The Compliance Guy

Hosted by Sean M. Weiss

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Episodes

440

Latest episode

Nov 2026

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EN-US

About the show

Sean is the host of “The Compliance Guy” a live production dedicated to the intersection of regulatory compliance and the business of medicine. The show provides timely, accurate, and easy to digest information to healthcare professionals. The show features interviews of industry leaders, government officials, and others helping to shape the healthcare landscape. Sean M. Weiss (AKA – The Compliance Guy) has been an industry respected name for more than 25-years. A physician and health system advocate, Sean engages with clients to ensure a “level-playing-field” and due process when allegations and/or accusations of impropriety are leveled by a payor or government investigation agency. When Sean is not engaging in administrative, civil and criminal matters on behalf of more than 30 nationally recognized law firms and clients, he is serving as a third-party compliance officer for a dozen organization across the country ranging in size and specialty to ensure a “Culture of Compliance”! Sean is a proud member in good-standing with the National Society of Certified Healthcare Business Consultants (NSCHBC), American Health Lawyers Association (AHLA), National Alliance of Medical Auditing Specialists (NAMAS), and the American Academy of Professional Coders (AAPC). Sean holds (CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, CMC, CMIS, CMOM) national certifications from the Health Care Compliance Association, The National Alliance of Medical Auditing Specialists, The American Academy of Professional Coders and Practice Management Institute.

Listen to episodes

60 recent

November 1, 202632 min

Season 10 - Episode 341 - #TerryTuesday: Care Management Billing Abuse, Plus Travel and Tech Talk

Show notes Sean M Weiss and Terry Fletcher are back together for a Terry Tuesday episode after a month away. They start with travel stories and tech, then spend most of the episode on why care management services are drawing audits. In this episode Catching up: Terry's two-week Hawaii trip, flying first class on miles, and a turbulent flight home with no in-flight internet. She also tells the story of American Airlines finding her after a post she wrote about the flight. Elon Musk and Starlink: The hosts discuss airlines adding Starlink, the Delta CEO's exchange with Musk, Neuralink, Tesla and the Roadster memes. Transitional care management (TCM): Terry says every patient must first be eligible. She also covers: Chronic and primary care management: Billing for well-controlled patients who don't need the service. Third-party vendors counting voicemails and generic reminders toward the 30-minute CCM requirement. Programs billed like a gym membership that patients never use. Payer scrutiny: Commercial payers are taking aggressive positions on CCM, TCM and RPM, and utilization outliers draw attention. Terry points to UnitedHealthcare's change on G2211 as an example of a payer pulling back after a surge in billing. Fighting fraud, waste and abuse: Moving away from "pay and chase" toward front-end edits that check eligibility, frequency and duplicate billing. Sean also mentions the Reducing Administrative Burdens and "Crush" fraud, waste and abuse working groups. Compliance risk: Deliberate ignorance and reckless disregard are factors in False Claims Act cases. Using AI tools to check whether a service can be billed does not replace verifying the sources they cite. Always-listening devices: Phones, smartwatches and voice assistants in practices that handle protected health information. A client in Texas considered banning them, and Sean and Terry discuss turning off the listening features. Lighter moments: Targeted ads and a Brussels sprouts debate, then Halloween plans.

November 1, 202636 min

Season 10 - Episode 340 - The $20 Billion Background Check: Fixing Provider Enrollment with H1

