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 Weiss and Terry Fletcher discuss why before you appeal anything, you need to confirm it is actually appealable and supported by the record.
• Terry shares what she is seeing with RAC audits and TPE reviews picking up again, especially the habit of practices ignoring letters that invite them to “ignore this if you agree.”
• Sean explains the difference between automated RAC review and complex review, including the role of algorithmic flagging and human review.
• They stress that silence can be used against a practice later, especially if auditors expand the scope because no response was made.
• The conversation covers why downcoding without reviewing the medical record is not something auditors should do casually.
• Terry and Sean both warn that response deadlines matter, and putting audit requests in a tray to deal with later can lead to denials and takebacks.
• Sean explains his ethical standard for appeal work: just because he can take a case does not mean he should.
• Terry gives a real-time cybersecurity alert about a reported eAssist breach and urges immediate password and HIPAA review.
• The episode closes with a strong reminder to treat HIPAA security, privacy, and documentation standards seriously.

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 risk, real-world billing mistakes, and the importance of knowing your lane.

• Why practices should vet all staff—not just providers—including medical assistants, revenue cycle staff, and anyone with patient or financial access.
• The compliance consequences of hiring an excluded individual, including mandatory reporting and possible repayment to federal payer programs.
• Why people can look qualified on paper but lack the practical skills required for the job.
• The difference between credentials and real-world competence.
• How consultants can damage their credibility by misrepresenting their background or working outside their expertise.
• Why honesty about professional limitations builds more trust than pretending to know everything.
• The importance of practical testing during the hiring process.
• Why consultants should refer work out when a matter falls outside their lane.
• How strong arguments can still produce unexpected outcomes in administrative law judge hearings.
• The central lesson: know your lane, stay in your lane, and verify the lane of everyone you rely on.

Key Topics

• Why practices should vet all staff—not just providers—including medical assistants, revenue cycle staff, and anyone with patient or financial access.
• The compliance consequences of hiring an excluded individual, including mandatory reporting and possible repayment to federal payer programs.
• Why people can look qualified on paper but lack the practical skills required for the job.
• The difference between credentials and real-world competence.
• How consultants can damage their credibility by misrepresenting their background or working outside their expertise.
• Why honesty about professional limitations builds more trust than pretending to know everything.
• The importance of practical testing during the hiring process.
• Why consultants should refer work out when a matter falls outside their lane.
• How strong arguments can still produce unexpected outcomes in administrative law judge hearings.
• The central lesson: know your lane, stay in your lane, and verify the lane of everyone you rely on.

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 ending September 14th, 2023
• Telehealth flexibilities extended until 2028
• Modifiers BB and BC for incident two services
• Proposed payment reductions for multiple procedures
• Importance of stakeholder comments in policy shaping
• Impact of Medicare policies on commercial payers
• G2211 complexity add-on code changes
• Future implications for physician billing and RVUs

• Stakeholders must comment by September 14 to influence policy.
• Telehealth flexibilities are extended until the end of 2027.
• Modifiers BB and BC will identify platform ownership and incident two services.
• Proposed rules include payment reductions for multiple procedures.
• Engaging with professional societies amplifies advocacy efforts.

Takeaways

• Stakeholders must comment by September 14 to influence policy.
• Telehealth flexibilities are extended until the end of 2027.
• Modifiers BB and BC will identify platform ownership and incident two services.
• Proposed rules include payment reductions for multiple procedures.
• Engaging with professional societies amplifies advocacy efforts.

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 challenges in healthcare
• Advocating for patient services outside insurance coverage
• Impact of diagnosis on service reimbursement
• Legal considerations in billing non-covered services
• Strategies to appeal insurance denials
• The role of preventive and lifestyle services in healthcare
• Limitations of insurance plans for wellness services
• Provider-patient communication about costs and coverage

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 that pushed the conversation into medical student use, supervisory rules, and the risk of stretching billing frameworks beyond their intent. The discussion closes with a cautionary look at fraud, waste, and abuse, plus the importance of proper credentialing and supervision.

Key topics

• Incident to vs. split shared visits
• What counts as a shared service
• Medical student documentation is not billable
• What a teaching physician may use
• Why cut and paste is not allowed
• Students are for education, not revenue
• Employment and supervision requirements still matter
• Telehealth supervision and ancillary services
• Fraud, waste, and abuse concerns

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 subscribing to authoritative listservs from agencies like OIG, CMS, OCR, and DOJ
• How healthcare providers can leverage alerts and newsletters to stay compliant
• The importance of understanding the definitions of fraud, waste, and abuse
• Practical tips for managing vast amounts of regulatory information in small practices
• Common pitfalls, like billing consult codes post-2010 or misinterpreting LCDs
• The evolution of healthcare information dissemination, from paper newsletters to digital alerts
• The role of exclusion lists and maintaining awareness of provider sanctions
• How to tailor subscription strategies to avoid inbox overload but still stay informed
• The value of free resources such as CMS alerts, Becker's Health, and decision health publications
• The impact of regulatory updates on claims processing and appeal strategies

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 response
• Development and distribution of monoclonal antibodies
• Government policies and their impact on COVID treatment
• Legal challenges and accusations of healthcare fraud
• The politicization of COVID medicine and science
• Whistleblower protection and judicial weaponization
• The importance of scientific integrity in public health
• Lessons learned from the pandemic response

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 frustrations and legal risks
• Out-of-country medical services
• Documentation sufficiency and audits

• Always document concerns thoroughly and keep records safe.
• Understand the difference between fraud, abuse, and waste.
• Research authoritative sources for compliance guidance.
• Staff should document all concerns and interactions.
• Practice transparency and truthful documentation.

Takeaways

• Always document concerns thoroughly and keep records safe.
• Understand the difference between fraud, abuse, and waste.
• Research authoritative sources for compliance guidance.
• Staff should document all concerns and interactions.
• Practice transparency and truthful documentation.

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
• Auditing practices and place of service
• Telehealth policy updates and compliance
• Medicaid and Medicare policy challenges
• Legal implications of non-compliance
• Resources for building compliance programs

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 automation in healthcare compliance
• Importance of accurate guidance documents

Here is a link to the Wolter Kluwer MediRegs Website: https://www.wolterskluwer.com/en/solutions/mediregs

Christina Panos, RHIA, ODS

Senior Subject Matter Expert and Sales Engineer, MediRegs