The Compliance Guy

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

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

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

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

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

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

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

1. Traveling overseas and needing medical attention... who is going to pay for it?

2. Modifier 25 CMS/AMA Joint Definitional Change...

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

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

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

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

Don't miss this one!

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

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

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

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

About Dr. Ward:

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

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

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

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

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

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

You're gonna love this one!

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

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

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

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

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

Topics Included:

1. Split/shared services – the definition of substantive portion will remain the same as it is now through 12/31/2024... Time will not be the controlling factor. HX, EX, and MDM can be used to make this determination of the substantive portion.

2. Extend flexibilities for certain assessments furnished via audio-only communication, through the end of CY 2024. If finalized, opioid treatment programs (OTPs) would be allowed to bill Medicare when video is not available, using technology permitted by the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Administration (SAMHSA). This extension would equalize telehealth flexibilities across providers of care and negate potential service disruptions due to the end of the COVID-19 public health emergency (PHE).

3. CMS proposes several additions to covered telehealth services under the MPFS, as well as an extension of several telehealth provisions from the Consolidated Appropriations Act (CAA) of 2023. Proposed changes include the add-on of health and well-being coaching services on a temporary basis (specific diagnoses and licensure/certifications will apply), as well as a refined process to review requests to add services to the Medicare Telehealth Services List. Telehealth provisions extended through December 31, 2024, will include:

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

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

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

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

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

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

4. There is a proposed reduction to the 2024 conversion factor that would reduce provider reimbursement. CMS is urging Congress to create a permanent fix for this issue but as it stands now, the proposed rate reduction stands. CMS is also proposing significant increases in payment for primary care and other kinds of direct patient care with the HCPCS add on G2211.

5. The proposed rule includes a new benefit category wherein family therapists, marriage therapists, and mental health counselors would be able to bill Medicare (Physician supervision necessary). Additionally, CMS proposes changes in payment and coding to account for resources utilized in the delivery of care involving a multidisciplinary clinical team and other staff members.

6. The Proposed Rule has significant implications for other virtual care and care management services, including Remote Physiologic Monitoring (“RPM”) and Remote Therapeutic Monitoring (“RTM”) services. Below is a summary of key provisions in the Proposed Rule relating to RPM, RTM, and other virtual care management services, along with opportunities and challenges for stakeholders in the space.

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

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

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

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

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

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

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

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

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

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

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

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

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

About Hassan F. Abdallah

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

compliance with extensive experience in designing and managing compliance based solution

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

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

requirements through a strategic and analytical view. 

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

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

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

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

the Dearborn and Dearborn Heights communities. 

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

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

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

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

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

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

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

Data Protection.

Prior to joining HAP, Hassan

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

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

1. AI and the impact on healthcare...

2. Q3014 Site of Service Fee Differential...

3. Patient Centered Care...

4. Statistically Valid Random Sample (SVRS) when and how can it be used...

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

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

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

About Ashley Morgan:

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

About Robert Liles:

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

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

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

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

About Elliot Golding:

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

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

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

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

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

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

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

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

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

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

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

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

1. Mayo Clinic

2. AdQuic Process

3. The end of the PHE and Telehealth Services

4. Cigna and their Modifier 25 Policy, and so much more!

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

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

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

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

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

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

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

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

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

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

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