benefits issues, and recoupment demands. Karen represents a diverse array of healthcare providers, including hospital systems, physician groups, ambulatory surgery centers, urgent care centers, outpatient clinics, billing companies, and telehealth companies. Karen has resolved significant disputes with payors, recovering millions of dollars for providers in civil actions and arbitrations. Karen received a bachelor’s degree in Psychology and Criminology from the University of California, Irvine and earned her law degree from Georgetown University of Law Center.

On this episode Terry Fletcher, Scott Kraft and Paul Spencer join Sean for their Monday Coding and Compliance Roundtable to discuss Cloning and Clinical Plagiarism and who is actually accountable for compliance within an organization.

This was a live stream with great audience participation and outstanding interaction between the panelists!

Alice Harris and Jenna Godlewski of Nexsen Pruet - Health Law Team join Sean to discuss The 2022 Strategic Plan also known as the "CMS Framework. The ladies identify Six Trends to Follow for the remainder of 2022 and well beyond, but they only scratched the surface! Here is the link to their article: Understanding the CMS 2022 Strategic Plan: Six Trends to Follow (nexsenpruet.com) The Six Trends focused on during our discussion include:

Medicare and Medicaid Beneficiaries Will Be Moved to ACO Contractors by 2030

Providers Will Be Subject to More Pre-Authorization Processes

Nursing Home Staffing Will Continue to Be Scrutinized

Expect Avalanche of New and Revised CMS Regulations

CMS’ Efforts to Ensure Prescription Drug Accessibility Will Include Increasing Use of Generics, Biosimilars, and Interchangeable Biologics

Expect CMS to Vastly Improve Access to Behavioral Health Services

This was a brilliant conversation you are not going to want to miss!

*There is an audio glitch in the very beginning as one of our guest's microphones was having some issues. We did the best we could to clean it up and think it turned out pretty okay!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

In this episode Sean takes on Modifier 25 and all the problems that comes with it. Critical explanations for how to properly define the modifier (significant and separately identifiable), NCCI Edit changes for 2022, OIG Report on Modifier 25, and how CMS and other payers are scrutinizing your claims!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

In this episode Terry joins Sean to discuss Transitional Care Management and Chronic Care Management and all of the auditing, billing, coding, and compliance information you need to get it right!

These are not profit centers, at least how they are structured so be careful and avoid the pitfalls associated with these services!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

On this episode Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM, Scott Kraft, Stephanie Allard, CPC, CEMA, RHIT Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I and John Paul Spencer join Sean live to discuss a variety of coding and compliance issues being uncovered in their daily auditing, coding and compliance activities on behalf of clients all across the United States!

Today's Topics Include:

Required OIG Compliance - Making sure you are in lockstep with the government
The Impact of Corrective Action Plans following a potential violation and how to ensure it's being adhered to
Preoperative visits billing for #emservices for the pre-op clearance in the same group that the surgeon/physician is a part of.
Laboratory services performed by critical access #hospitals for out-of-state providers leading to compliance #risks, and sometimes hospital closure

Don't miss this one!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

In this episode Sean sits down with Maggie Perritt - Medicare Compliance Officer for Mass Advantage (MA Plan) to discuss her role as a compliance officer for the plan, prior authorization, claims processing, claims adjudication, engagement with law enforcement and so much more!

Was a great discussion you will not want to miss!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

In this 20 minute episode Sean covers specific sections of the Medicare Program Integrity Manual (Chapter 3) as it relates to the Medicare Medical Record Review Standards and Requirements for MACs, RACs, UPICs, SMRCs, and CERTs... Don't miss this one especially if you are responsible for the appeals and adjudication of claims!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

Telehealth is the number 1 audit target for commercial and government payors. Whether it's originating site, place of services, interactive v audio only, requirements for documentation, etc. providers all over the country are struggling. Give us less than 50 minutes and we will make it all make sense!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

This Monday round table discussion was outstanding, with an amazing panel! I was joined by Christine Hall CHC CPC , CPB, CPMA, CRC, CEMC, CPC-I Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM John Paul Spencer, COC, CPC and Scott Kraft, CPMA, CPC!

We focused on the most pressing auditing billing compliance and coding challenges! Don't miss this outstanding panel discussion and remember, bring your questions and let our #smes sort out the complexities for you.

Footnote: Unfortunately Christine Hall lost power and had to join via iPad in the middle of a horrible storm in Florida so please excuse the issues with her volume.

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

Jordan Johnson, MSHA, iMPaCT of Oncospark joined Sean for an in-depth discussion! We focused on the major disconnects between operations and finance leading to the true dysfunction with patients.

Topics Include:

Private Equity and the impact on healthcare, and so much more!

This was a brilliant discussion with my good friend that if you miss you could very well regret!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

In this quick 15-minute episode Sean hits all the critical aspects of Modifier 59 and the more specific X-Modifiers. Think you know how and when to apply these modifiers and the potential risk(s) you face take a listen just to make sure!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

"Salty" Sean M. Weiss sits down with Terry Fletcher for their weekly #TerryTuesday to discuss telehealth place of service confusion, policies and procedures for split/shared services and a host of other issues creating "noise" and chaos in healthcare organizations! You definitely do not want to miss this one!

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote for The Compliance Guy Podcast in the 2 Categories mentioned above! Simply go to this link: https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

Terry Fletcher, Christine Hall, Stephanie Allard, and Scott Kraft Join Sean to discuss Auditing, Billing, Coding and Compliance in this 45-minute roundtable!

Topics Include:

Modifier 25 Audits (what is Cigna, Aetna and BCBS doing?)
Taking credit for interpretations (Impact on Medical Decision-Making)
Rheumatology Insights - Who do you need to listen to on infusions...
Templates and their impact on Level V EM Services Don't miss this outstanding panel of industry leaders!

Thank you for making us a Top 25 Podcast: https://lnkd.in/g3H9EH5w

The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened. Simply go to https://lnkd.in/grYHk-8P and register then it will take you to the nominations page for you to vote... Once you click on the "Andy Curry" and "Business" categories and you will find "The Compliance Guy" half way down... Click on it, then submit and you are done!

In this daily dose Sean tackles CMS's guidance on Coding Determinations when there are no coverage guidelines. The reasonable and necessary standards and limitations of liability are broken down in detail.

Sean was joined by Pat Marion of Compliance Concepts Inc (CCI) to discuss the world of regulatory compliance, the Office of Inspector General and how he and his team secured some of the largest settlements in the history of our industry. This was a great episode with a lot of great information you will not want to miss.

