Shows
The Compliance GuyEpisode 353 - #TerryTuesday - The Importance of Authoritative Documentation in HealthcareSummaryIn 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.TakeawaysHealthcare professionals often lack understanding of compliance...2025-03-0427 minThe Compliance GuyEpisode 352 - #TerryTuesday - Navigating HIPAA In A Post-COVID WorldSummaryIn 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.TakeawaysTerry and Sean both experienced health issues recently, leading to a brief hiatus.There has been a noticeable change in HIPAA protections...2025-02-2627 minThe Compliance GuySeason 8 - Episode 18 - Daily Dose - The Role of DOJ and OIG in Healthcare ComplianceSummary
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...2024-12-0235 min
The Compliance GuySeason 7 - Episode 49 - #TerryTuesday - When It's Clear As Mud!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...2024-09-1036 min
The Compliance GuySeason 7 - Episode 47 - #TerryTuesday - Navigating the Challenges of Telehealth Services and BillingIn 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
1. Understanding the...2024-08-2042 minThe Compliance GuySeason 7 - Episode 36 - #TerryTuesdayThis 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! 2024-07-0235 min
The Compliance GuyTCG The Best of The Best "Effective Leadership"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. 2024-01-2543 min
The Compliance GuySeason 6 - Episode -22 - Ronald Chapman II - Full Acquittal of Dr. KousaThe 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! 2023-08-0152 min
The Compliance GuySeason 6 - Episode 10 - Elliot Golding, Partner / McDermott Will & Emery LLPSean 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...2023-06-0136 min
The Compliance GuySeason 6 - Episode 2 - Legal with Liles / Parker - AdQICThis 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...2023-05-1253 min
The Compliance GuySeason 5 - Episode 25 - Monday Coding and Compliance RoundtableSean 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. 2023-02-221h 00
The Compliance GuySeason 5 - Episode 2 - #TerryTuesday - Medicare Fee Schedule Change and What it Really MeansTerry 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.2023-01-0332 min
The Compliance GuyTCG - Season 4 - Episode 48 - #TerryTuesdaySean 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...2022-12-0636 min
The Compliance GuyTCG - Season 4 - Episode 43 - Colin Callahan - What Prosecutors and Defense Counsel Look For In Expert WitnessesIn 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! 2022-11-2349 minThe Compliance GuyTCG - Season 4 - Episode 34 - #TerryTuesday - Time Based Coding... It's Not What You ThinkTerry 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! 2022-10-2539 minThe Compliance GuyTCG - Season 4 - Episode 33 - #TerryTuesday - Extension of the Public Health Emergency (PHE) and What it Means!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! 2022-10-1837 min
The Compliance GuyTCG - Season 4 - Episode 20 - #TerryTuesday - Healthcare Acronyms - The List Goes on and On and On...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. 2022-09-0654 min
The Compliance GuyTCG - Season 4 - Episode 17 - Non-compliant ProvidersIn 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! 2022-08-3036 min
The Compliance GuyTCG Daily Dose - Season 4 - Episode 11 - Routine Waiver of Copays and/or DeductiblesIn 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
2022-08-1917 min
The Compliance GuyTCG Season 4 - Episode 7 Colin Callahan of Flannery / GeorgalisColin 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...2022-08-1250 min
The Compliance GuyTCG Season 4 - Episode 6 - Steve Gallion of MedtrainerSteve 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...2022-08-1143 min
The Compliance GuySpecial Episode of TCG with Interview Performed by Scott KraftSean 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 Raje...2022-08-1037 min
The Compliance GuyTCG Season 4 - Episode 5 - Marlene Maheu, PhDDr. 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 b...2022-08-1049 min
The Compliance GuyTCG Season 4 - Episode 4 - #TerryTuesday on TCG with Special Guest Karen N. George, ESQOn 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 disp...2022-08-0941 min
The Compliance GuyTCG Episode 34 - #Terry Tuesday Jumping the Gun!"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 fo...2022-07-1237 min
The Compliance GuyThe Daily Dose / TCG - Episode 15 - Coding Determination without Coverage GuidelinesIn 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.2022-07-0813 min
The Compliance GuyTCG Season 3 Episode 32 - Pat MarionSean 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...2022-07-0755 min
The Compliance GuyThe Daily Dose / TCG - Episode 14 - HIPAA "Marketing"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!2022-07-0715 min
The Compliance GuyThe Daily Dose / TCG - Episode 13 - 4th of July Special Top 5 Compliance Risks for Rest of 2022!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:
