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.

SummaryIn 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.TakeawaysUnderstanding 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.

SummaryIn this episode, Sean M Weiss engages with Richa Kaul, CEO of Compliance with a Y, discussing the critical role of governance, risk, and compliance (GRC) in today's data-driven world. They explore the mission behind the organization, the importance of risk assessments, and the challenges posed by rapid advancements in AI technology. Richa emphasizes the need for ethical considerations in AI development and the necessity of human intervention in AI processes. The conversation highlights the balance between innovation and regulation, particularly in the context of data privacy and security.TakeawaysCompliance with a Y focuses on protecting consumer data through enterprise security.Risk assessments are crucial for both large and small organizations.GRC stands for Governance, Risk, and Compliance, and is increasingly important.AI technology is evolving rapidly, outpacing current regulations.Ethical AI development requires human oversight and intervention.Organizations must prioritize security over mere compliance.The healthcare sector is a significant focus for Compliance with a Y.AI can enhance risk visibility but should not replace human judgment.Regulations need to adapt to the fast-paced changes in technology.Integrity in business practices is essential for long-term success.

SummaryIn this episode, Sean M Weiss discusses the critical role of compliance officers in healthcare organizations, emphasizing their responsibilities, best practices, and the importance of regulatory compliance. He highlights the need for a proactive approach to risk assessment, the do's and don'ts of compliance, and the necessity of independence and objectivity in the compliance role. The episode concludes with a call to action for compliance officers to leverage available resources and foster a culture of compliance within their organizations.TakeawaysThe compliance officer is crucial for organizational integrity.Compliance programs must adhere to OIG's seven core elements.Regular risk assessments are essential for identifying vulnerabilities.Training and education are vital for compliance success.Independence in the compliance role prevents bias and conflicts.Separation between compliance and legal functions is necessary.Empowering compliance officers can reduce enforcement risks.Fostering a culture of compliance is a competitive advantage.Ignoring red flags can lead to significant penalties.Utilizing OIG and CMS resources enhances compliance effectiveness.oig.hhs.gov/compliance/ cms.gov/medicare/compliance-and-audits justice.gov/criminal/criminal-fraud/page/file/1562831/dl

SummaryIn this episode of the Compliance Guy podcast, Sean M Weiss reflects on the challenges and lessons learned in 2025 regarding compliance in healthcare. He emphasizes the importance of building a robust culture of compliance to prepare for the upcoming year, 2026, which is expected to bring increased scrutiny from federal agencies. Weiss outlines essential steps for healthcare organizations to strengthen their compliance programs, including conducting risk assessments, integrating HIPAA requirements, implementing training programs, and engaging third-party auditors. He concludes with a call to action for organizations to proactively adapt to regulatory changes and foster a culture of compliance.TakeawaysBuilding an effective compliance program is crucial.2025 was a challenging year for compliance professionals.Conducting a thorough compliance risk assessment is essential.Strengthening HIPAA privacy rule compliance is necessary.Implementing employee training programs is vital for compliance culture.Engaging third-party auditors can provide objective evaluations.Leadership oversight is critical for compliance success.Monitoring regulatory developments is necessary for adaptation.Cultivating a resilient compliance culture minimizes legal risks.Proactive compliance enhances operational integrity and patient trust.

SummaryIn this episode, Sean M Weiss and Terry Fletcher discuss the complexities of compliance in healthcare, particularly as the year comes to a close. They explore the importance of understanding revenue cycle management, the disconnect between clinical and payer policies, and the necessity of reading contracts thoroughly. The conversation emphasizes the need for common sense in clinical practices and the critical role of compliance programs in healthcare settings.TakeawaysThe importance of understanding revenue cycle management as the year ends.There is often a disconnect between clinical policies and payer policies.Providers must read and understand their contracts before signing.Medicare sets the standard for many insurance companies' policies.Insurance companies prioritize profit over patient care.Common sense is crucial in clinical practices and billing.Services should only be billed once completed, not prematurely.A written compliance plan is essential for healthcare practices.Compliance programs should be dynamic and regularly updated.Payer policies must align with clinical practices for effective compliance.

