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The Compliance Guy

The Compliance Guy

By Sean M. Weiss

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

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

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

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

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

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Special Episode of TCG with Interview Performed by Scott Kraft

The Compliance Guy

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TCG - Season 4 - Episode 29 - #TerryTuesday - Who is Responsible for Coding Claims
This is an awesome episode with my very good friend Terry Fletcher. Take a listen as our answer(s) may shock you! 
46:25
October 04, 2022
TCG - Season 4 - Episode 28 - Delivering Audit Results to Providers
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! 
25:08
October 03, 2022
TCG - Season 4 - Episode 27 - #TerryTuesday - DOJ and CMS Audits
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!  
37:23
September 27, 2022
TCG - Season 4 - Episode 26 - Coding and Compliance Roundtable
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! 
01:00:46
September 26, 2022
TCG - Season 4 - Episode 25 - Coding and Compliance Roundtable
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. 
54:54
September 15, 2022
TCG - Season 4 - Episode 24
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.
32:35
September 13, 2022
TCG - Season 4 - Episode 23 - Templated Compliance Plans - They Can Work!
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.
16:57
September 12, 2022
TCG - Season 4 - Episode 22 - "The Letter"
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! 
17:41
September 09, 2022
TCG - Season 4 - Episode 21 - Standards for Auditing Medical Documentation
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.
18:54
September 07, 2022
TCG - Season 4 - Episode 20 - #TerryTuesday - Healthcare Acronyms - The List Goes on and On and On...
In this episode Sean and Terry provide a comprehensive list of acronyms in healthcare from the obvious to the obscure. There is also talk of The Show Friends, Sean's beard, and much more. There is also, a complete list of Sean and Terry's Acronyms available on LinkedIn on Sean's feed. 
54:40
September 06, 2022
TCG - Season 4 - Episode 19 - Who's Knocking at Your Door!
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. 
21:06
September 01, 2022
TCG - Season 4 - Episode 18 - Legibility Resulting in Overpayments
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...   
13:44
August 31, 2022
TCG - Season 4 - Episode 17 - Non-compliant Providers
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! 
36:08
August 30, 2022
TCG - Season 4 - Episode 16 - 2022 FCA Penalties and Qui Tam Lawsuits
In this quick 15 minute episode Sean discusses the 2022 FCA increases for penalties and discusses the False Claims act and qui tam lawsuits. 
15:04
August 29, 2022
TCG - Season 4 - Episode 15 - Compliance and Legal Roundtable
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
55:30
August 26, 2022
TCG - Season 4 - Episode 14 - Eliminating Kickbacks in Recovery Act of 2018 (EKRA)
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 
22:36
August 24, 2022
TCG - Season 4 - Episode 13 - #TerryTuesday HIPAA and OSHA
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! 
44:38
August 23, 2022
TCG - Season 4 - Episode 12 - Monday Coding and Compliance Roundtable
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
01:07:04
August 22, 2022
TCG Daily Dose - Season 4 - Episode 11 - Routine Waiver of Copays and/or Deductibles
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 
17:43
August 19, 2022
TCG - Season 4 - Episode 10 - The Affordable Care Act (ACA) and It's Impact on Corporate Compliance Programs
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
18:19
August 17, 2022
TCG - Season 4 - Episode 9 - #Terry Tuesday
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) 
29:57
August 16, 2022
TCG - Season 4 - Episode 8 - Monday Coding and Compliance Roundtable
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!
01:01:31
August 16, 2022
TCG Season 4 - Episode 7 Colin Callahan of Flannery / Georgalis
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!
50:37
August 12, 2022
TCG Season 4 - Episode 6 - Steve Gallion of Medtrainer
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 
43:29
August 11, 2022
Special Episode of TCG with Interview Performed by Scott Kraft
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/)
37:43
August 10, 2022
TCG Season 4 - Episode 5 - Marlene Maheu, PhD
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/
49:06
August 10, 2022
TCG Season 4 - Episode 4 - #TerryTuesday on TCG with Special Guest Karen N. George, ESQ
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.
41:48
August 09, 2022
TCG Season 4 - Episode 3 - Monday Coding and Compliance Roundtable
