The Compliance Guy

Sean and Terry cover a practical warning for providers and billing teams: do not ignore audit letters, documentation requests, or compliance notices just because the language says you can if you agree. They also break down how RAC and TPE reviews work, why silence can be read as weakness, and why timely responses matter even when you think the issue is minor. Main topics In this episode, Sean Weis...

In this episode Sean and Terry take on a very real issue plaguing healthcare! Our dynamic duo in this episode focuses on a deceptively simple idea with high stakes in healthcare and consulting: verify claims before you trust them. Sean and Terry discuss why vetting staff, contractors, and consultants matters just as much as checking credentials on a resume. They connect that idea to compliance ris...

Summary In this episode, Terry Fletcher and Sean Weiss discuss the latest Medicare final rule, its implications for healthcare providers, and how stakeholders can engage in the comment process to influence policy changes. They explore key topics like telehealth flexibilities, modifiers, and upcoming payment adjustments for 2027. Key Topics Medicare final rule published on July 14th Comment period...

In this episode, Terry Fletcher and Sean discuss the complexities of lifestyle medicine, insurance reimbursement, and the importance of understanding what services are covered. They explore how providers can navigate insurance limitations while advocating for patient care. Key Topics Insurance reimbursement for lifestyle medicine Medical necessity and insurance coverage Billing and coding challeng...

This episode focuses on a compliance issue that keeps tripping up practices: incident to billing, split shared visits, and the limits of what medical students can document. Sean M Weiss and Terry walk through where the rules apply, where they do not, and why using student documentation to support a billable service is not allowed. Terry also shares a real world question from recent presentations t...

In this episode of The Compliance Guy, Terry Fletcher and Sean dive into the importance of proactive compliance and staying updated with federal and state healthcare regulations. This discussion is vital for healthcare providers who want to safeguard their practice from compliance risks and ensure they’re informed about the latest industry guidance. Key topics covered: The significance of subscrib...

Summary Dr. Ron Elfenbein shares his extraordinary journey through the COVID pandemic, his pioneering efforts with monoclonal antibodies, and the unjust legal challenges he faced after speaking out. This episode highlights the importance of scientific integrity, whistleblower protection, and the fight against political misuse of medical science. Key Topics Dr. Elfenbein's background and COVID...

Summary In this episode, Terry Fletcher and Sean Weiss discuss the frustrations faced by healthcare staff with compliance issues, telehealth documentation, and billing practices. They explore real-world challenges, legal considerations, and practical advice for staff trying to navigate complex regulations. Key Topics Telehealth documentation and compliance Billing and coding accuracy Staff frustra...

Summary In this episode, Terry Fletcher and Sean Weiss discuss the importance of having up-to-date, written compliance policies in healthcare practices, the risks of relying on memory or outdated policies, and how to effectively implement and audit compliance programs to avoid legal and financial pitfalls. Key Topics Importance of written compliance policies Risks of outdated or missing policies A...

Summary In this episode, Sean Weiss interviews Christina Panos from Wolters Kluwer to discuss the importance of regulatory compliance in healthcare, the capabilities of MediRegs, and how organizations can stay ahead in fraud, waste, and abuse prevention. Key Topics Healthcare fraud, waste, and abuse MediRegs features and benefits Regulatory updates and alerts Customizable compliance tools AI and a...

Summary This episode explores the ethical, legal, and practical implications of virtual critical care in healthcare, highlighting recent cases and regulatory challenges. Hosts Sean and Terry discuss the boundaries of telehealth, the moral dilemmas faced by providers, and the importance of appropriate, compliant virtual care practices. Key Topics Ethical dilemmas in virtual critical care Legal and...

Summary This episode features a detailed discussion on recent healthcare compliance issues, focusing on Medicare Advantage overpayments, the importance of proactive audits, and the evolving role of data analytics in fraud detection. Experts Terry Fletcher and Sean Weiss share insights on regulatory updates, best practices, and the need for strategic compliance in healthcare organizations. Key Topi...

Summary In this episode of The Compliance Guy, Sean Weiss and Terry Fletcher discuss various compliance issues related to audits, medical necessity, and the importance of thorough documentation in healthcare. They engage in a role play to illustrate common pitfalls in audits, emphasizing the need for physicians to conduct appropriate examinations and maintain accurate records. The conversation als...

