The Compliance Guy

The one and only Ronald Chapman II of the Chapman Law Group joins Sean to discuss their latest (5 in 12 months) of acquittals for Dr. Loey Kousa. Sean and Ron lay out what went right for the defense and why the prosecution's case failed. If you are a provider charged with a crime in healthcare or an attorney looking for strategies to ensure a level playing field and due process for your client then this episode is a must!

Sean was joined by Dr. Carolyn Ward, Director of Clinical Strategy for Particle Health to discuss challenges with interoperability and other dynamic challenges facing healthcare professionals... About Dr. Ward: Carolyn Ward is a dynamic and driven internal medicine physician with a passion for physician empowerment and data-driven decision making. With over eight years of experience in healthcare, including as Chief Resident at Rutgers Robert Wood Johnson Medical School, she has established herself as a leader in the field. As the Director of Clinical Strategy at Particle Health, Carolyn has taken her experience to the next level. She is responsible for developing the clinical product roadmap for the organization, ensuring that providers and patients are represented throughout the research and development process.Carolyn's mission is to enable simple and secure access to actionable patient data through Particle's modern API platform. She believes that the health data system must be more cohesive to prevent digital friction and to promote positive patient outcomes. Carolyn is an ideal fit for podcasts targeting audiences of C-suite executives and founders for health tech companies, physicians, and women in tech. She can offer unique insights on topics such as healthcare interoperability, AI in health data management, digital health innovation, and value based care innovation. Her knowledge, experience, and her passion make her an outstanding guest for any podcast looking to explore the challenges facing the industry and the opportunities for innovation.

Summary In this episode, Sean and Terry Fletcher discuss the complexities of prior authorization in healthcare, emphasizing its critical role in the reimbursement process. They explore the misconceptions surrounding prior authorization, the disconnect between healthcare providers and payers, and the challenges posed by Medicare Advantage plans. The conversation highlights the importance of compliance, medical necessity, and the legal aspects of prior authorization, providing insights for healthcare professionals navigating this intricate system. Takeaways Prior authorization is essential but does not guarantee payment. There is significant misinformation about prior authorization processes. The volume of prior authorization requests has been increasing annually. Medicare Advantage plans often complicate the reimbursement process. Providers must understand their insurance coverage limitations. Patients often believe all services requested by doctors are covered. Compliance in prior authorization is crucial for healthcare organizations. Medical necessity must be documented alongside prior authorization requests. The process for obtaining prior authorization can vary significantly by payer. Healthcare providers need to be proactive in managing prior authorizations.

Summary In this episode, the panel discusses the critical importance of honesty in healthcare compliance, the challenges posed by audits, and the responsibilities of providers in navigating vendor relationships. They explore the implications of using AI in clinical documentation, the escalation of compliance issues to law enforcement, and the risks associated with outsourcing, particularly in emergency departments. The conversation emphasizes the need for thorough vetting of vendors and maintaining a culture of compliance within healthcare organizations. Takeaways Healthcare professionals must prioritize honesty in compliance matters. Audits are becoming more frequent and complex, requiring vigilance. Providers should not rely solely on vendors for compliance; they must understand their responsibilities. AI tools in documentation require careful oversight to ensure accuracy. Escalation to law enforcement can occur for compliance failures, not just billing issues. Outsourcing can lead to significant compliance risks if not managed properly. Providers must validate vendor claims and ensure they align with regulations. Documentation practices must be tailored to the specific requirements of each service line. A culture of compliance must be fostered from the top down in healthcare organizations. Ignoring compliance issues can lead to costly repercussions down the line.

Summary In this conversation, Sean and Terry discuss the critical importance of conducting audits in healthcare practices, emphasizing the need for both internal and external reviews to ensure compliance and accuracy in coding and billing. They highlight real-world examples of practices that have suffered due to a lack of audits and the biases that can occur in internal reviews. The discussion also touches on the role of compliance in healthcare and the upcoming topic of prior authorizations. Takeaways Many practices have never conducted an audit of their coding and billing. Internal audits can be biased and may not capture all issues. External audits provide an objective perspective on compliance. Providers often make assumptions about documentation that can lead to errors. The Department of Justice emphasizes independence in auditing practices. Training and education are crucial for coding staff. Practices can lose significant revenue due to improper billing. Compliance plans should include prior authorization processes. Auditing is essential for identifying fraud and ensuring compliance. Investing in audits can save practices money in the long run.