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!  
59:19
August 08, 2022
TCG Season 4 - Episode 2 - 2022 CMS Framework
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!
01:03:15
July 29, 2022
TCG Season 4 - Episode 1 - Modifier 25... "It's A Trap"
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!
22:36
July 27, 2022
TCG Episode 40 - #Terry Tuesday Care Management Services... Read The Rules!
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!
34:50
July 26, 2022
TCG Episode 39 - Monday Coding and Compliance Roundtable
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!
01:13:53
July 25, 2022
TCG Episode 38 - Maggie Perritt - Medicare Compliance Officer
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!
49:46
July 21, 2022
The Daily Dose / TCG - Episode 16 - CMS Medical Record Review Standards and Requirements
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!
20:19
July 20, 2022
TCG Episode 37 - #Terry Tuesday Telehealth, The Cold Hard Facts!
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!
49:18
July 19, 2022
TCG Episode 36 - Monday Coding and Compliance Roundtable
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!
01:02:44
July 18, 2022
TCG Episode 35 - Jordan Johnson of Oncospark
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!
51:25
July 15, 2022
The Daily Dose / TCG - Episode 16 - Modifier 59
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!
16:44
July 14, 2022
TCG Episode 34 - #Terry Tuesday Jumping the Gun!
"Salty" Sean M. Weiss sits down with Terry Fletcher for their weekly #TerryTuesday to discuss telehealth place of service confusion, policies and procedures for split/shared services and a host of other issues creating "noise" and chaos in healthcare organizations! You definitely do not want to miss this one!  Thank you for making us a Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/  The Compliance Guy has been Nominated in 2 categories (Andy Curry Award and The Business Category) for a People's Choice Award. The voting has now opened and if you would, please vote 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!
37:29
July 12, 2022
TCG Episode 33 Monday Compliance Roundtable
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!
45:30
July 11, 2022
The Daily Dose / TCG - Episode 15 - Coding Determination without Coverage Guidelines
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.
13:49
July 08, 2022
TCG Season 3 Episode 32 - Pat Marion
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/
55:59
July 07, 2022
The Daily Dose / TCG - Episode 14 - HIPAA "Marketing"
In this episode Sean tackles "Marketing" under the Privacy Rule... What constitutes marketing and what is not marketing and when do you require an authorization from patients and when is it covered under Treatment, Payment and Operations. 15 minutes and it should all make sense!
15:48
July 06, 2022
TCG Season 3 Episode 31 - #TerryTuesday
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...
34:29
July 05, 2022
The Daily Dose / TCG - Episode 13 - 4th of July Special Top 5 Compliance Risks for Rest of 2022!
Yes, it is July 4th (Independence Day), 2022! Today, Sean focused on his Top 5 Compliance Risks for the remainder of 2022! Risk Areas included: 5. Information Blocking 4. Split/Shared Services 2022/2023 with a detailed explanation of what to expect... 3. Telehealth Services 2. Social Media 1. Evaluation and Management Services with a compare and contrast between CMS and Commercial Payers definition of "Medical Necessity"
31:11
July 04, 2022
TCG Season 3 Episode 30 - Breaking Special with Ronald Chapman, II
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)
51:29
July 02, 2022
TCG Season 3 Episode 29 - OIG, UPIC, MFCU - How The Programs Really Work
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)
01:03:27
July 01, 2022
TCG Season 3 Episode 28 - The King of Statistics
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
48:32
June 30, 2022
The Daily Dose / TCG - Episode 12 - The Comprehensive Error Rate Testing Program
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!
14:58
June 29, 2022
TCG Season 3 Episode 27 - #TerryTuesday
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!
45:10
June 28, 2022
TCG Season 3 Episode 25 - The "Godfather" of Compliance
“The Godfather” of corporate governance and compliance joined Sean to discuss the False Claims Act, Regulatory Compliance Matters and what healthcare professionals should be aware of to avoid unwanted legal entanglements. As the Deputy Chief Counsel, Office of the General Counsel, United States Department of Health and Human Services, Dallas, Texas, Gabriel advised and represented various agencies of the Department of Health and Human Services, including the Center for Medicare and Medicaid Services, the Public Health Service, the Social Security Administration, and the Office of the Inspector General. Gabriel's personal practice includes representing individuals and organizations accused of healthcare fraud and 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.