Pat Marion, one of the founders of CCI, addresses compliance, regulatory and audit issues for a number of health care companies and professionals. This includes the development of audit and statistical methodologies to resolve ongoing compliance issues. His clients range includes academic medical practices, large physician practices, health care systems, hospitals, nursing homes, DME suppliers, pharmacies as well as hospice and home health providers. In light of his extensive past professional experience, he is a recognized expert on issues related to the Federal False Claims Act as well as the Federal Anti-Kickback Statute and Stark Law. Accordingly, he is frequently called upon to assist clients in evaluating situations that may implicate those laws and to provide an assessment of the applicability to specific factual situations. Mr. Marion also assists clients in meeting the compliance requirements of Corporate Integrity Agreements (CIAs), and acting as an Independent Review Organization (IRO) for health care entities and practitioners that have entered into a CIA with the Office of Inspector General (OIG). He is often engaged to assess compliance in high risk areas with regulatory requirements. He also conducts due diligence compliance reviews for health care entities contemplating new business relationships. He performs forensic audits related to potential self disclosures to Governmental authorities, and is involved in counseling clients on risk assessment and remediation strategies. Mr. Marion has successfully completed voluntary disclosures for clients with the Department of Justice, the Office of Inspector General and local Medicare contractors. Mr. Marion participates and presents frequently at health care compliance forums on significant issues in the health care enforcement and regulatory arena.

Mr. Marion was a staff auditor and audit supervisor with the Office of Inspector General ("OIG") for the United States Department of Health and Human Services from 1974 to 1990. During that time, he had significant experience auditing providers to Medicare's regulations and policies with respect to various payment issues, including those related to physician payments. Mr. Marion also served as an audit manager with the OIG's Office of Audit Services from 1990 to 1997. As an audit manager in the IG's Region 3 office, Pat conducted numerous local and national audits on behalf of the Medicare program and has pioneered the use of the Federal False Claims Act to resolve certain healthcare related civil fraud investigations. Pat has attained national prominence as the national coordinator of the Physicians at Teaching Hospitals (PATH) initiative and has played leading roles in the DRG 72-hour window project and the Medicare credit balance investigation. He has significant experience auditing providers to Medicare's regulations and policies, and supervising others in their audit duties, with respect to various Medicare payment issues. Medicare credit balance investigation. He has frequently been called upon to provide briefings to congressional and high level departmental officials and has often been quoted in various national publications.

Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

In this episode Sean tackles "Marketing" under the Privacy Rule... What constitutes marketing and what is not marketing and when do you require an authorization from patients and when is it covered under Treatment, Payment and Operations. 15 minutes and it should all make sense!

This is TCGs 100th Episode and I could not have picked a better person to create the podcast with!!! In this #TerryTuesday episode we take on New vs. Established Patients and the contradiction in multiple areas between AMA and CMS. These are not as straightforward as everyone thinks they are.

We also tackle just the highlights of the 2023 EM Guidlines released by the AMA...

Yes, it is July 4th (Independence Day), 2022! Today, Sean focused on his Top 5 Compliance Risks for the remainder of 2022! Risk Areas included:

Information Blocking
Split/Shared Services 2022/2023 with a detailed explanation of what to expect...
Telehealth Services
Social Media
Evaluation and Management Services with a compare and contrast between CMS and Commercial Payers definition of "Medical Necessity"

On this episode of the compliance guy Ronald Chapman II, Esq. LLM of the The Chapman Law Firm sits down with Sean as they break down the $484 million dollar trail acquittal in the United States vs. Pain Centers case they just came off of!

This is an episode you cannot afford to miss because what happened to these doctors can happen to you!

Thank you for making us number 6 on the Top 25 Regulatory Compliance Podcasts: 25 Best Regulatory Compliance Podcasts You Must Follow in 2022 (feedspot.com)

Matt Lawhon and Eric Rubenstein sit down with Sean to discuss their former agencies inner workings and clear up the misperceptions on how an investigation at each of these entities is initiated and the actual steps taken during one!

Thank you for making us number 6 on the Top 25 Regualtory Compliance Podcasts: 25 Best Regulatory Compliance Podcasts You Must Follow in 2022 (feedspot.com)

Sean sits down with Frank Cohen, Director of Analytics and Business Intelligence for DoctorsManagement, LLC

Such an outstanding discussion on statistical sampling and post audit extrapolation! Spend some time with us to learn and better understand how to create a process from the start to avoid fatal flaws resulting in bigger problems and how to effectively challenge payers when they fail to follow statistical standards!

Frank Cohen's areas of expertise include data mining, applied statistics, and predictive analytics. In addition, he provides compliance risk analysis and meaningful assistance to healthcare organizations in the areas of process improvement, compliance, quality and profitability.

Frank works with a wide range of clients including solo-physician offices to practices with over 1,000 physicians, academic medical centers, cancer clinics, legal and accounting professionals, government agencies, and national associations such as MGMA and AMA. He and his team have worked with physicians and practices in nearly 60 different specialties and within every state in the U.S.

The author of several books, including his newest, “Don't Do Something, Just Stand There: A Primer for Evidence-Based Practice,” Frank is a sought-after speaker. He has participated in and published numerous articles and studies and trained thousands of physicians, administrators, CPAs and other healthcare professionals in all areas of healthcare analytics.

His experience also includes eight years as a physician assistant in both the Navy and as a civilian, clinic administrator and hospital CEO. Frank's clients appreciate his depth of knowledge and especially his ability to deliver complex analytical findings

CERT is a program that gets very little attention but still packs a significant punch with their ability to demand overpayment refunds and/or escalate potential fraud, waste, and abuse to law enforcement... Don't sleep on this one! In less than 15 minutes I break down all of the critical aspects of this program!

Terry and Sean take on Evaluation and Management Services (pre-2021) as it relates to audits and investigations like you have never heard it explained before. The fact that these services are low-hanging fruit and highly subjective make them the easiest of targets to go after!

What elements are really required for an established patient (2 of 3) and how does "Medical Necessity" really impact the overall level of service!

So much to unpack in this episode!

“The Godfather” of corporate governance and compliance joined Sean to discuss the False Claims Act, Regulatory Compliance Matters and what healthcare professionals should be aware of to avoid unwanted legal entanglements. As the Deputy Chief Counsel, Office of the General Counsel, United States Department of Health and Human Services, Dallas, Texas, Gabriel advised and represented various agencies of the Department of Health and Human Services, including the Center for Medicare and Medicaid Services, the Public Health Service, the Social Security Administration, and the Office of the Inspector General.

Gabriel's personal practice includes representing individuals and organizations accused of healthcare fraud and assisting and advising healthcare organizations on corporate governance and compliance matters. Gabriel is board certified as a specialist in Health Law by the Florida Bar.