Summary In this episode, Sean and Terry discuss various topics related to healthcare compliance. They start by sharing their recent experiences, including Sean's trip to Alaska. Then, they dive into the theme of the episode, which is when things are as clear as mud in the healthcare community. They discuss the challenges of finding clear guidelines and regulations for certain situations, such as timely completion of medical records and coding for patient visits without symptoms. They emphasize the importance of creating internal policies and best practices to navigate these ambiguous situations. Takeaways Finding clear guidelines and regulations in the healthcare community can be challenging. Creating internal policies and best practices is crucial to navigate ambiguous situations. Timely completion of medical records is important for credibility and believability. Referring a patient to a specialist is considered minimal to low risk, not moderate. Prescription drug management is only a part of the overall medical decision-making process. Coding for patient visits without symptoms requires careful documentation and consideration of the appropriate codes. Having internal policies can help mitigate fines and refunds during audits. Being proactive and compliant is essential in the ever-changing healthcare landscape.

Summary The conversation revolves around the topic of padding medical bills and the importance of clear communication with patients regarding their financial responsibilities. The speakers discuss instances where unnecessary charges are added to the bill, such as billing for lifestyle medicine codes during a visit for a finger fracture or adding charges for services that were not provided. They emphasize the need for providers to stay in their lane and let the billing office handle financial matters. The conversation also touches on the No Surprise Act and the importance of notifying patients about potential changes in billing during procedures. Overall, the speakers stress the importance of running a compliant practice and ensuring patients are not surprised by their financial responsibilities. The conversation covers various topics related to compliance and healthcare, including personal anecdotes, the importance of commenting on proposals, the need for a collective voice in healthcare, the impact of fee schedule reductions, the complexities of telehealth, the role of contracts in telehealth, and the significance of having an effective compliance program. The main takeaways include the importance of staying informed and engaged in healthcare policy, the need for healthcare professionals to advocate for themselves and their patients, the value of having a strong compliance program, and the potential consequences of non-compliance. Program Takeaways Providers should avoid adding unnecessary charges to medical bills, such as billing for services that were not provided or adding charges for unrelated conditions. Clear communication with patients regarding their financial responsibilities is crucial to avoid surprises and maintain a good patient-provider relationship. Providers should let the billing office handle financial matters and stay focused on providing medical care. Understanding and adhering to the rules and regulations set by insurance companies and government programs is essential to avoid compliance issues. Providers should have a waiver of liability or an advanced beneficiary notification in place for procedures that may convert from preventive to therapeutic or diagnostic services. Running a compliant practice includes educating providers on coding guidelines and ensuring proper documentation to support billed services. Stay informed and engaged in healthcare policy Advocate for yourself and your patients Have a strong compliance program Understand the potential consequences of non-compliance

In this episode, Sean and Terry discuss the recent incident where Sean accidentally went live with colorful language during a recording. They also dive into the proposed changes to the telehealth services and fee structure for 2025. Terry explains the challenges and limitations of telehealth services, especially when it comes to billing and coding. They highlight the importance of understanding the regulations and requirements for telehealth services, as well as the need for clear guidelines and definitions from CMS. They also touch on the financial constraints and budget issues that impact physician reimbursement. Takeaways 1. Understanding the regulations and requirements for telehealth services is crucial for healthcare providers. 2. Clear guidelines and definitions from CMS are needed to ensure proper billing and coding for telehealth services. 3. The financial constraints and budget issues in healthcare impact physician reimbursement. 4. Physicians and healthcare providers should stay informed and provide feedback on proposed changes to the fee structure and telehealth services. 5. The shortage of healthcare providers and the need for fair compensation are pressing issues that need to be addressed.