Sean M Weiss welcomes Ariel, CEO of H1, to the Compliance Guy podcast to talk about why provider enrollment and credentialing cost so much and how responsible AI can help.In this episode Why every hospital and insurer runs its own doctor background check, and why that takes two to six months. Ariel's estimate that commercial credentialing costs about $20 billion a year. Roughly half is direct cost and half is lost revenue, and the figure excludes CMS and government enrollment. How many providers are involved: about 7 million NPIs, about 5 million ever credentialed, and about 4 million that need active re-credentialing. Sean's own estimate was about 2 million. Sean's math: that works out to thousands of dollars per provider every year. Why incident-to billing is not a workaround for waiting on credentialing. Fees for public information, such as board certifications and state licensure. Fraud, waste and abuse at CMS: the recent unannounced visits to adult daycare facilities, and the drop in hospices in Los Angeles County after closer enrollment scrutiny. Sean's view that waste drives more loss than outright fraud, and his conversations with CMS leaders. H1's work on the CMS National Provider Directory: public records of where doctors are licensed and board certified, and which insurance they accept. Why Ariel and Sean see provider data as a safe, practical use of AI. How H1 reaches patients: it powers nine of the ten largest health plan directories and about 70% of digital health apps. Ariel says it reaches roughly 190 million Americans. H1's mission to connect the world to the right doctor, free for patients and doctors. Sean's update on his conversations with CMS and the fraud, waste and abuse working group.

September 14, 2026Episode 43924 min

Season 10 - Episode 439 - #TerryTuesday - RAC Audits, TPE Reviews, and Why Ignoring Requests Can Hurt

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.

September 11, 2026Episode 43832 min

Season 10 - Episode 438 - #TerryTuesday - Stay in Your Lane: The Advice Healthcare Consultants Ignore

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.

August 27, 2026Episode 43730 min

Season 10 - Episode 437 - #TerryTuesday - Proposed CMS Changes 2027

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 14th Comment period ending September 14th, 2023 Telehealth flexibilities extended until 2028 Modifiers BB and BC for incident two services Proposed payment reductions for multiple procedures Importance of stakeholder comments in policy shaping Impact of Medicare policies on commercial payers G2211 complexity add-on code changes Future implications for physician billing and RVUs 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. 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.

August 19, 202626 min

Season 10 - Episode 436 - #TerryTuesday - The Complexities of Lifestyle Medicine

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 medicine Medical necessity and insurance coverage Billing and coding challenges in healthcare Advocating for patient services outside insurance coverage Impact of diagnosis on service reimbursement Legal considerations in billing non-covered services Strategies to appeal insurance denials The role of preventive and lifestyle services in healthcare Limitations of insurance plans for wellness services Provider-patient communication about costs and coverage

August 19, 2026Episode 43528 min

Season 10 - Episode 435 - #TerryTuesday: Incident Two, Split Shared Visits, and Why Medical Student Documentation Cannot Be Billed

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 visits What counts as a shared service Medical student documentation is not billable What a teaching physician may use Why cut and paste is not allowed Students are for education, not revenue Employment and supervision requirements still matter Telehealth supervision and ancillary services Fraud, waste, and abuse concerns

August 5, 2026Episode 43224 min

Season 10 - Episode 434 - #TerryTuesday - Staying Ahead of Regulatory Updates: A Guide for Healthcare Practices

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 DOJ How healthcare providers can leverage alerts and newsletters to stay compliant The importance of understanding the definitions of fraud, waste, and abuse Practical tips for managing vast amounts of regulatory information in small practices Common pitfalls, like billing consult codes post-2010 or misinterpreting LCDs The evolution of healthcare information dissemination, from paper newsletters to digital alerts The role of exclusion lists and maintaining awareness of provider sanctions How to tailor subscription strategies to avoid inbox overload but still stay informed The value of free resources such as CMS alerts, Becker's Health, and decision health publications The impact of regulatory updates on claims processing and appeal strategies

July 29, 2026Episode 43358 min

Season 10 - Episode 433 - Dr. Ron Elfenbein - The Untold Story of a COVID Hero and the Fight for Medical Truth

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 response Development and distribution of monoclonal antibodies Government policies and their impact on COVID treatment Legal challenges and accusations of healthcare fraud The politicization of COVID medicine and science Whistleblower protection and judicial weaponization The importance of scientific integrity in public health Lessons learned from the pandemic response

July 28, 2026Episode 43228 min

Season 10 - Episode 432 - #TerryTuesday - This is The Stuff That Frustrates Us!

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 compliance Billing and coding accuracy Staff frustrations and legal risks Out-of-country medical services Documentation sufficiency and audits 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. 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.