53:59
June 27, 2022
TCG Season 3 Episode 26 - Monday Compliance Roundtable
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!
40:19
June 27, 2022
TCG Season 3 Episode 24 - Incident-To... Don't Ignore This Episode
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!
17:27
June 23, 2022
TCG Season 3 Episode 23 - #TerryTuesday
Is it or is it not a HIPAA violation??? Terry and Sean take on a topic that few enjoy but all must comply with!
51:41
June 21, 2022
The Daily Dose / TCG - Episode 11 - The Use of Statistical Sampling and Overpayment Extrapolation
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.
18:28
June 20, 2022
TCG Episode 22 - Stephen Soloway - The Best of The Best!
"I'm the best. The Sharpshooter. The caviar. The Rolls Royce of Rheumatology" This is Stephen Soloway... and no one can dispute who he is or why he is the best! Sean spent more than an hour discussing a vast number of topics with Dr. Soloway regarding his book "Bad Medicine", the struggles he's had and continues to go through, battling the government and commercial insurance companies, beating Pancreatic Cancer, being elected into the Professional Sports Authenticators (PSA) Hall of Fame, and so much more! Dr. Soloway has dedicated his life to helping patients and colleagues. Patients come from around the 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
01:10:54
June 17, 2022
The Daily Dose / TCG - Episode 10 - Medicare Integrity Program
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.
18:13
June 16, 2022
The Daily Dose / TCG - Episode 9 - Medical Record Review Determinations
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!
12:15
June 15, 2022
TCG Season 3 Episode 21 - #TerryTuesday
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!
43:36
June 15, 2022
TCG Season 3 Episode 20 - Monday Compliance Roundtable
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!
54:48
June 13, 2022
The Daily Dose / TCG - Episode 8 - Targeted, Probe and Educate (TPE)
CMS' Targeted Probe and Educate (TPE) is a critical process to understand since things can and do vary by MAC. Understanding the process is critical to ensure release from the program. In this episode Sean addresses all the critical aspects of the program, how a TPE Audit is initiated, and what is considered an acceptable error rate. Don't miss this Friday episode!
12:19
June 10, 2022
The Daily Dose / TCG - Episode 7 - LCD Inconsistency / Sub Regulatory Guidance and Allina Health System
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)!
13:28
June 09, 2022
The Daily Dose / TCG - Episode 6 - Additional Documentation Requests (ADRs)
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
11:24
June 08, 2022
TCG Season 3 Episode 19 - #TerryTuesday
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!!!
39:02
June 07, 2022
The Daily Dose / TCG - Episode 5 - Corrective Action Plans
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
11:33
June 06, 2022
TCG Season 3 Episode 18 Taxpayers Against Fraud - Candid Discussion About the False Claims Act
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/
42:21
June 03, 2022
The Daily Dose / TCG - Episode 4 - MEDICARE IMPROPERLY PAID PHYSICIANS FOR SPINAL FACET-JOINT DENERVATION SESSIONS
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.
10:17
June 03, 2022
The Daily Dose / TCG - Episode 3 - Cigna Requires Documentation for EM Services and Modifier 25
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.
11:01
June 02, 2022
The Daily Dose / TCG - Episode 2 - Timely Claims Payment and Prompt Pay Laws
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.
10:40
June 01, 2022
TCG Season 3 Episode 17 #TerryTuesday with Special Guest Brianna J. Santolli
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!
01:02:35
May 31, 2022
The Daily Dose / TCG - Episode 1 - DOJ Settling the First False Claims Act Enforcement Action Since the Launch of the Civil Cyber-Fraud Initiative
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.
06:53
May 31, 2022
TCG Season 3 Episode 16 Karen Weintraub / Healthcare Fraud Shield
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/
36:04
May 19, 2022
TCG Seasons 3 Episode 15 Cloning and Clinical Plagiarism
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/
36:52
May 17, 2022
TCG Season 3 Episode 14 Rozmin Bapat RCM, Auditing, Billing and Compliance
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/
57:32
May 12, 2022
TCG Seasons 3 Episode 13 U.S. Government Accountability Office (GAO) Medicaid and CMS Telehealth Report
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/
35:16
May 10, 2022
TCG Season 3 Episode 12 Dr. Naveen Sikka - Allergy and Immunology
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/
56:31
May 05, 2022