Summary Join Sean Weiss as he discusses behavioral health coding, billing, and the current challenges faced by providers with expert Sonda Kunzi. Explore topics like reimbursement issues, telehealth, and regulatory complexities in behavioral health care. Key Topics Behavioral health reimbursement challenges Telehealth regulations and compliance Impact of COVID-19 on behavioral health services

Summary This episode explores the complexities of virtual supervision under Medicare, emphasizing compliance, operational best practices, and the potential benefits when implemented correctly. Key Takeaways Virtual supervision is a payment, workflow, and compliance rule, not just a convenience. Real-time audio-video technology is required for virtual direct supervision. Separate telehealth policie...

Summary In this episode, Terry Fletcher discusses common compliance pitfalls in healthcare, billing errors, fraud risks, and the importance of accurate documentation and risk management. He emphasizes the need for healthcare providers to stay informed and vigilant against fraud and billing mistakes. Key Topics Healthcare billing errors and compliance pitfalls Fraud risks and detection in healthcar...

Summary This episode features a comprehensive discussion on healthcare compliance, audits, and payment integrity, with insights from industry experts on recent trends, challenges, and legal considerations in healthcare billing and review processes. Key Topics Prepayment reviews and quality reviews in healthcare Legal considerations and due process in audits CMS restructuring and payment models Sub...

Summary In this episode, Sean Weiss and Terry Fletcher discuss the complexities and pitfalls of billing add-on code G2211 for E&M services, emphasizing the importance of medical necessity, proper documentation, and understanding payer policies. Key Topics G2211 coding and billing Medical necessity and documentation Pediatric billing considerations Payer policies and reimbursement rates Risks o...

Summary In this episode, Sean Weiss and Frank Cohen explore the realities of AI, its limitations, and its implications for healthcare and legal fields. They discuss how AI models work, the importance of human oversight, and the risks of overestimating AI capabilities. Key Topics How AI tokenizes words and predicts next tokens The misconception that AI reasons or learns like humans The importance o...

Summary In this episode of The Compliance Guy, hosts Sean Weiss and Terry Fletcher explore the importance of internal audits, provider documentation, and maintaining objectivity in healthcare compliance. They discuss common pitfalls like over-familiarity with providers, the impact of personality on compliance, and the significance of external reviews to ensure practice integrity. Key Topics Intern...

Summary This episode features a lively panel discussion on critical issues in healthcare compliance, including the use of cell phones for medical communication, prepayment reviews, and critical care documentation. Experts Joe Rivet, ESQ, Scott Kraft, Jordan Johnson, Stephanie Allard, and David Duhaime share insights, practical advice, and regulatory updates to help providers navigate complex compl...

Summary In this episode of the Compliance Guy podcast, host Sean Weiss interviews healthcare compliance expert Susan Wahlberg. They discuss the evolving landscape of healthcare regulation, focusing on the roles of the FTC, FDA, and OCR, and explore how compliance professionals can stay ahead in a rapidly changing environment. Key Topics Role of the FTC in healthcare data privacy and enforcement Em...

Summary In this episode, healthcare attorney and expert Dean Viskovich discusses the complexities of telehealth, medical necessity, and laboratory compliance, providing practical guidance for labs and billing companies navigating CMS and payer requirements. Key Topics Medical necessity and legal standards Impact of recent court decisions on labs Best practices for compliance and documentation Here...

Summary In this episode, Sean and Terry Fletcher discuss the latest issues in healthcare compliance, focusing on problematic billing practices, the risks of retrospective diagnosis coding, and the influence of third-party payers like Optum. They explore how these practices threaten provider integrity and patient care, offering insights and advice for healthcare professionals navigating these chall...

Summary In this engaging discussion, Sean Weiss and Terry Fletcher explore the recent CMS final rule that bans fax machines and snail mail in healthcare transactions. They analyze the implications for revenue cycle management, the move towards digital documentation, and the broader impact on healthcare modernization and value-based care. Topics CMS final rule banning fax and snail mail Impact on r...