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.

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.

Summary

In this episode of the Compliance Guide podcast, Sean Weiss speaks with Jonathan Porter, a former prosecutor turned defense attorney, about the complexities of healthcare compliance and the legal landscape surrounding it. They discuss the transition from prosecution to defense, the power dynamics in legal practice, and the challenges faced by healthcare providers in navigating compliance issues.

The conversation highlights the importance of robust compliance programs, the intricacies of medical billing, and the role of metadata in legal cases. Jonathan shares insights on best practices for compliance and the increasing scrutiny on kickback investigations, emphasizing the need for healthcare providers to document their processes and decisions effectively.

Takeaways

• Transitioning from prosecutor to defense attorney involves a significant shift in power dynamics.
• Prosecutors often have more power and options than defense attorneys.
• The healthcare compliance landscape is complex and requires thorough understanding.
• Many younger prosecutors are focused on quick wins rather than collaboration.
• Healthcare providers face challenges in understanding intricate billing codes and regulations.
• Robust compliance programs are essential for healthcare organizations.
• Documenting processes and decisions can protect against legal scrutiny.
• Kickback investigations are increasing, necessitating careful documentation of relationships with pharmaceutical companies.
• Metadata plays a crucial role in legal cases, providing insights into provider actions.
• Open communication and transparency can mitigate risks of legal action.

Summary

In this episode, Sean and Terry discuss the alarming prevalence of embezzlement in medical practices, particularly focusing on the role of family dynamics and the importance of compliance and auditing. Terry shares a recent experience where she uncovered significant embezzlement in a client's practice, emphasizing the need for vigilance and proper oversight in financial practices. The conversation highlights the necessity of implementing robust auditing processes and being aware of the potential for fraud, especially in family-run medical offices.

Takeaways

• Embezzlement in medical practices is alarmingly common.
• Family members in administrative roles can pose a risk for fraud.
• Regular audits are essential for financial oversight.
• Providers must be proactive in monitoring their finances.
• Desperation can lead individuals to commit fraud.
• The first instance of theft often leads to more.
• Healthcare practices need to treat patients with respect.
• Compliance programs should be regularly reviewed and updated.
• It's crucial to have clear processes for financial transactions.
• Trust but verify: always keep an eye on financial practices.

Summary

In this episode, the panel discusses the evolving landscape of telehealth, the implications of AI-driven ambient scribes in medical documentation, and the challenges posed by payer downcoding of evaluation and management services. The conversation emphasizes the importance of compliance, understanding payer contracts, and the need for proactive measures to ensure quality patient care amidst regulatory changes.

Takeaways

• Telehealth is becoming more prevalent and will not go away.
• Providers must understand the implications of telehealth regulations in their states.
• Ambient scribing technology is being integrated into healthcare but raises compliance concerns.
• Providers are responsible for the accuracy of their documentation, regardless of AI assistance.
• Payer downcoding is a significant issue that requires providers to track and appeal claims.
• Understanding participation agreements is crucial for providers to navigate payer practices.
• Regular audits are necessary to identify patterns of documentation issues.
• Providers must engage in advocacy to address unfair practices by payers.
• The healthcare industry must adapt to new technologies while ensuring compliance and quality care.
• Education and training for providers on documentation practices are essential.

Summary

In this conversation, Sean and Terry discuss the latest updates in telehealth regulations, focusing on new Medicare codes, changes in billing practices, and the implications for healthcare providers. They emphasize the importance of understanding these changes to ensure compliance and effective patient care.

Takeaways

• Telehealth services will revert to pre-COVID regulations after 2025.
• New codes for chronic pain management have been introduced.
• Behavioral health services will continue to be covered under telehealth.
• Hospital outpatient visits now have specific billing requirements.
• Providers must be aware of the limitations on telehealth services.
• Documentation is crucial for billing outpatient services.
• Telehealth regulations are evolving, and providers need to adapt.
• The importance of reading updates thoroughly to catch key changes.
• Changes in telehealth may affect patient access to care.
• Healthcare providers should prepare for the upcoming regulatory landscape.

Link to MLN Booklet https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf

Summary

In this engaging conversation, Sean and Terry discuss the challenges and importance of audits in medical practices, the resistance to change within healthcare, and the critical role of compliance and implementation of recommendations. They share personal anecdotes and insights from their experiences, emphasizing the need for meaningful change and the consequences of ignoring audit findings.

Takeaways

• Audits are essential for compliance and improving patient care.
• Many practices fail to implement audit recommendations effectively.
• Resistance to change is a common issue in healthcare settings.
• Change is necessary for growth and improvement in medical practices.
• Practices often do audits just to fulfill requirements, not to improve.
• Ignoring audit findings can lead to financial penalties and legal issues.
• Training and educating staff is crucial for successful implementation of changes.
• Consultants should be credible and knowledgeable about the specific practice area.
• Meaningful change must be validated and monitored through audits.
• Practices need to be proactive in addressing audit findings to avoid negative consequences.

