Summary

In this episode of The Compliance Guy podcast, Sean M Weiss engages in a detailed conversation with attorney Summer McKeivier about the complexities of healthcare law, particularly focusing on incident two billing, healthcare fraud prosecutions, and the challenges faced by providers in navigating compliance issues. They discuss the current trends in healthcare fraud, the role of medical directors and Medicare Administrative Contractors (MACs), and the implications of inexperienced prosecutors in healthcare cases. The conversation also highlights the impact of accusations on healthcare professionals and the importance of understanding medical necessity in the context of local coverage determinations. Throughout the discussion, both Sean and Summer share insights from their experiences in the field, emphasizing the need for knowledgeable representation in healthcare law.

Takeaways

• Summer McKeivier is a leading attorney in healthcare law.
• Incident two billing is a significant issue in healthcare compliance.
• Wound care is currently a major focus for healthcare fraud investigations.
• CMS's definition of medical necessity often differs from providers' perspectives.
• Local Coverage Determinations (LCDs) do not have the effect of law.
• Medical directors may lack the necessary expertise in specific healthcare areas.
• Healthcare providers face challenges due to poorly written LCDs.
• Overpayment disputes can escalate if not addressed properly.
• Inexperienced prosecutors can lead to unjust accusations in healthcare cases.
• Accusations can severely impact healthcare professionals' ability to practice.

Summary

In this episode of the Compliance Guy podcast, Sean M Weiss welcomes Don Self, a veteran in the medical billing industry, to discuss his extensive experience and insights. They explore Don's two recent books, touching on topics such as medical office management, evaluation and management services, and the importance of understanding ERISA. The conversation highlights the challenges faced by healthcare providers in documentation and billing, as well as the need for better practices in the industry. Personal anecdotes and reflections on mentorship add depth to the discussion, making it both informative and engaging.

Takeaways

• Don Self has over 40 years of experience in the medical billing industry.
• The importance of mentorship in professional growth is emphasized.
• Don's books are accessible and filled with practical advice.
• Evaluation and management services continue to challenge providers.
• Documentation practices have become more complex and subjective.
• Healthcare systems in other countries can offer valuable lessons.
• Local coverage determinations are crucial for understanding payment policies.
• ERISA provides significant protections for employees and providers.
• Many providers are unaware of their rights under ERISA.
• The conversation encourages proactive engagement with insurance carriers.

Summary

In this episode of The Compliance Guy podcast, Sean M Weiss interviews Steven Adler, co-chair of litigation at Mandelbaum Barrett PC, focusing on non-compete agreements and restrictive covenants in healthcare. They discuss the complexities of these agreements, the rights of patients, and the implications of a recent case involving Dr. Timothy Vogel, a pediatric neurosurgeon. The conversation highlights the importance of legal counsel in navigating employment agreements and the enforceability of non-compete clauses.

Takeaways

• Non-competes are often negotiated and rarely go to trial.
• Restrictive covenants can include non-solicitation and confidentiality clauses.
• Patients have the right to choose their treating physician, even if a non-compete exists.
• Courts generally respect the doctor-patient relationship in these cases.
• The enforceability of non-compete agreements varies by state and circumstance.
• Legal counsel is crucial when signing employment agreements in healthcare.
• Many physicians mistakenly believe non-compete agreements are unenforceable.
• The geographic scope of non-compete agreements must be reasonable.
• Blue penciling allows courts to modify overly broad agreements.
• The credibility of witnesses can significantly impact trial outcomes.

Summary

In this engaging conversation, Sean M Weiss and Terry Fletcher explore the evolving landscape of healthcare in 2025, emphasizing the importance of reflection on career paths, the integration of AI in healthcare, and the vast opportunities available within the industry. They discuss the significance of passion in one's career and the need for continuous learning and adaptation in a rapidly changing environment.

Takeaways

• This is an interesting year for healthcare professionals.
• The AMBA conference highlighted the importance of in-person networking.
• Reflecting on career goals is essential, especially at year-end.
• AI is a powerful tool but requires human oversight.
• Healthcare offers diverse career paths beyond traditional roles.
• Collaboration between billing and coding professionals is crucial.
• Understanding compliance is vital for all healthcare roles.
• Passion for the job can lead to greater job satisfaction.
• Continuous learning is necessary to stay relevant in healthcare.
• There are many resources available for career development in healthcare.

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss the current state of telehealth services amidst the ongoing government shutdown. They explore the changes in telehealth regulations since the public health emergency, the challenges faced by Medicare in reimbursing telehealth services, and the implications of the False Claims Act for healthcare providers. The conversation emphasizes the importance of compliance and the need for practices to adapt to the evolving landscape of telehealth.

