The Compliance Guy

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 thoro...

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!

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 reviewer...

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 win...

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 cult...

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...

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 attend...

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.

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!

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 lea...

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....

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 d...

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 m...

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 presen...

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.

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...

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...

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...

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 blo...

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) Service...

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!

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 medic...

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.

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 ar...

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!