This is a controversial topic depending on which side of the yellow line you stand on... The question is does all work with a consultant require attorney client privilege... This is a great discussion for those of you looking to engage in coding and billing audits.

This was a great live show! Sean was joined by Terry, Christine, and Paul to discuss Medical Decision-Making for levels of EM service when Rx Management is involved. There was a lot to unpack in this episode so don't miss this one!

Terry and Sean take on the importance of words in the medical record. There is no slowing of the audit trend so providers better buckle up!

In this episode Terry and Sean take on what it means to flat-line with your coding and how to avoid unnecessary scrutiny!

This one is a head-scratcher for The Compliance Guy for so many reasons... Not going to give it away but this is a really good episode you are gonna want to catch!

We had a great program on Monday with Terry Fletcher CPC CEMC CCC CCS CCS-P CMC ACS-CA SCP-CA PACS QMPM Christine Hall Stephanie Allard, CPC, CEMA, RHIT Scott Kraft and John Paul Spencer and their take on some hard-hitting issues: 1. Practices wanting to use RNs or MAs to do post of visits after 90-global surgery 2. Medical necessity for E/M services and the fact that a face-to-face visit has occurred in the office not being the only required component to be able to bill. And so much more!

Terry Fletcher CPC CEMC CCC CCS CCS-P CMC ACS-CA SCP-CA PACS QMPM and #TheComplianceGuy, addressed critical issues in the latest #TerryTuesday episode. In this episode, we delved into current events affecting our country, marking a significant departure from our usual content. Listeners can fast forward to the 15-minute mark for an insightful discussion on Untied Healthcare and Aetna's decision to stop covering the G2211. The reason? Misinterpretation of the concept of a longitudinal relationship by the majority and over-utilization of the code. Other payors are sure to follow! A heartfelt thank you to all the #linkedin family, friends, followers, and listeners for your continuous support and engagement. Join us as we navigate through the world of #COMPLIANCE. Peace and Love! Sean

Sean sat down with Dana McMahon, Chief Compliance Officer for Stryker to discuss all the great things she and her team are doing to ensure a culture of compliance and to lead Stryker into the future. Beyond that Dana is the Global President for Stryker Women's Network (see bio below)! This is one great discussion you do not want to miss! Bio Dana serves as Chief Compliance Officer for Stryker and is responsible for overseeing the global compliance, privacy, and enterprise risk programs and functions. Under her leadership, the Compliance function has been focused on driving value for Stryker by partnering across the businesses to enable growth and manage risk. Dana also currently serves as the global president for Stryker Women’s Network, which seeks to improve Stryker’s results by fostering an open and inclusive culture, with a focus on attracting, developing, and retaining talented women. Dana has more than 20 years of experience in the life sciences industry. She joined Stryker in 2017 as Chief Legal Counsel, leading a global legal team advising on regulatory and quality, manufacturing and supply, technology and cybersecurity, commercial and government contracting, and privacy. Prior to Stryker, she served as Assistant General Counsel at Novo Nordisk, where during her 14-year career she held several positions of escalating responsibility within the legal team, overseeing support to the commercial, clinical, medical affairs, R&D, compliance, and government affairs organizations. Dana has worked extensively on matters related to product development and commercialization, market access and reimbursement, and compliance and risk management. Previously, Dana worked in private practice at O’Melveny in New York City. Dana received her law degree from New York University School of Law and her bachelor’s degree from Hamilton College.

Terry and Sean sat down to discuss credentialing vs contracting. What are the main differences, how do you handle various aspects of each and the pitfalls to avoid.

The full panel was back this week taking on an array of topics impacting healthcare organizations across the country! Join Stephanie, Paul, Scott, Christine and Terry as they discuss and debate HCC Coding Issues, No Charging Physicians and others who refer to the practice and so much more...

This episode Terry and Sean take on adding services to your revenue mix and the costs for doing so if "Medical Necessity" is not met. There is a ton to unpack in the episode. Sean also blogged about this topic on LinkedIn Monday, July 1, 2024... take a look at that blog!

Terry and Sean are back at it once again taking on the big issues impacting healthcare providers! It's all about risk mitigation and creating a culture of compliance!