TCG Season 3 Episode 11 Locums and Reciprocal Agreements
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/
52:28
May 03, 2022
TCG Season 3 Episode 10 #TerryTuesday To Refund or Not To Refund...
Terry joins Sean to discuss whether to refund or not to refund on a variety of topics including Offshoring (CCM, TCM, etc.), Bundled Services, Durable Medical Equipment, and Amended Medical Records (Addendums, Late Entries, Corrections)... Gray areas area addressed as well: Internal or External Audit of E/M services finds level 5's are auditing at level 3 or 4. Office Visits w/minor procedures not supported on same date. 99211 vs 93792 for Protimes (INR testing) when CMS strongly recommends the 93792 and discourages the 99211, but no published rules. Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/
52:20
April 26, 2022
TCG Season 3 Episode 9 Opioid Crisis and Increase Prosecutions
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!
57:02
April 22, 2022
TCG Season 3 Episode 8 #TerryTuesday - PHE Extension
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...
52:18
April 19, 2022
TCG Season 3 Episode 7 Self Disclosure Protocol vs. Medicare Voluntary Refund Process
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
48:43
April 16, 2022
TCG Season 3 Episode 6 #TerryTuesday
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!
54:33
April 12, 2022
TCG Season 3 Episode 5 with Terry Fletcher
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)!
45:57
April 05, 2022
TCG Episode 4 with Chandler Martin
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.
47:24
April 01, 2022
TCG Episode 4 with Chandler Martin
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.
47:24
April 01, 2022
TCG Episode 4 with Chandler Martin
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.
47:24
April 01, 2022
TCG Season 3 Episode 3 with Christine Hall
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...
01:06:43
March 25, 2022
TCG Season 3 Episode 2 Medicare's 60-Day Rule
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.
49:01
March 24, 2022
TCG Season 3 Episode 1 Eric Rubenstein - Ret OIG Special Agent
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
59:43
March 17, 2022
TCG Episode 26 with Terry Fletcher The Buck Stops Here
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!
47:32
March 15, 2022
TCG Episode 25 Live with Ronald Chapman, II / Fight The Feds
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!
55:50
March 11, 2022
Episode 24 TCG with Terry Fletcher - Revenue Cycle Management and Its Impact on Compliance
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.
54:43
March 08, 2022
Episode 23 with Terry Fletcher Part II of The Medicare Appeals Process
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!
58:45
February 22, 2022
Episode 22 TCG with Ashley Morgan of Liles Parker - Administrative Proceedings and Provider Revocations
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.
50:54
February 14, 2022
Episode 21 TCG #TerryTuesday Medicare Appeals Part 1
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.
39:17
February 09, 2022
Episode 20 TCG with Jose "Joe" Vela, Jr. of Clark Hill
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...
01:16:50
February 04, 2022
Episode 19 TCG with Terry Fletcher on our #TerryTuesday Segment
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!!!
56:13
January 25, 2022
Episode 18 TCG with Dr. Laura Purdy - Telehealth
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!
56:39
January 24, 2022
Episode 17 Stark and Antikickback Update for 2022
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.
31:12
January 22, 2022
Episode 16 TCG with Terry Fletcher Credit Balances
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!
37:51
January 18, 2022
Episode 15 with Traci Brown - Lies, Fraud and Identity Theft
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!!!
59:59
December 16, 2021
Episode 14 - TCG - #TerryTuesday
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
51:01
December 14, 2021
TCG with Jeana Singleton - Advanced Practitioner Billing, Data Mining by UPICS, CERT, RAC, MAC, and OIG
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!
50:59
December 09, 2021
TCG - Part 1: The Best of The Best - What These Mangers Do to Sustain Success
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
43:01
December 08, 2021
TCG - No Surprise Billing Act - Steve Verno
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!
17:37
December 08, 2021
TCG Episode 10 - CMS Omnibus Rule and OSHA ETS Court Rulings
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.
24:42
December 02, 2021
TCG Live with Clint Pulver / I Love It Here
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!
56:44
November 24, 2021
TCG with Terry Fletcher #TerryTuesday
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!!!
01:00:05
November 23, 2021
TCG The Unified Program Integrity Contractor (UPIC)