SummaryIn this episode of the Compliance Guy podcast, Sean M Weiss interviews Dr. Raj Bothra, who shares his harrowing experience of being wrongfully accused of Medicare fraud and excessive narcotics distribution. Dr. Bothra discusses the complexities of the case, the role of the DOJ and FBI, and the injustices he faced during his trial. He emphasizes the need for judicial reform and advocates for awareness about the flaws in the legal system that can lead to wrongful accusations. The conversation highlights the importance of understanding the legal landscape for healthcare professionals and the impact of the opioid crisis on the judicial process.TakeawaysThe trial was pivotal in shaping legal defenses against the DOJ.Dr. Bothra's background includes significant humanitarian work.The charges against Dr. Bothra were based on flawed data.The judicial system can be biased against defendants.Dr. Bothra spent 1,300 days in prison without trial.The opioid crisis influenced the prosecution's approach.Expert testimonies were crucial in Dr. Bothra's acquittal.The grand jury system needs reform to ensure fairness.Dr. Bothra's story is a cautionary tale for healthcare professionals.There is a pressing need for judicial reform to prevent future injustices.

SummaryIn this episode, Sean M Weiss and Terry Fletcher discuss the complexities surrounding Additional Documentation Requests (ADRs) from Medicare Advantage plans. They emphasize the importance of compliance, the legal obligations of providers, and the potential consequences of ignoring these requests. The conversation also touches on the ongoing investigations into Medicare Advantage fraud and the need for providers to navigate these challenges carefully while maintaining good relationships with payers.TakeawaysResponding to ADRs is a legal obligation for providers.Ignoring ADRs can lead to serious consequences.Providers should negotiate terms if requests are unreasonable.HIPAA allows disclosures for payment-related activities.Payers are permitted to request specific documentation for audits.Maintaining a good relationship with payers is crucial.Providers can ask for clarification on ADR requests.Documentation requests should be fulfilled within narrow parameters.The OIG investigates Medicare Advantage plans for fraud.Providers should utilize electronic means for submitting documentation.

SummaryIn this episode, Sean M Weiss discusses the critical role of compliance officers in healthcare organizations, emphasizing their responsibilities, best practices, and the importance of maintaining objectivity and independence. He outlines the do's and don'ts of compliance, highlights essential resources for compliance officers, and stresses the need for separation between compliance, legal, and operations to ensure effective oversight and ethical conduct.TakeawaysThe compliance officer is pivotal in safeguarding organizational integrity.Compliance officers must adhere to laws like the False Claims Act and HIPAA.Regular risk assessments are crucial for identifying high-risk areas.Establishing anonymous reporting mechanisms encourages whistleblowing.Ignoring red flags can expose organizations to significant risks.Objectivity and independence are essential for effective compliance.Resources from OIG and CMS are vital for compliance programs.Separation of compliance from legal and operations is necessary.Fostering a culture of ethical conduct mitigates potential liabilities.Compliance is a continuous process that requires vigilance and adaptation.

SummaryIn this conversation, Terry Fletcher and Sean M Weiss discuss the recent announcement by ChatGPT regarding its decision to cease providing health and legal advice due to a significant error rate. They explore the implications of this decision, the ongoing debate about the accuracy of AI chatbots, and the potential consequences of AI errors in professional fields.TakeawaysChatGPT announced it will stop providing health or legal advice.The error rate for ChatGPT is reported to be over 40%.Debate exists about the accuracy of AI chatbots.Significant hallucination rates in AI-generated content are concerning.The decision to stop providing advice may be influenced by legal pressures.AI's limitations in professional fields raise ethical questions.Users should be cautious when relying on AI for critical information.The conversation highlights the need for human oversight in AI applications.Misinformation from AI can have serious consequences.The future of AI in professional settings remains uncertain.

SummaryIn 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.TakeawaysSummer 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.

SummaryIn 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.TakeawaysDon 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.

SummaryIn 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.TakeawaysNon-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.

SummaryIn 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.TakeawaysThis 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.

SummaryIn 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.TakeawaysTerry 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.

SummaryIn 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.TakeawaysClinical 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!

SummaryIn 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.TakeawaysISO 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.podscan_GgfsN2GSvh9FSIkR0ejEM1HNEzDwwrDo

SummaryIn 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.TakeawaysTime 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.