Summary

In this conversation, the panel discusses various challenges in the healthcare industry, focusing on the roles of students in medical practices, the complexities of Medicaid, and the implications of proposed CMS regulations on skin substitutes. They emphasize the importance of compliance, accurate documentation, and the need for providers to be aware of the evolving landscape of healthcare regulations and billing practices.

Takeaways

• Students cannot perform or do any work that is billable and reimbursable.
• Documentation is key to halting audits and investigations.
• Medicaid faces challenges with enrollment and funding.
• Providers must understand the billing rules for students and graduates.
• AI can lead to cloning in documentation if not used carefully.
• Vendors must be held accountable for their products and claims.
• The EMR is a tool that requires proper management and understanding.
• Medicaid managed care plans can be poorly managed and lead to issues.
• Providers need to be cautious of schemes in billing practices.
• Skin substitutes are becoming a focal point for compliance and billing scrutiny.

Summary

In this episode, Sean and Terry discuss the critical importance of accurate and specific documentation in healthcare, particularly in the context of E&M services and audits. They explore the challenges faced by providers in maintaining detailed records, the implications of using generic phrases, and the role of defense operatives in ensuring compliance. The conversation emphasizes the need for patient-centric documentation practices to enhance care quality and protect against audits.

Takeaways

• Documentation is essential for compliance and patient care.
• E&M service documentation must be specific and detailed.
• Generic phrases in documentation can lead to audit issues.
• Providers should avoid lazy documentation practices.
• Smart phrases should be used judiciously and tailored to each patient.
• Patient records must reflect individual care, not just generic templates.
• The financial implications of documentation practices are significant.
• Auditors look for substance over volume in medical records.
• Healthcare providers must prioritize patient-centered documentation.
• Understanding payer guidelines is crucial for accurate billing.

Summary

In this episode of Terry Tuesday, Sean and Terry discuss the challenges and insights from recent audits in emergency rooms, focusing on overutilization of services, critical care documentation, and the importance of accurate medical records. They highlight the need for compliance in healthcare practices and the implications of poor documentation on patient care and billing.

Takeaways

• Terry recently completed a large paper audit with significant findings.
• Emergency rooms often overutilize diagnostics and labs for simple complaints.
• There is a lack of understanding of medical necessity in ER documentation.
• Critical care documentation is often misapplied in ER settings.
• Standard orders for tests can lead to unnecessary costs and audits.
• Providers must analyze and incorporate data from external sources in their documentation.
• Overutilization can lead to targeted probes and audits by payers.
• Healthcare providers need to be aware of their billing patterns and compliance.
• Documentation must reflect the medical necessity of services rendered.
• Providers on salary still need to be accountable for their documentation.

Summary

In this episode, Sean and Terry discuss the complexities surrounding the G2211 add-on code in healthcare billing. They reflect on personal experiences, the importance of understanding coding regulations, and the implications of team-based care. The conversation highlights the challenges faced by healthcare providers in navigating compliance and the potential misuse of coding practices. They emphasize the need for proper education and adherence to guidelines to avoid pitfalls in billing practices.

Takeaways

• The G2211 code is often misused and misunderstood.
• Team-based care is essential for appropriate billing of G2211.
• Providers must have a longitudinal relationship with patients to use G2211.
• Urgent care facilities should not use the G2211 code.
• Misuse of G2211 can lead to increased scrutiny from regulators.
• Education on coding guidelines is crucial for healthcare providers.
• The complexity of patient care should dictate billing practices.
• Providers should avoid automatic billing for G2211 without proper review.
• Regulatory compliance is becoming stricter under the current administration.
• Healthcare providers must be aware of the risks associated with coding practices.

You Don't Want To Miss This One!

Summary

In this episode, Sean and Terry discuss the critical importance of proper documentation in healthcare, particularly focusing on the discrepancies that arise when dealing with cash patients versus insured patients. They emphasize that documentation should be consistent and thorough, regardless of the patient's financial status, to mitigate compliance risks and protect both providers and patients. The conversation also touches on the broader implications of healthcare practices, including the influence of insurance companies and pharmaceutical companies on treatment options.

Takeaways

• Documentation should be universal across all patient types.
• Cash patients often receive inadequate documentation.
• Proper documentation protects against medical liability risks.
• Providers must document services regardless of insurance coverage.
• Documentation is essential for continuity of care.
• Inadequate records can harm patient care and outcomes.
• Compliance risks increase with poor documentation practices.
• Providers are responsible for documentation even after retirement.
• Audits can go back six years, regardless of provider status.
• Be proactive in documentation to prepare for audits.