5. Information Blocking
4. Split/Shared Services 2022/2023 with a detailed explanation of what to expect...
3. Telehealth Services
2. Social Media
1. Evaluation and Management Services with a compare and contrast between CMS and Commercial Payers definition of "Medical Necessity"2022-07-0431 min
The Compliance GuyTCG Season 3 Episode 30 - Breaking Special with Ronald Chapman, IIOn 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)2022-07-0251 min
The Compliance GuyTCG Season 3 Episode 29 - OIG, UPIC, MFCU - How The Programs Really WorkMatt 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)2022-07-011h 03
The Compliance GuyTCG Season 3 Episode 28 - The King of StatisticsSean 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...2022-06-3048 min
The Compliance GuyTCG Season 3 Episode 27 - #TerryTuesdayTerry 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!2022-06-2845 min
The Compliance GuyTCG Season 3 Episode 25 - The "Godfather" of Compliance“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...2022-06-2753 min
The Compliance GuyTCG Season 3 Episode 23 - #TerryTuesdayIs it or is it not a HIPAA violation??? Terry and Sean take on a topic that few enjoy but all must comply with!2022-06-2251 min
The Compliance GuyTCG Episode 22 - Stephen Soloway - The Best of The Best!"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...2022-06-171h 10
The Compliance GuyThe Daily Dose / TCG - Episode 8 - Targeted, Probe and Educate (TPE)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!2022-06-1012 min
The Compliance GuyThe Daily Dose / TCG - Episode 5 - Corrective Action PlansCorrective 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.com2022-06-0611 min
The Compliance GuyTCG Season 3 Episode 18 Taxpayers Against Fraud - Candid Discussion About the False Claims ActThis 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...2022-06-0342 min
The Compliance GuyThe Daily Dose / TCG - Episode 4 - MEDICARE IMPROPERLY PAID PHYSICIANS FOR SPINAL FACET-JOINT DENERVATION SESSIONSIn 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.2022-06-0310 min
The Compliance GuyThe Daily Dose / TCG - Episode 3 - Cigna Requires Documentation for EM Services and Modifier 25In 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.2022-06-0211 min
The Compliance GuyTCG Season 3 Episode 17 #TerryTuesday with Special Guest Brianna J. SantolliBrianna 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!2022-05-311h 02The Compliance GuyTCG Season 3 Episode 16 Karen Weintraub / Healthcare Fraud ShieldKaren 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...2022-05-1936 min
The Compliance GuyTCG Seasons 3 Episode 15 Cloning and Clinical PlagiarismTerry 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/2022-05-1736 min
The Compliance GuyTCG Seasons 3 Episode 13 U.S. Government Accountability Office (GAO) Medicaid and CMS Telehealth ReportIn 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/2022-05-1035 min
The Compliance GuyTCG Season 3 Episode 12 Dr. Naveen Sikka - Allergy and ImmunologyRenowned 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...2022-05-0556 min
The Compliance GuyTCG Season 3 Episode 11 Locums and Reciprocal AgreementsIn 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/2022-05-0352 min
The Compliance GuyTCG Season 3 Episode 10 #TerryTuesday To Refund or Not To Refund...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...2022-04-2652 min
The Compliance GuyTCG Season 3 Episode 9 Opioid Crisis and Increase ProsecutionsIn 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...2022-04-2257 min
The Compliance GuyTCG Season 3 Episode 8 #TerryTuesday - PHE ExtensionIn 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...2022-04-1952 min
The Compliance GuyTCG Season 3 Episode 6 #TerryTuesdayIn 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!2022-04-1254 min
The Compliance GuyTCG Season 3 Episode 5 with Terry FletcherIt'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)!2022-04-0545 minThe Compliance GuyTCG Episode 4 with Chandler MartinChandler 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.2022-04-0247 minThe Compliance GuyTCG Episode 4 with Chandler MartinChandler 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.2022-04-0247 min
The Compliance GuyTCG Episode 4 with Chandler MartinChandler 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.2022-04-0247 min
The Compliance GuyTCG Season 3 Episode 3 with Christine HallChristine 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...2022-03-251h 06
The Compliance GuyTCG Season 3 Episode 1 Eric Rubenstein - Ret OIG Special AgentThe 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:
1. UPICS
2. Telehealth
3. DoJ Prosecutions
4. Updates on Fraud, Waste and Abuse
5. Investigations by the OIG - How they start and how they escalate2022-03-1759 minThe Compliance GuyTCG Episode 26 with Terry Fletcher The Buck Stops HereIn 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!2022-03-1547 min
The Compliance GuyTCG Episode 25 Live with Ronald Chapman, II / Fight The FedsRonald 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!2022-03-1155 minThe Compliance GuyEpisode 24 TCG with Terry Fletcher - Revenue Cycle Management and Its Impact on ComplianceIn 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.2022-03-0854 minThe Compliance GuyEpisode 23 with Terry Fletcher Part II of The Medicare Appeals ProcessTerry 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!2022-02-2358 minThe Compliance GuyEpisode 22 TCG with Ashley Morgan of Liles Parker - Administrative Proceedings and Provider RevocationsIn 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...2022-02-1450 minThe Compliance GuyEpisode 21 TCG #TerryTuesday Medicare Appeals Part 1In 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.2022-02-0939 minThe Compliance GuyEpisode 16 TCG with Terry Fletcher Credit BalancesIn 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!2022-01-1837 minThe Compliance GuyEpisode 15 with Traci Brown - Lies, Fraud and Identity TheftSpecial 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!!!2021-12-1659 minThe Compliance GuyEpisode 14 - TCG - #TerryTuesdayWhether 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:
1. Where to start
2. Key Elements to the proposal
3. Key Definitions
4. The Rationale
5. General Description
6. Objectives
7. Costs
8. Development
9. Summary2021-12-1451 min
The Compliance GuyTCG with Jeana Singleton - Advanced Practitioner Billing, Data Mining by UPICS, CERT, RAC, MAC, and OIGThis 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...2021-12-0950 minThe Compliance GuyTCG - Part 1: The Best of The Best - What These Mangers Do to Sustain SuccessIn 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...2021-12-0943 minThe Compliance GuyTCG - No Surprise Billing Act - Steve VernoIn 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!2021-12-0817 minThe Compliance GuyTCG Episode 10 - CMS Omnibus Rule and OSHA ETS Court RulingsIn 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.2021-12-0224 minThe Compliance GuyTCG Live with Clint Pulver / I Love It HereIn 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...2021-11-2456 minThe Compliance GuyTCG with Terry Fletcher #TerryTuesdayTerry 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:
1. Breakdown of the OIG Work Plan
2. Audits of Emergency Room Physician Evaluation and Management Services
3. Audits of Autoimmune Disorder drugs for self-injection and/or infusion
4. Urine Drug Testing (UDT) for SUD's
5. Place of Service for Physician Services when Beneficiary is Inpatient (Part A)
This episode is jam packed with critical information and...2021-11-231h 00The Compliance GuyCMS Omnibus Rule and OSHA's Emergency Temporary Standard (ETS)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 th...2021-11-1453 minThe Compliance GuyTCG Compliance RoundtableIn 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!2021-11-041h 00The Compliance GuyTCG Live with Karen Baird / Tennessee Medical AssociationKaren 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!2021-10-2740 minThe Compliance GuyTCG with Terry Fletcher - TPE AuditsIn 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.2021-10-1944 minThe Compliance GuyTCG with Terry Fletcher - Payor AuditsTerry sits down with Sean for her #TerryTuesday discussion on the many payor audits providers can be subject to with a great breakdown of each!2021-10-0520 min
The Compliance GuyJeanmarie Loria - Managing Partner (CEO) Advize HealthSean 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...2021-10-021h 01The Compliance GuyInterview with Dr. Matthew KolinskiDr. 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!2021-09-2058 minThe Compliance GuyCompliance Audit RoundtableIn 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!2021-09-101h 00The Compliance GuyThe False Claims ActIn 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.2021-08-2752 minThe Compliance GuySuper Lawyer Ronald Chapman, II of Chapman Law GroupIn 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.2021-08-271h 13The Compliance GuyInformation Blocking with Attorney Amanda Waesch of BMDIn 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!2021-08-2752 minThe Compliance Guy2022 Medicare Physician Fee Schedule Proposed RuleIn 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.2021-07-2236 minThe Compliance GuyBuilding of an Effective Compliance ProgramIn 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.2021-07-0642 minThe Compliance GuyUPICs - A Former Investigator's InsightsIn 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...2021-07-0152 minThe Compliance GuyIncident To - A Legal Perspective with David GlaserIn 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!2021-07-0140 minThe Compliance GuyIncident-to with Scott KraftIn 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.2021-06-3040 minThe Compliance GuyThe Gold Standard for LCDs and Clinical Summaries/RebuttalsIn 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.2021-06-3040 minThe Compliance GuyPerforming an Effective Compliance Probe / InvestigationIn 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.2021-06-2959 minThe Compliance GuyEpisode 3-2In 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.2021-06-2833 minThe Compliance GuyEpisode 3 - Part 1In 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...2021-06-2834 minThe Compliance GuyEpisode 3 - 2In 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.2021-06-2833 minThe Compliance GuyEpisode 3 - P1In 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!2021-06-2834 minThe Compliance GuyDOJ Evaluation of Corporate Compliance ProgramsIn 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.2021-06-2539 minThe Compliance GuyCreating and Structuring Winning AppealsIn 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.2021-06-211h 04The Compliance GuyConducting a Fraud InvestigationFraud, 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.2021-06-0838 minThe Compliance GuyA Compliance Officer Roadmap to Self-Disclosure ProtocolIn 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.2021-06-0850 minThe Compliance GuyAudit Escalation and Non-Retaliation PoliciesSean 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.2021-06-0126 minThe Compliance GuyStand Your Ground With PayersDuring 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:
1. Ex Post Facto Laws and Guidance on post-payment reviews
2. Medical Necessity including Clinical Judgement and The Treating Physician Rule
3. Sources and Authoritative Guidance; where to look and what to avoid
4. Judgement Error and Provider Without Fault2021-06-0145 min