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...
29:45
November 16, 2021
CMS Omnibus Rule and OSHA's Emergency Temporary Standard (ETS)
Brianna Santolli, ESQ and Terry Fletcher join Sean to discuss the realse on November 5, 2021 The CMS Interim Final Omnibus Rule followed by the OSHA ETS were released... These have been declared as "Mandates" but since their issuance there have been several legal maneuvers to block these mandates from being carried out. On Thursday November 11, 2021 several states led by Texas file a motion to block the mandates with the 5th Circuit Court out of New Orleans, LA. The filing was successful (Read my blog post on LinkedIn – Saturday November 13, 2021). On the same day the Department of Justice (DOJ) vowed to fight 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!
53:07
November 14, 2021
TCG Compliance Roundtable
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!
01:00:18
November 04, 2021
TCG Live with Karen Baird / Tennessee Medical Association
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!
40:17
October 27, 2021
TCG Live with Jared Walker, Founder / Dollar For
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.
52:08
October 26, 2021
TCG with Terry Fletcher - TPE Audits
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.
44:25
October 19, 2021
Season 2 TCG "Leveling the Playing Field"
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
39:10
October 12, 2021
TCG with Clint Pulver
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!
18:18
October 06, 2021
TCG with Terry Fletcher - Payor Audits
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!
20:38
October 05, 2021
Jeanmarie Loria - Managing Partner (CEO) Advize Health
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.
01:01:12
October 02, 2021
Interview with Dr. Matthew Kolinski
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!
58:17
September 20, 2021
TCG Ronald Chapman II Executive Order and Garland Memo Breakdown
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
56:23
September 17, 2021
Compliance Audit Roundtable
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!
01:00:25
September 10, 2021
The False Claims Act
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.
52:38
August 27, 2021
Super Lawyer Ronald Chapman, II of Chapman Law Group
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.
01:13:13
August 27, 2021
Information Blocking with Attorney Amanda Waesch of BMD
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!
52:19
August 27, 2021
PCI Compliance and Credit Card Processing
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!
01:03:27
August 10, 2021
Breaking Podcast on Telehealth
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!
01:00:33
August 05, 2021
2022 Medicare Physician Fee Schedule Proposed Rule
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.
36:45
July 21, 2021
Building of an Effective Compliance Program
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.
42:20
July 05, 2021
UPICs - A Former Investigator's Insights
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...
52:40
July 01, 2021
Incident To - A Legal Perspective with David Glaser
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!
40:46
July 01, 2021
Incident-to with Scott Kraft
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.
40:18
June 30, 2021
The Gold Standard for LCDs and Clinical Summaries/Rebuttals
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.
40:19
June 30, 2021
Performing an Effective Compliance Probe / Investigation
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.
59:04
June 29, 2021
Episode 3-2
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.
33:02
June 28, 2021
Episode 3 - Part 1
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...
34:16
June 28, 2021
Episode 3 - 2
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.
33:02
June 28, 2021
Episode 3 - P1
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!
34:16
June 28, 2021
DOJ Evaluation of Corporate Compliance Programs
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.
39:37
June 25, 2021
Creating and Structuring Winning Appeals
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.
01:04:42
June 21, 2021
Conducting a Fraud Investigation
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.
38:38
June 08, 2021
A Compliance Officer Roadmap to Self-Disclosure Protocol
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.
50:00
June 08, 2021
Audit Escalation and Non-Retaliation Policies
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.
26:40
June 01, 2021
Stand Your Ground With Payers
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
45:18
June 01, 2021
Episode 2 OIG, Price Transparency and COVID-19
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)
01:25:50
May 21, 2021
The Compliance Guy Live - Episode 1
https://www.youtube.com/watch?v=won0yKn6HUY&ab_channel=ComplianceGuyLIVE
01:03:00
May 10, 2021