The Compliance Guy

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.

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...