Gabriel is a graduate of DePaul University College of Law and the University of Massachusetts. He is also certified in Health Care Compliance (CHC) by the Society of Corporate Compliance and Ethics and the Health Care Compliance Association (SCCE/HCCA). This national accreditation reflects a professional level of competence and experience in compliance processes sufficient to assist healthcare business organizations to understand and address legal obligations and to promote organizational governance and integrity through the operation of effective compliance programs.

Gabriel's specific practice areas include Federal Government Strategies, Healthcare Compliance & Operations, Healthcare Government Investigations & Litigation, Healthcare Qui Tam Investigations & Litigation, State & Local Government Relations, and HIPAA & Health Information Privacy & Security.

In this episode the panel takes on HCC Audits, Behavioral Health Issues in coding / documentation and the mass confusion that exists in Split/Shared Services and what you need to know to ensure you get it right in light of the final rule taking effect January 1 2023!

Yes, I know, Incident-To... but here's the thing, everyone is getting it wrong and that's a fact! Guess who makes the most mistakes with these types of services; Yep, you guessed it, the government! Give me 17 minutes and I will clear it up for you in easy to follow plain speak!

Is it or is it not a HIPAA violation??? Terry and Sean take on a topic that few enjoy but all must comply with!

This Daily Dose Episode focuses on when a payer can use statistical sampling and extrapolation... You may think you know the answer but take a listen and you might just be surprised.

"I'm the best. The Sharpshooter. The caviar. The Rolls Royce of Rheumatology" This is Stephen Soloway... and no one can dispute who he is or why he is the best! Sean spent more than an hour discussing a vast number of topics with Dr. Soloway regarding his book "Bad Medicine", the struggles he's had and continues to go through, battling the government and commercial insurance companies, beating Pancreatic Cancer, being elected into the Professional Sports Authenticators (PSA) Hall of Fame, and so much more! Dr. Soloway has dedicated his life to helping patients and colleagues. Patients come from around the world as well as from around the country to seek his help. Dr. Soloway's devotion to patient's needs have earned him Top Doctor Awards every year since 2003 and he is regarded as one of the leaders in the Philadelphia, New Jersey, and Delaware area for Rheumatologic care. He's recently written a book titled Bad Medicine: The Horrors of American Healthcare.

His credentials are as follows:

Nominated Chairman Department of Rheumatology Division of Internal Medicine Inspira Health Network
Clinical Associate Professor Rowan University School of Osteopathic Medicine
Adjunct Clinical Associate Professor Drexel University College of Medicine
Castle Connolly America's Top Doctor
Philadelphia Magazine and Inside New Jersey Magazine Top Doctor

As an industry leader he sits on numerous boards and panels within the pharmacology industry along with national advisory panels for all major companies involved in arthritis or osteoporosis research. He is known within the medical community as a medical detective and will proudly announce "If I can't fix you, I will get someone that can."

Dr. Soloway is involved not only in arthritis and osteoporosis treatment, but sports and occupational medicine as well. He runs osteoporosis, knee, and back pain clinics. Dr. Soloway enjoys giving back to the community thru charity and by teaching doctors from several medical institutions in New Jersey and Pennsylvania. He has been board certified in Internal Medicine since 1991 and Rheumatology since 1993 with specialized certificates in Osteoporosis

Today I tackled the Medicare Integrity Program and more specifically the UPICs and their actual role and clearing up routine misperceptions of what a UPIC actually does, how they do it and who they collaborate with.

This episode went a bit longer 18 minutes as there was just so much to unpack to ensure we didn't leave any stone unturned.

In this episode we look at one of the most critical aspects of Chapter 3 (Section 3.3.1.1) of the #Medicare Program Integrity Manual. This section speaks to #Clinical Review #Judgment and #Medical #Necessity. This section applies to the MACs, CERT, MRAC, SMRC, and UPICs and should be used by all #healthcareprofessionals to stand your ground against payers and their contractors!

So much to unpack in such a short period of time!

The #Modifier25 is leading to chaos and confusion... Tune in as we debunk the myths and set the record straight on what the payors are actually doing!

What an awesome panel discussion with Scott Kraft, Stephanie Allard, and Paul Spencer of DoctorsManagement! Show topics included:

CIGNA Policy Change on Modifier 25 (EM Services with Separate Service/Procedure on same date)
Urine Drug Testing - Screening vs. Definitive, when can a provider go straight to definitive testing, medical necessity, and the laboratory's responsibility
Coming out of the Pandemic and the biggest Audit Targets (Testing, EM Services, Telehealth, etc.)

Such a brilliant discussion with an outstanding panel!

CMS' Targeted Probe and Educate (TPE) is a critical process to understand since things can and do vary by MAC. Understanding the process is critical to ensure release from the program. In this episode Sean addresses all the critical aspects of the program, how a TPE Audit is initiated, and what is considered an acceptable error rate.

Don't miss this Friday episode!

This is such an important episode for those involved in FCA cases, OIG settlement discussions, and CMS Appeals... In this 13 minute episode we unpack the 2014 OIG Report "LOCAL COVERAGE DETERMINATIONS CREATE INCONSISTENCY IN MEDICARE COVERAGE", The 2019 Supreme Court ruling on Azar v Allina Health System and the difference between regulation(s) and guidance document(s)!

A lot of questions are asked about what to submit when an ADR is recevied for claims and what are the timeframes for submission of pre and post payment reviews. Take a listen to this insightful 10 minute segment on when and how to respond to an ADR

This episode was a ton of fun as we got to discuss #cms and #commercialinsurance surveys and the difference between patient experience and patient satisfaction since they are inherently different! A little bit about MACRA and MIPS but overall how your reimbursement is impacted!

I am going to say this up front... I was struggling with allergies today so there are approximately 6 times you will get to hear me cough/clear my throat ... I was going to have it clean/scrubbed but it would not have been ready today so, I am sorry for that (Terry don't kill me!) but, do not let it detract from the quality of the content!!!

Corrective Action Plans (CAPS) are critical to ensure providers are able to resolve allegations of wrong-doing. This episode addresses a lot of the nuacned aspects to building a successful CAP as part of an SDP or settlement agreement. Don't miss this critical episode.

If you would like a copy of the modle CAP created by Sean M. Weiss, email him at sstpierreweiss@drsmgmt.com

This is an awesome episode for so many reasons... Jacklyn DeMar joined Sean to discuss the role for TAF Education Fund to discuss whistleblower claims and the False Claims Act. It is so critical to understand all sides of healthcare compliance and how the law works so please do not miss this candid discussion!

