The Compliance Guy

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 i...

The #Modifier25 is leading to chaos and confusion... Tune in as we debunk the myths and set the record straight on what the payors are actually doing!

What an awesome panel discussion with Scott Kraft, Stephanie Allard, and Paul Spencer of DoctorsManagement! Show topics included: 1. CIGNA Policy Change on Modifier 25 (EM Services with Separate Service/Procedure on same date) 2. Urine Drug Testing - Screening vs. Definitive, when can a provider go straight to definitive testing, medical necessity, and the laboratory's responsibility 3. Coming out...

CMS' Targeted Probe and Educate (TPE) is a critical process to understand since things can and do vary by MAC. Understanding the process is critical to ensure release from the program. In this episode Sean addresses all the critical aspects of the program, how a TPE Audit is initiated, and what is considered an acceptable error rate. Don't miss this Friday episode!

This is such an important episode for those involved in FCA cases, OIG settlement discussions, and CMS Appeals... In this 13 minute episode we unpack the 2014 OIG Report "LOCAL COVERAGE DETERMINATIONS CREATE INCONSISTENCY IN MEDICARE COVERAGE", The 2019 Supreme Court ruling on Azar v Allina Health System and the difference between regulation(s) and guidance document(s)!

A lot of questions are asked about what to submit when an ADR is recevied for claims and what are the timeframes for submission of pre and post payment reviews. Take a listen to this insightful 10 minute segment on when and how to respond to an ADR

This episode was a ton of fun as we got to discuss #cms and #commercialinsurance surveys and the difference between patient experience and patient satisfaction since they are inherently different! A little bit about MACRA and MIPS but overall how your reimbursement is impacted! I am going to say this up front... I was struggling with allergies today so there are approximately 6 times you will get...

Corrective Action Plans (CAPS) are critical to ensure providers are able to resolve allegations of wrong-doing. This episode addresses a lot of the nuacned aspects to building a successful CAP as part of an SDP or settlement agreement. Don't miss this critical episode. If you would like a copy of the modle CAP created by Sean M. Weiss, email him at sstpierreweiss@drsmgmt.com

This is an awesome episode for so many reasons... Jacklyn DeMar joined Sean to discuss the role for TAF Education Fund to discuss whistleblower claims and the False Claims Act. It is so critical to understand all sides of healthcare compliance and how the law works so please do not miss this candid discussion! Jacklyn DeMar is the Director of Legal Education at Taxpayers Against Fraud Education Fu...

In this episode Sean tackles the 2021 report issued by OIG to address inappropriate billing for and overuse of spinal facet-joint denervation for pain management. In total, Medicare improperly paid physicians $9.5 million during the audit period of January 2019 - August 2020... This is a must for providers performing these procedures. A whole lot to unpack in this one.

In this episode Sean addresses the policy change being pushed forward by Cigna requiring documentation to be faxed to a dedicated fax line beginning August 13, 2022 for EM Services (99212-99215) when billed with Modifier 25 and a minor procedure on the same day.

In this episode we discuss the federal Timely Claims payment Law and State Prompt Pay Laws. In this 10 minute segment a lot is revealed to ensure you're on the right track to getting your claims paid.

Brianna J. Santolli, Esq. of Riker Danzig Scherer Hyland & Perretti LLP joined Terry A Fletcher BS CPC CEMC CCC CCS CCSP CMC ACS-CA SCP-CA, QMPM and Sean on a special episode of TCG / #TerryTuesday to discuss the updates of the #nosurprisesact...There is a ton to unpack in this episode and there's no doubt things get a bit sideways with Sean driving!

Welcome to the “Daily Dose” on The Compliance Guy. Each day you will be caught up with a different event or multiple events in the world of healthcare. This segment is not meant to be a deep dive but rather a breakdown of what significant issue(s) government investigational agencies such as DOJ, OIG, FBI, OCR, CMS, and other healthcare contractors are focused on. Additionally, topics f...

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 fas...

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...

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...

In this episode Terry and Sean discuss accountability within CMS and more specifically Medicaid Telehealth Services (Quality of Care)... This episode is so important for so many reasons... take a listen and we are sure you will agree. Thank you for helping to make The Compliance Guy a 2022 Top 25 Podcast: https://blog.feedspot.com/regulatory_compliance_podcasts/

Renowned allergist / immunologist Naveen Sikka of US Allergy & Asthma sits down with Sean to discuss the world of Allergey / Immunology and Asthma... After his fellowship in St. Paul, Dr. Sikka was part of North Texas Allergy and Asthma Associates where he spent 8-years. During our discussion Dr. Sikka and I discussed how biologics are impacting patient care, and tackled a bit of controversy;...

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...

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...

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...

In this episode Terry joins Sean to discuss the latest PHE Extension and what that means to the healthcare industry. What does this mean for the "Blanket Waivers" (1135) including physician services, telehealth services, dietary services, and more...

In this episode I taken on the SDP vs MVRP and provide a detailed breakdown of each as well as when to use each and when to avoid them... Elements covered in this episode include but are not limited to: Fraud and Abuse Laws Overview OIG Agency Breakdown Anti-Kickback Statute, Stark Law, False Claims Act, Exclusion Statute Duty to Refund, Generally Discovery; Investigation process; Document retenti...

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!