Here is the latest episode of The Compliance Guy!

Summary

In this episode of The Compliance Guy, Sean M Weiss and Terry Fletcher discuss various topics related to compliance, telehealth, and revenue cycle management. They emphasize the importance of accurate documentation in medical records, the impact of government shutdowns on telehealth services, and the responsibilities of EMR companies in ensuring accurate data entry. The conversation highlights the consequences of inaccurate documentation and the need for providers to maintain compliance in their practices.

Takeaways

• The government shutdown impacts telehealth services.
• Compliance applies to various aspects of business and healthcare.
• Inaccurate documentation can lead to serious consequences.
• Every medical encounter must support the billed service level.
• EMR systems can default to incorrect coding, causing issues.
• Providers must ensure their documentation is accurate and up-to-date.
• The responsibility for medical record accuracy lies with the provider.
• EMR companies may have liability for errors in their systems.
• Documentation should stand on its own without unnecessary coding.
• Providers need to advocate for better EMR functionality.

Summary

The 2026 Compliance Roundtable discusses critical issues in healthcare compliance, focusing on prior authorizations, telehealth, clinical laboratories, and incident two billing provisions. Experts (Joe Rivet, Terry Fletcher, Scott Kraft, Stephanie Allard, Jordan Johnson, and David Duhaime) share insights on the challenges faced by providers, the impact of legislation, and the evolving landscape of healthcare regulations. The conversation highlights the need for reform and the importance of understanding the complexities of compliance in the healthcare industry.

Takeaways

• Prior authorizations serve as a gatekeeper to control healthcare costs.
• The burden of prior authorizations can create barriers to timely care.
• Congress is considering reforms to the prior authorization process.
• Medicare Advantage plans often complicate access to care compared to traditional Medicare.
• Virtual supervision has changed the definition of direct supervision in healthcare.
• Incident two billing provisions pose significant compliance risks for providers.
• The error rate in incident two billing is alarmingly high.
• PAMA cuts to laboratory services could negatively impact patient care.
• AI in healthcare presents risks related to patient information security.
• The importance of understanding the nuances of healthcare regulations is critical for compliance.

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss the implications of AI in healthcare, particularly focusing on AI scribes and the importance of patient consent. They explore the challenges and responsibilities healthcare providers face in ensuring patient privacy and compliance with regulations. The conversation highlights the need for transparency in AI usage and the potential risks associated with it, emphasizing the importance of patient safety and accountability in the evolving landscape of healthcare technology.

Takeaways

• AI scribes are becoming a significant issue in healthcare.
• Patients often rush through signing consents without understanding them.
• There is a lack of clarity on what patients are agreeing to when they consent to AI usage.
• Healthcare providers must ensure compliance with regulations regarding AI.
• Patients should be informed about their rights to opt out of AI scribing.
• The responsibility for AI outputs lies with the healthcare provider.
• AI is rapidly changing the landscape of healthcare operations.
• There is a need for better safeguards and regulations around AI in healthcare.
• Patient safety must be prioritized over efficiency in healthcare practices.
• Healthcare providers need to adopt a patient-centered approach in AI implementation.

• Navigating AI in Healthcare: Consent and Compliance
• The Rise of AI Scribes: What Patients Need to Know

Summary

In this episode, Sean M Weiss interviews Katy Talento, CEO of All Better Health, discussing her journey in healthcare policy reform, the challenges of navigating the healthcare system, and the importance of price transparency. Katy shares insights from her time in the White House, her approach to firing PBMs to reduce drug spending, and her optimistic outlook on future healthcare reforms.

Takeaways

• All Better Health focuses on building health plans for self-funded employers.
• Prior authorizations can be waived for urgent care needs.
• Firing PBMs can significantly reduce drug spending for employers.
• Price transparency is crucial for competitive healthcare pricing.
• Katy Talento emphasizes the need for fearlessness in healthcare policy.
• The current administration is showing some commitment to price transparency.
• Healthcare legislation is complicated and often misunderstood by lawmakers.
• Katy's experience in the White House provided unique insights into healthcare policy.
• The importance of patient advocacy in navigating healthcare challenges.
• Optimism exists for future healthcare reforms despite current challenges.

Website: https://allbetter.health/

About Katy Talento:

Katy is a licensed health benefits consultant, veteran health care reformer, epidemiologist and thought leader. As the top health advisor at the White House Domestic Policy Council, Katy spearheaded transformative policies to end secret health care prices across the United States, end predatory medical collections practices, lower prescription drug prices, guarantee health records access and interoperability for patients and their care teams, combat the opioid addiction crisis and eliminate domestic HIV/AIDS. She first developed her take-no-prisoners approach to waste and corruption as an oversight investigator and legislative director on Capitol Hill, born of love and duty toward the hardworking American taxpayers.

Katy has traveled the world, holding U.S. foreign aid programs accountable for results, as well as protecting the workforce of multinational energy companies from infectious disease threats. On the faculty of Georgetown University Medical School, Katy managed the school’s participation in a multi-site NIH study. She founded a mentorship program for junior high girls in inner city DC and even served two years as a Catholic nun! Katy earned her graduate degree in Epidemiology from Harvard School of Public Health and an undergraduate degree from the University of Virginia.

Based in northern Virginia, Katy quarterbacks AllBetter’s nationwide, custom-curated partnerships of advisors, actuaries, member services teams and analytics gurus to deliver on the AllBetter client promise: significant savings, more generous benefits, and happier employees.

Summary

In this episode of The Compliance Guy, Sean Weiss interviews Joe Rivet, a healthcare attorney with extensive experience in federal matters, including prior authorization processes and the No Surprises Act. They discuss the potential changes in legislation regarding prior authorizations, the challenges faced by physicians in getting necessary treatments approved, and the implications of recent Supreme Court rulings on healthcare legislation. Joe shares insights on navigating appeals, the importance of advocating for patients, and the complexities of the IDR process.