Takeaways

• Terry Fletcher celebrated her birthday during the episode.
• The government shutdown has significant implications for telehealth services.
• Telehealth regulations have changed since the public health emergency.
• Only specific diagnoses are currently covered for telehealth under Medicare.
• Practices must ensure compliance to avoid false claims.
• The importance of having a telehealth facilitator in healthcare practices.
• The future of telehealth services remains uncertain post-shutdown.
• Providers must be transparent with patients regarding telehealth services.
• The conversation highlights the risks of submitting false claims.
• Sean M Weiss emphasizes the need for ethical practices in healthcare.

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss the critical aspects of Clinical Documentation Integrity (CDI) in healthcare. They explore the importance of compliance, the implications of audits, and the responsibilities of providers in maintaining accurate medical records. The conversation highlights the need for integrity in documentation before any improvements can be made, emphasizing that compliance is essential for both legal and ethical practice in healthcare.

Takeaways

• Clinical Documentation Integrity (CDI) is crucial for accurate medical records.
• Compliance must be prioritized before any improvements can be made.
• Providers often overlook legal and compliance issues in documentation.
• Audits reveal significant gaps in healthcare practices.
• Education and training are essential for healthcare staff.
• Providers must be aware of changing regulations and adapt accordingly.
• Documentation should reflect the true nature of patient care.
• Telehealth practices must comply with HIPAA regulations.
• Ignoring compliance can lead to severe consequences for providers.
• Healthcare professionals need to take accountability for their documentation.

I was joined by Terry, Stephanie, Scott, Paul and Christine for this all new episode to discuss a variety of issues including tied to Auditing, Coding, Compliance, and Documentation.

I was so good to be back after a 3-week break to spend time with the panel and with all of our listeners/viewers and friends!

Summary

In this conversation, Sean M Weiss and Walter Haydock discuss the implications of ISO IEC 42001 in the healthcare sector, focusing on AI governance, regulatory compliance, and the management of bias in AI systems. They explore the challenges faced by multi-site healthcare organizations, the importance of leadership in ethical AI use, and real-world examples of organizations implementing ISO 42001. The discussion also touches on the legislative landscape surrounding AI and the need for clear policies in healthcare AI applications.

Takeaways

• ISO 42001 is a blueprint for managing AI risk.
• Bias in AI is unavoidable but can be managed.
• Leadership commitment is essential for effective AI governance.
• ISO 42001 aids in compliance with regulations like HIPAA.
• Multi-site healthcare systems face unique challenges in AI implementation.
• Ethical AI use is crucial in telemedicine applications.
• Real-world examples show the benefits of ISO 42001 certification.
• Behavioral health can greatly benefit from AI governance.
• Integrating ISO standards enhances overall AI governance.
• Legislators need to improve their understanding of AI issues.

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Summary

In this episode, Sean M Weiss and Terry Fletcher discuss various trends and issues in healthcare auditing, coding, and documentation. They reflect on their recent experiences and the importance of accurate coding practices to avoid risks associated with incomplete documentation. The conversation also touches on behavioral change interventions and the challenges providers face in maintaining compliance with evolving regulations. The episode concludes with a teaser for the next discussion on shared visits.

Takeaways

• Time flies, and boy, they were not kidding.
• An abundance of macros and smart phrases can lead to issues.
• Providers should only code for services actively managed during encounters.
• Incomplete documentation invites risk and potential legal issues.
• Behavioral change interventions require proper documentation and patient agreement.
• It's not the volume of documentation, but the quality that matters.
• Smart phrases and macros can lead to compliance problems if misused.
• The current administration is intensifying scrutiny on healthcare practices.
• Providers need to be aware of the risks associated with coding for unrelated diagnoses.
• Next episode will focus on the complexities of shared visits.

Summary

In this episode, Sean and Terry discuss the critical role of hospitalists in patient care, emphasizing the importance of understanding their responsibilities and the challenges posed by overutilization and compliance issues. They highlight the necessity of medical necessity in documentation and the potential risks associated with billing practices that may violate regulations. The conversation underscores the need for proper protocols, audits, and a focus on patient care to ensure that hospitalists fulfill their roles effectively without contributing to unnecessary costs or compliance violations.

Takeaways

• Hospitalists play a vital role in patient care within hospitals.
• Overutilization of hospitalists can lead to compliance issues and denials.
• Medical necessity is crucial for billing and documentation.
• Providers should avoid creating unnecessary encounters for revenue generation.
• Hospitalists are often not part of insurance programs, leading to out-of-network costs for patients.
• Proper policies and procedures are essential for hospitalist practices.
• Regular audits can help identify vulnerabilities in billing practices.
• Understanding the roles of different providers is key to effective patient care.
• Documentation should reflect actual patient interactions and medical necessity.
• Healthcare organizations must prioritize compliance to avoid legal issues.