The Compliance Guy

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.feed...

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.c...

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_p...

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 re...

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...

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 (A...

"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_comp...

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 i...

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

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

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

This is TCGs 100th Episode and I could not have picked a better person to create the podcast with!!! In this #TerryTuesday episode we take on New vs. Established Patients and the contradiction in multiple areas between AMA and CMS. These are not as straightforward as everyone thinks they are. We also tackle just the highlights of the 2023 EM Guidlines released by the AMA...

Yes, it is July 4th (Independence Day), 2022! Today, Sean focused on his Top 5 Compliance Risks for the remainder of 2022! Risk Areas included: 5. Information Blocking 4. Split/Shared Services 2022/2023 with a detailed explanation of what to expect... 3. Telehealth Services 2. Social Media 1. Evaluation and Management Services with a compare and contrast between CMS and Commercial Payers definitio...

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...

Matt Lawhon and Eric Rubenstein sit down with Sean to discuss their former agencies inner workings and clear up the misperceptions on how an investigation at each of these entities is initiated and the actual steps taken during one! Thank you for making us number 6 on the Top 25 Regualtory Compliance Podcasts: 25 Best Regulatory Compliance Podcasts You Must Follow in 2022 (feedspot.com)

Sean sits down with Frank Cohen, Director of Analytics and Business Intelligence for DoctorsManagement, LLC Such an outstanding discussion on statistical sampling and post audit extrapolation! Spend some time with us to learn and better understand how to create a process from the start to avoid fatal flaws resulting in bigger problems and how to effectively challenge payers when they fail to follo...

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

Terry and Sean take on Evaluation and Management Services (pre-2021) as it relates to audits and investigations like you have never heard it explained before. The fact that these services are low-hanging fruit and highly subjective make them the easiest of targets to go after! What elements are really required for an established patient (2 of 3) and how does "Medical Necessity" really impact the o...

“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 vari...

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

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

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

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

"I'm the best. The Sharpshooter. The caviar. The Rolls Royce of Rheumatology" This is Stephen Soloway... and no one can dispute who he is or why he is the best! Sean spent more than an hour discussing a vast number of topics with Dr. Soloway regarding his book "Bad Medicine", the struggles he's had and continues to go through, battling the government and commercial insurance companies, beating Pan...

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.