Takeaways

• Prior authorization processes are being scrutinized for their impact on patient care.
• The proposed 'Doctors Know Best' bill aims to empower physicians.
• Advocating for patients is crucial, especially in off-label drug use cases.
• The No Surprises Act has significant implications for healthcare providers and patients.
• There is a lack of private right of action under the No Surprises Act.
• The IDR process is complicated and often exploited by private companies.
• Medical necessity determinations can be challenged, even after prior authorization approval.
• Physicians should not accept denials without exhausting all options.
• Recent Supreme Court rulings have clarified the limitations of private actions in healthcare disputes.
• Transparency in enforcement actions is needed for better accountability in healthcare.

Summary

In this episode of The Compliance Guy Podcast, host Sean Weiss speaks with Evan Gottlob, a former federal prosecutor turned defense attorney, about the complexities of regulatory compliance in healthcare law. They discuss the decision-making process behind prosecutions, the impact of indictments on healthcare professionals, and the importance of protecting whistleblowers. Evan shares insights on civil investigative demands and the drivers behind False Claims Act cases, emphasizing the need for organizations to build a culture of compliance to prevent legal issues. The conversation highlights the challenges faced by healthcare providers and the legal landscape surrounding compliance and fraud.

Takeaways

• Prosecutors must ensure they have a strong case before charging individuals.
• Indictments can have devastating effects on healthcare professionals' careers.
• The grand jury process is often biased towards the prosecution.
• Complex white-collar cases can be easier to present due to more evidence.
• Civil Investigative Demands (CIDs) can lead to criminal investigations.
• Whistleblowers play a crucial role in exposing fraud in healthcare.
• Organizations must take employee concerns seriously to prevent retaliation.
• Building a culture of compliance is essential for healthcare organizations.
• Legal representation is critical when facing investigations.
• The healthcare industry is plagued by significant fraud and waste.

Summary

In this episode, Sean Weiss and Terry Fletcher discuss the critical importance of complete and accurate medical documentation in healthcare. They explore the consequences of incomplete records, the role of electronic medical records (EMRs), and the need for accountability among healthcare providers. The conversation emphasizes that clinicians must take responsibility for their documentation to ensure compliance and support medical necessity. The episode also touches on the complexities of medical coding and the importance of clear communication in clinical records.

Takeaways

• Incomplete documentation can lead to compliance issues.
• Providers must accept accountability for their documentation.
• EMRs should not be blamed for incomplete records.
• Documentation must support medical necessity and clinical judgment.
• Auditors need complete records to defend against claims.
• Assumptions in documentation can lead to errors.
• Clear definitions in coding are essential for accurate billing.
• Providers should not rely on templates to convey critical information.
• Documentation standards change regularly and must be adhered to.
• Healthcare professionals must work together to ensure complete records.

Summary

In this episode, Sean Weiss and Terry Fletcher discuss the new year and the importance of compliance in healthcare. They highlight the upcoming legislative changes affecting telehealth, the roles of medical students, and the challenges of documentation and accountability in healthcare practices. The conversation emphasizes the need for proper training, understanding of roles, and the importance of doing the right thing in healthcare to avoid risks and ensure compliance.

Takeaways

• January 30th is a critical date for telehealth funding.
• Medical students have limited roles compared to licensed providers.
• Documentation must be accurate and compliant with regulations.
• Providers must personally perform key components of services.
• Using medical students for billing can lead to compliance issues.
• Training and understanding roles are essential in healthcare.
• Fraud and abuse can result in significant penalties.
• Healthcare providers must be proactive in audits and compliance.
• Integrity in healthcare is crucial, even when not being watched.
• Proper billing practices are necessary to avoid legal repercussions.

Summary

In this milestone episode 400 of The Compliance Guy, Sean M Weiss and Terry Fletcher discuss the implications of virtual supervision in healthcare, particularly in the context of Medicare guidelines. They explore the risks associated with relying on technology for supervision, emphasizing the importance of patient safety and compliance. The conversation highlights the need for clear policies and compliance programs to navigate the complexities of healthcare regulations, especially regarding incident two services. As they wrap up the year, they reflect on the importance of maintaining a culture of compliance and the challenges faced by healthcare providers in adapting to new regulations.

Takeaways

This is episode 400 of The Compliance Guy.

Our topic today is virtual supervision.

Immediately available shouldn't be a subjective opinion.

This is a patient safety issue.

Failure to create a corporate compliance program is irresponsible.

We can try it for a quarter.

The risk reward just isn't there.

This should not be something that's worked into your workflow.

You need to look at it and say, okay, just in case.

Be good to yourself, but more importantly, y'all be good to each other.

Summary

In this episode, Sean Weiss discusses the complexities surrounding ancillary providers and their billing practices, particularly focusing on CMS and commercial payer rules. He explains the definitions and roles of ancillary staff, the intricacies of incident to billing, and the compliance requirements for split shared services. The conversation emphasizes the importance of understanding these regulations to ensure proper reimbursement and avoid potential pitfalls in healthcare billing.

Takeaways

• Understanding the roles of ancillary staff is crucial for compliance.
• CMS defines ancillary staff as non-independent billers.
• Incident to billing allows non-physician services to be billed under a physician's NPI.
• Direct supervision by a physician is required for incident to billing.
• Split shared services have specific requirements for billing under a physician's NPI.
• Documentation must capture substantive portions of services provided.
• Regular audits of staff roles and job descriptions are necessary.
• Understanding payer guidelines can help avoid billing denials.
• Compliance gaps can lead to recoupments and legal issues.
• Healthcare attorneys can assist with complex compliance issues.