Jacklyn DeMar is the Director of Legal Education at Taxpayers Against Fraud Education Fund, where she began as the staff attorney in August of 2014. In her capacity as Director of Legal Education, Jacklyn works with whistleblowers, their counsel, and government attorneys on various False Claims Act matters, as well as matters involving the IRS, SEC, and CFTC whistleblower programs. She files amicus curiae briefs in federal courts across the country – including the U.S. Supreme Court – and serves as editor-in-chief of TAFEF's legal periodical, the False Claims Act & Qui Tam Quarterly Review. She is also responsible for coordinating the TAFEF Annual Conference, the nation's largest annual False Claims Act conference.

Jacklyn has focused on False Claims Act and other fraud practice for most of her career, since graduating cum laude from American University's Washington College of Law in 2009. She has experience practicing at large Washington D.C. firms, as well as ample experience in the e-Discovery field from her experience working for one of the largest e-Discovery providers in the United States. She is a member of the Maryland and D.C. bars.

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

In this episode Sean tackles the 2021 report issued by OIG to address inappropriate billing for and overuse of spinal facet-joint denervation for pain management. In total, Medicare improperly paid physicians $9.5 million during the audit period of January 2019 - August 2020... This is a must for providers performing these procedures.

A whole lot to unpack in this one.

In this episode Sean addresses the policy change being pushed forward by Cigna requiring documentation to be faxed to a dedicated fax line beginning August 13, 2022 for EM Services (99212-99215) when billed with Modifier 25 and a minor procedure on the same day.

In this episode we discuss the federal Timely Claims payment Law and State Prompt Pay Laws. In this 10 minute segment a lot is revealed to ensure you're on the right track to getting your claims paid.

Brianna J. Santolli, Esq. of Riker Danzig Scherer Hyland & Perretti LLP joined Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM and Sean on a special episode of TCG / #TerryTuesday to discuss the updates of the #nosurprisesact...

There is a ton to unpack in this episode and there's no doubt things get a bit sideways with Sean driving!

Welcome to the “Daily Dose” on The Compliance Guy. Each day you will be caught up with a different event or multiple events in the world of healthcare. This segment is not meant to be a deep dive but rather a breakdown of what significant issue(s) government investigational agencies such as DOJ, OIG, FBI, OCR, CMS, and other healthcare contractors are focused on. Additionally, topics from the world of Auditing, Coding, and Operations will addressed.

These are 5–10-minute segments focusing on headlines, with a brief explanation of what you need to know to ensure your organization's operations and compliance initiatives are headed in the right direction.

Karen Weintraub joins Sean to discuss Special Investigative Units, the state of healthcare, fraud and the what the future holds. It is so critical to understand that not all who work on the payor side are "Out to get you" and that in a lot of cases healthcare professionals like Karen are trying to refute allegations of misconduct. Take a listen and we are sure you're going to agree, this was a fascinating interview with a fascinating healthcare professional!

About Karen:

Karen Weintraub is the Executive Vice President SIU for Healthcare Fraud Shield. As EVP, Ms. Weintraub is responsible for the design and development of the company's healthcare fraud detection software products and services. She provides subject matter expertise on system design and workflow, business rule development, data mining and fraud outlier algorithms as well as SIU policies and procedures.

Prior to joining Healthcare Fraud Shield, Ms. Weintraub was the Senior Manager of SIU Services at GDIT and the Supervisor of Investigations for Health Net, Inc. and managed all northeast healthcare investigations for all commercial, Medicaid and Medicare business and claims of fraudulent activity.

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

Terry Joins Sean on this episode to discuss Cloning and Clinical Plagiarism including the Do's and Don'ts of Electronic Health Records! A review of OIG's Report on EMRs (CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EMRs) and what leads to allegations of "Fraud".

What is copy-pasting? what is over-documentation? When is it okay to carry-forward information?

This is a topic that is not going away and as prevalent today as it was years ago!

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

My special guest will be Rozmin Bapat, Founder of CodeRite Healthcare Consulting. It was a fascinating discussion with a fascinating healthcare professional!

Rozmin and I got a chance to discuss a lot of different aspects of healthcare, a bit about her rise through the ranks and what inspires her to keep going!

Don't miss this outstanding episode!

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

In this episode Terry and Sean discuss accountability within CMS and more specifically Medicaid Telehealth Services (Quality of Care)... This episode is so important for so many reasons... take a listen and we are sure you will agree.

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

Renowned allergist / immunologist Naveen Sikka of US Allergy & Asthma sits down with Sean to discuss the world of Allergey / Immunology and Asthma... After his fellowship in St. Paul, Dr. Sikka was part of North Texas Allergy and Asthma Associates where he spent 8-years.

During our discussion Dr. Sikka and I discussed how biologics are impacting patient care, and tackled a bit of controversy; oral immunotherapy treatment (OIT).

Dr. Sikka shares his thoughts on payors, targeted audits, and what providers should be doing to sure up their documentation, ensure proper billing /coding and how to deal with medical necessity issues causing claim denials.

So much great information whether you are a provider or a patient, you do not want to miss this episode!

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

In this episode Terry Joins Sean to discuss the ins and outs of Locum Tenens and Reciprocal Agreements for Medicare. Lots to unpack in this episode including covered visit services, continuous services and the exception to the 60-days, global surgery package, modifiers and how physical therapists play into all this...

Don't miss this one!

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

Terry joins Sean to discuss whether to refund or not to refund on a variety of topics including Offshoring (CCM, TCM, etc.), Bundled Services, Durable Medical Equipment, and Amended Medical Records (Addendums, Late Entries, Corrections)...

Gray areas area addressed as well:

Internal or External Audit of E/M services finds level 5's are auditing at level 3 or 4.

Office Visits w/minor procedures not supported on same date.

99211 vs 93792 for Protimes (INR testing) when CMS strongly recommends the 93792 and discourages the 99211, but no published rules.

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

In this critical episode Sean is joined by Robert Liles, ESQ, and renowned opioid expert Dr. James Shear to discuss the ongoing crisis in America, increases in regulatory oversight, and prosecutors' focus on criminal prosecutions... Prescribers of narcotics need to be on-guard to ensure they are taking all necessary precautions to ensure patient compliance as well as their own.

It's no longer just a matter of determining what's in a patients' system but what isn't... diversion is a significant problem and providers have an obligation to ensure total compliance. The episode also covers how and when to discharge non-compliant patients and what providers need to do to cover their assets!

The increase in data-driven and "medical necessity" audits by government investigators and commercial payor special investigative units for billing presumptive and definitive urine drug tests and urine drug screens continue to plague practices, laboratories, and health systems across the country.

Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast:

https://blog.feedspot.com/regulatory_compliance_podcasts/

Don't miss a moment of this critical podcast!

In this episode Terry joins Sean to discuss the latest PHE Extension and what that means to the healthcare industry. What does this mean for the "Blanket Waivers" (1135) including physician services, telehealth services, dietary services, and more...

In this episode I taken on the SDP vs MVRP and provide a detailed breakdown of each as well as when to use each and when to avoid them... Elements covered in this episode include but are not limited to:

Fraud and Abuse Laws Overview

OIG Agency Breakdown

Anti-Kickback Statute, Stark Law, False Claims Act, Exclusion Statute

Duty to Refund, Generally

Discovery; Investigation process; Document retention

OIG Self Disclosure Protocol

CMS Self Referral Disclosure Protocol

MAC Voluntary Refund Processes

In this episode Terry joins Sean to breakdown OIG Self-Disclosure Protocol vs. Medicare's Voluntary Refund and what each means to your medical practice, hospital, health system, or organization. Things are off to a fast start right out of the gate. This is one of the best episodes yet for our dynamic duo!

It's #TerryTuesday on TCG and we are stoked to bring you this episode! Terry joins Sean to discuss Recovery Audit Contractor Audits (RACs) and their impact on healthcare operations... Sean and Terry have a whole lot of baggage to unpack on this episode regarding Local Coverage Determinations (LCDs), Local Coverage Articles (LCA) and National Coverage Determinations (NCDs)!

Chandler joins Sean to discuss the No Surprise Bill Act / Good Faith Estimate (GFE) on this episode! There is a ton to unpack as well as clear up.

Chandler works in the Nexsen Pruet's Columbia office and practices in the areas of healthcare and general business/corporate law. He focuses the bulk of his practice on assisting healthcare clients with regulatory, contractual, and transactional matters and has represented a wide variety of health care systems, hospitals, physicians, physician practices, and other healthcare providers and healthcare-related businesses.

Chandler joins Sean to discuss the No Surprise Bill Act / Good Faith Estimate (GFE) on this episode! There is a ton to unpack as well as clear up.

Chandler works in the Nexsen Pruet's Columbia office and practices in the areas of healthcare and general business/corporate law. He focuses the bulk of his practice on assisting healthcare clients with regulatory, contractual, and transactional matters and has represented a wide variety of health care systems, hospitals, physicians, physician practices, and other healthcare providers and healthcare-related businesses.

Chandler joins Sean to discuss the No Surprise Bill Act / Good Faith Estimate (GFE) on this episode! There is a ton to unpack as well as clear up.

Chandler works in the Nexsen Pruet's Columbia office and practices in the areas of healthcare and general business/corporate law. He focuses the bulk of his practice on assisting healthcare clients with regulatory, contractual, and transactional matters and has represented a wide variety of health care systems, hospitals, physicians, physician practices, and other healthcare providers and healthcare-related businesses.

Christine Hall joins Sean on The Compliance Guy Live to discuss the state of healthcare compliance, and the role auditors, coders, and billers play to ensure clean and accurate claims. What is CMS focused on with audits and what are some of the OIG hot targets providers need to be aware of...

Attorneys Jesse Whitten and Steve Lokensgard of Faegre, Drinker, Biddle & Reath, LLP join The Compliance Guy (TCG) to discuss Medicare's 60-Day Rule and its impact on Medicare Advantage and Medicaid Managed Care Plans.

The one, the only Eric Rubenstein joined Sean on the first episode of season 3 to ensure we came out of the gate swinging. The episode focused on all things OIG Compliance!

Topics:

UPICS
Telehealth
DoJ Prosecutions
Updates on Fraud, Waste and Abuse
Investigations by the OIG - How they start and how they escalate

In this final Episode of season 2 Terry and Sean discuss who bares the ultimate responsibility for the claims sent out the door to payors. What benefit if any does coder liability insurance have, what is required from an ethics and responsibility standpoint by the associations that credential or license a healthcare professional. What happens in a False Claims Act case, who is the likely target and who faces exclusion?

Do not miss this final episode of season 2 of The Compliance Guy!

Ronald Chapman, II joins Sean to discuss his new book Fight the Feds, "Unraveling Federal Criminal Investigations".

Do not miss this episode... there is so much to unpack. Whether you are a student of the law or you are an experienced attorney this book is a must for your shelf and this episode is a must for your here and now knowledge!

In this episode Terry joins Sean for their weekly #TerryTuesday on The Compliance Guy Podcast to discuss Revenue Cycle Management (RCM) and its impact on compliance efforts in physician practices, hospitals, and health systems. Additionally, Sean discusses how he uses RCM when investigating matters for administrative actions and/or trial.

This episode is packed with steps to take to ensure a thorough analysis of the revenue cycle as well as do's and dont's.

Terry Fletcher joins Sean for their #TerryTuesday episode and take on Levels III through V (ALJ, DAB and Judicial Review) of the Medicare Appeals Process to ensure listeners have a firm understanding for how to file an appeal at each level and what all is involved to ensure success. Don't miss Part II!

In this episode Sean sits down with Ashley Morgan of Liles Parker to discuss the Administrative Appeals Process within CMS and the recoupments after level II and recent rulings by the 5th Circuit Court of Appeals and other courts. Sean and Ashley provide insights for who's reviewing your claim(s), what the program integrity manual sets as Medical Record (MR) Scope of Work (SOW) for claims reviewers and how to ensure due process.

The episode also focuses on what leads to a provider's revocation of billing privileges with CMS and the steps that can be taken to reverse the revocation. Revocations are happening at a frenzied pace and before it happens to you, get the facts!

This is such a critical discussion for those who are responsible for filing appeals at a medical practice, hospital, health system, suppliers, or other types of medical organization.

In Part I of a II part series on appeals Sean and Terry tackle the Redetermination and Reconsideration in extreme detail.

What's Covered in Part I:

Terms to be familiar with

Areas of focus to determine if you should appeal

Pitfalls to avoid

Required timelines and forms to file your appeal

If you struggle with appeals this no nonsense, straightforward approach will set you on the path to filing winning appeals.

Jose "Joe" Vela Jr., J.D., LL.M. joins #thecomplianceguy podcast tomorrow (Friday / February 4th) to discuss Civil Investigative Demands (CID) issued by the Department of Justice (DOJ) and how the Office of Inspector General (OIG) is used to carry out the subpoena.

We will be discussing the False Claims Act (FCA), Health Care Fraud Statute, the significance of a compliance plan and creating a culture of compliance within your organization.

Recently transitioned from the Assistant U.S. Attorney's (AUSA) Office to private practice "Joe" discusses recent cases he prosecuted how cases turned from civil to criminal and what got culprits caught in the first case.

