The Compliance Guy

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: 1. Computer Assisted Coding (CAC) - What is it and the reasons why providers are facing potential #falseclaimsact allegations! 2. The routine waiver of co-payments and/or deductibles - What the OIG and DOJ have to say about it, and why it's illegal! 3. 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! 1. Medicare ABN vs. Commercial Payer Waiver of Liability  2. EM Services - How and when time drives pre 2021 services 3. The ins and outs of psych services 4. 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:  1. CMS conference call on the end of the public health emergency.  2. What is a medically appropriate history and examination for EM Services...  3. Coding for Psychotherapy Services and then the complexity of adding an EM Service. 4. 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:  1. 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)  2. Rural Healthcare - The continued shortage, hospitals shutting down and equity in healthcare.  3. 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: 1. Changes to the United Health Care Appeal Process 2. Rendering Telehealth Service over state lines 3. Behavioral Health and the increased interest in auditing these services and why 4. 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: 1. Having great #yelpreviews won't protect you against being audited... 2. Steps to take when #adr letter, audit #letters are received... 3. Missing #deadlines and why that leads to #recoupments... 4. 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:  1. 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.  2. 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.  3. How to deal with "clinical plagiarism" in 2023 with the changes to EM Guidelines.  4. 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. 1. Reviewing #EMR’s and how #data information is displayed, which can hurt leveling an encounter if there is a lack of detail.  2. Places #coders and #auditors need to look when auditing #inpatient notes in 2023 and why.... 3. 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:  1. Information Blocking Rule 2. No Surprises Act / Independent Dispute Resolution 3. Preparing for a Payor and/or Contractor Audit  4. 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:  1. Evaluation and Management Services - What does it mean to take a clinically relevant history and examination 2. Telehealth Services - The Challenge Continues  3. 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:  1. Macro statements and their impact on documentation 2. Surgical Package and how it differs payer to payer 3. Adding ancillary services without understanding federal/state guidelines 4. 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:  1. Mandatory Compliance and Enforcement 2. The implementation of the 60-Day Rule and how it actually works 3. The Relator (qui tam) Bar and Effective Changes under ACA

In this episode, Sean and Terry take on questions from listeners and subscribers...  Topics:  1. Telehealth  2. Documentation Requirements for Telehealth  3. Use of Locum Tenens  4. 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: 1. Laboratory services - the issues between ordering physicians and labs... 2. The use of templates for procedures and how they do not always support the service or drug codes being billed and 3. 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... 4. 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. 5. 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:  1. Required OIG Compliance - Making sure you are in lockstep with the government 2. The Impact of Corrective Action Plans following a potential violation and how to ensure it's being adhered to 3. Preoperative visits billing for #emservices for the pre-op clearance in the same group that the surgeon/physician is a part of.  4. 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:  4. 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:   1. Modifier 25 Audits (what is Cigna, Aetna and BCBS doing?)  2. Taking credit for interpretations (Impact on Medical Decision-Making)  3. Rheumatology Insights - Who do you need to listen to on infusions...   4. 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: 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"

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: 1. CIGNA Policy Change on Modifier 25 (EM Services with Separate Service/Procedure on same date) 2. Urine Drug Testing - Screening vs. Definitive, when can a provider go straight to definitive testing, medical necessity, and the laboratory's responsibility 3. 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: 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 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. 1. Commercial Payer and CMS explanation for use of 99211 for covid screening and assessment 2. Evaluation and Management Service Audit Targets by OIG and Payers 3. 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: 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. 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: 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 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: 1. Ex-post Facto Guidelines and Laws 2. Understanding Payer Participation Agreements 3. Breakdown of Clinical Judgement, Medical Necessity, and The Treating Physician Rule 4. AMA Definition of Risk When Clinical and Non-Clinical Reviews are Deployed by Payors 5. 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: 1. Originating site. 2. Audio only vs. Interactive. 3. Compliant Platform(s) and the risks you face for non-compliance. 4. Licensure requirements for rendering services across state lines. 5. 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: 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 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