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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 14thComment period ending September 14th, 2023Telehealth flexibilities extended until 2028Modifiers BB and BC for incident two servicesProposed payment reductions for multiple proceduresImportance of stakeholder comments in policy shapingImpact of Medicare policies on commercial payersG2211 complexity add-on code changesFuture implications for physician billing and RVUsStakeholders 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 medicineMedical necessity and insurance coverageBilling and coding challenges in healthcareAdvocating for patient services outside insurance coverageImpact of diagnosis on service reimbursementLegal considerations in billing non-covered servicesStrategies to appeal insurance denialsThe role of preventive and lifestyle services in healthcareLimitations of insurance plans for wellness servicesProvider-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 visitsWhat counts as a shared serviceMedical student documentation is not billableWhat a teaching physician may useWhy cut and paste is not allowedStudents are for education, not revenueEmployment and supervision requirements still matterTelehealth supervision and ancillary servicesFraud, 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 DOJHow healthcare providers can leverage alerts and newsletters to stay compliantThe importance of understanding the definitions of fraud, waste, and abusePractical tips for managing vast amounts of regulatory information in small practicesCommon pitfalls, like billing consult codes post-2010 or misinterpreting LCDsThe evolution of healthcare information dissemination, from paper newsletters to digital alertsThe role of exclusion lists and maintaining awareness of provider sanctionsHow to tailor subscription strategies to avoid inbox overload but still stay informedThe value of free resources such as CMS alerts, Becker's Health, and decision health publicationsThe 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 responseDevelopment and distribution of monoclonal antibodiesGovernment policies and their impact on COVID treatmentLegal challenges and accusations of healthcare fraudThe politicization of COVID medicine and scienceWhistleblower protection and judicial weaponizationThe importance of scientific integrity in public healthLessons 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 complianceBilling and coding accuracyStaff frustrations and legal risksOut-of-country medical servicesDocumentation sufficiency and auditsAlways 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 policiesRisks of outdated or missing policiesAuditing practices and place of serviceTelehealth policy updates and complianceMedicaid and Medicare policy challengesLegal implications of non-complianceResources 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 abuseMediRegs features and benefitsRegulatory updates and alertsCustomizable compliance toolsAI and automation in healthcare complianceImportance 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

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 careLegal and malpractice considerations in telehealthImpact of COVID-19 on virtual healthcare practices

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 Topics Medicare Advantage overpayment risksThe role of OIG alerts in complianceData analytics in fraud detectionBest practices for healthcare audits

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 also touches on the impact of electronic medical records (EMR) and artificial intelligence (AI) on healthcare practices, highlighting the risks of relying on outdated or incorrect information. The episode concludes with a call for healthcare providers to take responsibility for their documentation and patient care. Takeaways Audits often reveal common sense oversights in healthcare practices.Physicians must understand the difference between hospital-based and private practice standards.Medical necessity is crucial for justifying patient evaluations and management services.Technicalities in documentation should not overshadow clinical responsibilities.Inaccurate or outdated information in EMRs can lead to significant risks in patient care.Providers should not rely on loopholes in guidelines to justify their actions.The importance of a medically appropriate history and examination cannot be overstated.Documentation should reflect current patient status, not historical data.AI and EMR systems can exacerbate existing documentation issues if not managed properly.Healthcare providers must prioritize accuracy and thoroughness in patient evaluations.

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 challengesTelehealth regulations and complianceImpact 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 policies from supervision policies to avoid confusion.Organizations must verify service eligibility and supervision compliance before billing.Immediate availability of the supervisor is a critical operational and documentation requirement.Global surgery exclusions and state law overlays are key considerations.Proper training, documentation, and auditing are essential for compliance.When done right, virtual supervision enhances access, efficiency, and workforce flexibility.