This is a fascinating discussion you will not want to miss especially when we lay out a roadmap for healthcare professionals and physicians to follow to ensure compliance.

You can find the podcast here on linkedin facebook youtube apple podcast spotify podcasts amazon iheart radio and more than 80 podcast platforms...

In this episode Terry and I attack audit targets all should expect in 2022 coming out of the pandemic. The year is already off to one of the fastest paces I have experienced in my 27 years of working in this industry.

Commercial Payer and CMS explanation for use of 99211 for covid screening and assessment
Evaluation and Management Service Audit Targets by OIG and Payers
Rituxan Audits and so much more!!!

This was such an amazing podcast with Dr. Laura Purdy, Chief Telemedicine Officer with Rise Health! There was so much to unpack on this episode from where we started with telehealth prior to the pandemic to where we are now, ethics and compliance risks, and the incredible things coming down the pike.

Dr. Purdy, Ret/Sr. Major, graduated Ball State University and then entered the military and attended the Uniformed Services University, the only Congress created medical school for the military!

Hang out with us for a while and learn all about this amazing lady's rise to prominence in the telehealth field!

In this episode I address at a high-level the Stark and Antikickback updates put into effect January 1, 2022! There is a lot to unpack in this episode.

As promised I am providing a link to the Federal Register for sourcing and further analysis of the rules.

In this episode Sean and Terry during their #TerryTuesday breakdown Credit Balances for the Centers for Medicare and Mediciad Services (CMS). Such a significant episode! Don't make the mistake of holding on to money that doesn't belong to you and wind up in a FCA situation!

Special guest Traci Brown, CSP joins Sean to talk about detecting lies, fraud and identity theft and the things she and investigators look for during interviews.

What does it mean to have shifty eyes? If you don't make eye contact does it make you a liar? What about body language, yawning, the Pan Am Smile, running feet, and so much more!

This is such a great interview with one of the Nation's leading authorities on dealing with deception!!!

Whether you are a consultant providing professional services or you're the client searching for a competent and qualified consultant, this episode is for you! Terry and Sean sit down to discuss how to write a winning proposal... This podcast is a step-by-step process to ensuring that expectations are met on the front-end by both the consultant and the potential client... Areas of focus include:

Where to start
Key Elements to the proposal
Key Definitions
The Rationale
General Description
Objectives
Costs
Development
Summary

This was such an insightful interview with one of the industry's best and brightest attorneys! Jeana sits down with Sean to discuss the rapid changing landscape in healthcare, changes to the CMS Physician Fee Schedule for 2022 (Changes to Physician Assistants (PAs) billing, the impact on Split/Shared Services and the impact the changes will have on the billing of Advanced Practitioners). We also discuss the ins and outs of Incident-To Services and the associated risks with this type of service provision.

The conversation shifts to how agencies are using data to investigate physician practices. There is so much that is discussed in this episode you won't want to miss it!

In this episode Sean takes on strategies for effective leadership... Yup, you read that correctly, "The Compliance Guy" is going back to his roots of practice management in this episode to share with you strategies to creating a roadmap to achieving your goals and objectives.

Prior to entering the world of compliance Sean cut his teeth in the world of practice management. Take a listen, you just might be surprised by what a regulatory professional knows about revenue cycle management, effective leadership, and strategic planning.

Episode Objectives:

Organization and Management

Personnel and Policies

Managed Care

Time Management

Financial Method, Billing Systems and Controls

In this episode, Sean brings to life his very good friend's Steve Verno's PowerPoint Presentation. Over the past several years Steve has suffered from a number of Transient Ischemic Attacks (TIAs) or mini strokes that have impacted his speech but not his ability to create amazing presentations on a number of topics.

Over the coming weeks and months Sean will be recording a number of Steve's presentations to share with all of you along with the actual presentation, which will be available via email request to either Steve Verno or Sean.

We hope you enjoy these presentations!

In this episode Sean addresses from a non-political standpoint the most recent court rulings in Louisiana, Missouri, and Florida and what the road ahead looks like if and when these cases are appealed.

In this episode Clint Pulver sits down with Sean to discuss mentoring, leadership and creating that single moment in time! There are so many aspects to this discussion that leaders, regardless of their industry or how large or small their organization is will be able to take away and begin implementing immediately! The key to any successful business is your employees and once they can say "I Love It Here" you have achieved the ultimate level of sucess!

Clints latest Book I Love It Here "How Great Leaders Create Organizations Their People Never Want to Leave" is available now at Amazon, Barns and Noble and where ever books are sold. Pick up your copy today!

Terry Joins Sean to discuss the Office of Inspector General (OIG) Work Plan! As the new year approaches you need to be prepared to conduct internal audits and the best thing to do is create an audit elements guide and set yourself up for success:

Topics of Discussion:

Breakdown of the OIG Work Plan
Audits of Emergency Room Physician Evaluation and Management Services
Audits of Autoimmune Disorder drugs for self-injection and/or infusion
Urine Drug Testing (UDT) for SUD's
Place of Service for Physician Services when Beneficiary is Inpatient (Part A)

This episode is jam packed with critical information and analysis to ensure you remain at the top of your compliance game!!!

It is #TerryTuesday and that can only mean my good friend Terry Fletcher is joining me for our special segement! This week we are tackling the UPICs and clearing up misperceptions and misunderstandings for who they are and what they actually do! You do not want to miss this one...

Brianna Santolli, ESQ and Terry Fletcher join Sean to discuss the realse on November 5, 2021 The CMS Interim Final Omnibus Rule followed by the OSHA ETS were released... These have been declared as "Mandates" but since their issuance there have been several legal maneuvers to block these mandates from being carried out. On Thursday November 11, 2021 several states led by Texas file a motion to block the mandates with the 5th Circuit Court out of New Orleans, LA. The filing was successful (Read my blog post on LinkedIn – Saturday November 13, 2021). On the same day the Department of Justice (DOJ) vowed to fight the block issued by the 5th to see that the mandates are enforced.

Several states have had their measures blocked as well declaring them unconstitutional! The legal battles are far from over! What is contained in this podcast are the facts of the mandates at the time of release!

In this episode Scott Kraft, Stephanie Allard and J. Paul Spencer join Sean to discuss the 2022 Physician Fee Schedule Final Rule, Evaluation and Management Service pitfalls in 2021 tied to the new guidelines and changes to the Split/Shared Services. Lots of great information that all healthcare professionals need to be aware of!

There was also a discussion of Chronic Care Management (CCM) Services and Incident-to, which got quite animated! Great episode with great guests and outstanding audience participation!

Karen joined Sean on this episode to discuss the TN Association and their incredible government and legal advocacy, comprehensive education opportunities, and the fact they are pioneers with their partnerships with the biggest insurers and governmental payers. Whether you are in the state of TN or not, you will want to hear what Karen and Sean discuss because it just may help you in your state!

Jared Walker, Founder of Dollar For (www.dollarfor.org) joined me for this critical discussion on the medical debt crisis! Jared inspires me every single day and he should inspire you as well...

Nationally, 17.8 percent of people with a credit report as of 2020 had medical debt in collections, and 13 percent had accrued debt in the prior year but were not yet in collections. Of those who had medical debt, the average amount was $2,424 last year. These findings are roughly in line with previous Census Bureau estimates.

The South has the most people with medical debts, or 23.8 percent of all residents, and the largest average amounts past due, as of 2020. The Northeast had the lowest debt loads, with 10.8 percent of individuals with credit reports in arrears, and the smallest unpaid tabs. People living in low-income areas owed the most, while those residing in high-income regions owed the least.

States that expanded Medicaid in 2014 saw a decline in the average yearly accrual of medical debt through 2020 that was 34 percentage points greater than states that did not expand their Medicaid rolls.

Almost all income groups in non-Medicaid expansion states saw their medical debts rise annually from 2009 to 2020. The poorest communities were most affected: In 2020, they added $836 on average in new medical debt per capita, up from an annual amount of $630 in 2009.

Between 2009 and 2020, total medical debt in collections decreased less than reductions in nonmedical debt. By 2020, individuals had more medical debt in collections than they had in debt in collections from all other sources combined, including credit cards, phone bills, and utilities.

The above statistics provided by the Stanford Institute for Economic Policy Research who indicated that the nationwide medical debt estimate is probably larger than $140 billion.

In this episode of TCG, Terry joins Sean to discuss the re-launch of the TPE Audit Program by The Centers for Medicare and Medicaid Services (CMS)... There have been some significant changes to the process so hang around until the end to make sure you capture all the critical information to ensure when you get "The Letter" you are prepared.

Welcome to season 2 of TCG. In my first episode we lay out how to level the playing field with payers and we did this! Here is what is included in this episode:

Ex-post Facto Guidelines and Laws
Understanding Payer Participation Agreements
Breakdown of Clinical Judgement, Medical Necessity, and The Treating Physician Rule
AMA Definition of Risk When Clinical and Non-Clinical Reviews are Deployed by Payors
Breakdown of Reasonable, Appropriate and Necessary

This was an incredibly special podcast for me as it is not often you get to say, "I got to interview an Emmy Award Winner"! My discussion with Clint Pulver (yes, that Clint Pulver) while short, the impact of his message will linger long after you reach the end!

Terry sits down with Sean for her #TerryTuesday discussion on the many payor audits providers can be subject to with a great breakdown of each!

Sean is joined by Jeanmarie Loria to discuss her evolution in healthcare from CPC to Managing Director (CEO) at Advize Health! The discussion takes an in-depth look into the current and future landscape of our industry. Jeanmarie provides invaluable insights and truly is a breath of fresh air and an inspiration for the younger, aspiring generation of healthcare leaders! She truly is one of the most interesting women in healthcare!!!

About Jeanmarie:

Ms. Loria provides quality consulting and project management services that accelerate clients' ROI and satisfaction. At Sunera Healthcare (now Advize Health), Ms. Loria streamlined operations and improved client retention resulting in a steady, ongoing stream of income. Ms. Loria‘s focus at Advize Health is to deliver the utmost quality of service in all Audit and Advisory services.

Previously with KPMG's North Florida Advisory Practice, Ms. Loria coordinated and executed testing efforts surrounding the healthcare industry to deliver process improvement and integration with data mapping, policy and procedure design and development, and organizational analysis and alignment. She performed integrated IT audit testing and reviews specific to healthcare and insurance organizations by analyzing business processes and assessing the effectiveness of controls surrounding key financial modules, general IT controls, and interfaces.

As a skilled project manager, Ms. Loria has an acute ability to focus on data flow and business applications by interviewing companies to develop an organized process overview, drilling into areas of potential weakness and then building plans to mitigate risk. She has a MBA with a concentration in Finance, and her certifications include Project Management Professional, Six Sigma Green Belt, and Conflict Resolution Mediator.

Dr. Kolinski joins Sean to discuss his latest book Work - Passion - Life Balance - and the process of "Reengineering"! The world we work in doesn't allow for many opportunities to balance the demands of the job and what we seek as fulfillment. Dr. Kolinski talks about what professionals should and can be doing to take the steps necessary to create that perfect work-life balance! Don't miss this insightful discussion!

If you missed this live episode you can catch the podcast here! I sat down with Ronald Chapman II, Esq. LLM Chapman II to discuss and breakdown the Biden-Harris Executive Order and its impact on approximately 100 million American workers! We address the "work-around" employed by OSHA as well as previous Supreme Court cases that could impact future litigation... This is a comprehensive explanation of where things are and what can be expected in the days, weeks and months ahead!

We then shift to the Garland Memorandum and what it means for the Session's and Brand Memos! You just might be surprised to learn what this all means to you!

This episode was previously live on LinkedIn, Facebook and YouTube and the video version is available if you prefer to watch it!

executiveorder #covidvaccinemandate #hospitals #healthsystems #physicians #nurses #providers #healthcareprofessionals #levelplayingfield #thecomplianceguy #OSHA #CMS #medicare

In this special episode Sean is Joined by Nationally Recognized Medical Auditors Stephanie Allard, Scott Kraft and J. Paul Spencer from the National Alliance of Medical Auditing Specialists (NAMAS) to discuss Risk Mitigation, Coding, Billing, Documenation and Audit issues providers, hospitals and health systems face daily!

In this episode Sean takes on The False Claims Act (FCA) and all the ins and outs of these type cases. Sean shares his insights and expertise in this critical area of regulatory compliance and health law. The importance of understanding this Act cannot be overstated.

In this episode Sean sits down with Ron Chapman to discuss Fraud, Waste and Abuse in healthcare, strategic litigation defense services and the never ending battle with the Department of Justice! This dynamic conversation is one you do not want to miss.

In this episode, Sean and Amanda sit down and discuss Information Blocking and the misperceptions and misinformation that exists. Providers (physician practices, hospitals, health systems, etc.) need to understand their obligation(s) to providing patients access to their protected health information in a readable/useable format in a timely manner... Failure to comply can have significant financial repercussions (up to $1 million in fines).

Don't miss this dynamic discussion!

This is the latest episode of The Compliance Guy... I sat down with Ray McGrogan and Steven Kleinberg, Co-founders of CardChoice International to discuss PCI Compliance and the misunderstandings between this and HIPAA Compliance and other little known facts about this type of compliance that is the responsibility of each entity and not your vendor or bank!

The guys did a great job of explaining so many aspects of credit card processing requirements and dos and don'ts and the trouble companies can get into for violating the rules... for example, surcharging a debit card whether or not a PIN is entered is a violation but yet so many business are doing it.

Tune in to this episode and walk away with more than you would have expected!

Today it was a privilege to welcome Terry Fletcher and Brianna Santolli on to the Compliance Guy Podcast to discuss Telehealth misunderstandings! Given the fact there is federal guidance, state guidance and then variances from state to state it's no wonder risk continues to increase while complete understanding for the requirements lags! Don't miss this in-depth discussion with two outstanding professionals who certainly have mastered their craft!

Topics of discussion:

Originating site.
Audio only vs. Interactive.
Compliant Platform(s) and the risks you face for non-compliance.
Licensure requirements for rendering services across state lines.
Potential for med/mal issues, telehealth/Telefraud schemes; and so much more!

Thank you to all my listeners/subscribers for tuning-in and listening to what I and my very special guests have to say on this critical topic and one that is sure to land at the top of every insurance payer and investigational agency if it already hasn't!

In this episode Sean and Scott Kraft discuss a few of the more pressing sections of the MPFS 2022 Proposed Rule including the Conversion Factor reduction and clinical labor cost reductions (Potential Specialty Financial Losers), Changes to Physical and Occupational Therapy and the use of PTAs and OTAs, and Split/Shared Service propsed rule changes. This is definitely not an episode you want to miss.

In this segment Sean discusses the ins and outs of building an effective compliance program. The seven steps outlined by the OIG are address in addition to step 8 (Risk Assessment). This is not just an introduction to compliance... Sean takes the time to engage in the various components to ensure your complete understanding.

In this segment attorney and former special investigator Matt Lawhon sits down with Sean to discuss the ins and outs of various 3-letter agencies and their contractors processes for conducting provider / health organization investigations and what providers need to understand once "The Letter" arrives or the investigator shows up to your practice/hospital. Matt clears up misperceptions surrounding what it is that a UPIC does (Investigate vs Audit) to ensure you understand precisely what is going on. This is a must listen to podcast...

In this segment David Glaser, ESQ sits down with Sean to discuss the misunderstanding between regulation and guideline. This is not a coding session about Incident-to, this is intended for auditor, compliance officers, providers and administrators to understand the operational risk(s) associated with billing Incident-to and how to mitigate your risk accordingly. This podcast is a must for anyone going through an audit or investigation or has a pending case against them. David provides a tremendous amount of insight into areas you think you know but may have interpreted wrong or have been taught wrong!

In this segment Scott Kraft sits down with Sean to discuss the ins and outs and dos and don'ts of Incident-to. This overly complex high-risk audit target continues to plague providers and confuse prosecutors and the investigators they rely on. Should you or should you not bill Incident-to... find out in this must listen to segment.

In this segment J.Paul Spencer sits down with Sean to discuss the critical importance of Local Coverage and National Coverage Determinations in addition to Local Coverage Articles when determining payment policy and responding to an audit! Is CMS the "Gold Standard"? A discussion regarding provider generated clinical summaries/rebuttals used during an appeal is addressed.

In this segment Sean discusses the steps and provides insight to the various regulations and other critical information to ensure you get your investigation right. Taking the time to do a bona fide investigation whereby every I is dotted and T is crossed is paramount to avoiding problems.

In this episode Sean and Jenna Godlewski, Special Counsel for Nexsen Pruet sit down to discuss CMS' Supplemental Medical Review Contractor (SMRC) and the impact they're having on providers, hospitals and health systems.

In this episode Sean sits down with Amanda Waesch of Brennan Manna and Diamond (BMD) to discuss Stark Law and the enfocement changes in 2021 and those coming in 2022...

In this episode Sean sits down with Jenna Godlewski, Special Counsel for Nexsen Pruet to discuss the Supplemental Medical Review Contracto (SMRC) and the disruption they are causing in the health space for providers, hospitals and health systems. Noridian is the SMRC for The Centers for Medicare and Medicaid Services and their reach is quite broad as you will come to learn during this segment.

In this segment Sean sits down with Amanda L. Waesch of Brennan Manna and Diamond (BMD) to discuss the November of 2020 Final Rule on Stark Law and Profit/Gain Sharing. This segment is a must for all provider groups, hospitals and health systems!

In this segment Sean discusses the DOJ Criminal Division's Evaluation of Corporate Compliance Programs. Sean breaks down various aspects of what most consider a prosecutors playbook. A discussion of conducting internal audits and developing corrective actions to ensure listeners are intune with what is required ensures risk mitigation.

In this session Sean discusses appeal strategies with a central focus on Medicare. Appeals are technical in nature but are a lost art and this podcast you'll understand how and when to appeal to the different levels. Specific terms are defined, forms are addressed, and processes for the 5-levels are broken down. A full explanation of the structural changes put forth in the 2017 final rule that were not well explained is finally provided...

If you have ever struggled with appealing claims to Medicare then this is a podcast you do not want to miss.

Fraud, Waste and Abuse continue to plague the healthcare system and drive consumer prices and medical practice costs sky-high. In this episode Sean discusses the ins and outs of conducting a fraud investigation in addition to various laws, statutes, regulations and Acts as well as requirements for a corrective action plan.

In this session Sean discusses how to determine whether a self-disclosure protocol through the OIG is the right decision for your medical practice/organization. This is an in-depth look into a complex process to ensure you make the right decision.

Sean discusses the importance of properly structured policies to ensure medical organizations position themselves to drive their "Culture of Compliance" and foster compliance with their employees. Sean also offers some outstanding giveaways to you the listener.

During this 45 minute podcast Sean provides providers and their staff the areas they need to focus to ensure a level playing field with payers. The areas of concentration are:

Ex Post Facto Laws and Guidance on post-payment reviews
Medical Necessity including Clinical Judgement and The Treating Physician Rule
Sources and Authoritative Guidance; where to look and what to avoid
Judgement Error and Provider Without Fault

In this episode we are joined by former Special Agent for the Office of Inspector General Eric Rubinstein, Chief Innovation Officer of OncoSpark Jordan Johnson and the Employmeny Law After Hours Podcast Team (Monica Andress and Bryan Meek)

https://www.youtube.com/watch?v=won0yKn6HUY&ab_channel=ComplianceGuyLIVE