Building a strong compliance culture requires more than just checking boxes. It demands a shift in mindset across the entire organization. In this informative episode of Compliance Deconstructed, hosts Jessica Zeff, Lorie Davis, and Elvan Baker break down the foundational principles that turn compliance from a burden into a powerful driver of trust, integrity, and long-term success.

Compliance culture is more than a policy manual; it’s the framework that ensures ethical behavior, consistent practices, and clear accountability. Businesses that prioritize compliance not only avoid costly penalties but also create a workplace built on transparency, strong leadership, and shared responsibility, all of which are elements that searchers often seek when exploring how to strengthen compliance and ethics within their organizations.

Today’s discussion highlights the essential role leaders play in shaping compliance, showing how their example sets the tone for the entire company. Your hosts also emphasize why compliance must be everyone’s responsibility - reinforced through training, communication, and empowerment at all levels.

Finally, the episode explores how compliance professionals can strengthen partnerships across departments by acting as allies and problem-solvers. By fostering collaboration, accessibility, and open communication, organizations can transform compliance into a shared value that supports growth and resilience.

Key Takeaways:

• Compliance is more than rules. It’s a cultural framework for ethical and effective business.
• Strong compliance culture starts with leadership setting the right tone.
• Hiring practices should evaluate candidates’ perspectives on compliance.
• Ongoing training and open communication are critical to sustaining compliance.
• Compliance should be viewed as a shared responsibility across all employees.
• Building partnerships turns compliance into a collaborative, growth-focused effort.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

In this episode of Compliance Deconstructed, hosts Jessica Zeff, Lorie Davis, and Elvan Baker break down the complexities of the “Big Beautiful Bill” and its potential impact on healthcare. The conversation highlights both the bill’s stated goal of simplifying billing and the unintended consequences that could create new challenges for patients and professionals alike.

For compliance professionals and healthcare leaders, understanding healthcare policy changes requires more than reading the surface-level intentions. It’s important to critically examine proposed regulations, compare goals with likely outcomes, and identify potential risks such as coverage gaps, workforce shortages, or added administrative burdens…ensuring your organization remains compliant and patients continue to receive uninterrupted care.

Jessica, Lorie, and Elvan also explore how this bill could affect vulnerable populations, including patients who depend on Medicaid and other essential programs. With proposed changes to eligibility redeterminations, many patients may face instability in maintaining coverage, placing a significant strain on state agencies, health plans, and the individuals themselves.

And if all that weren’t enough, the discussion focuses strongly on how healthcare workforce development could suffer if provisions around student loans and loan forgiveness are limited. These changes may deter new professionals from entering the field, deepening existing shortages and reducing patient access to critical care. This conversation emphasizes the importance of proactive planning, cross-department collaboration, and continuous monitoring of legislative updates to stay ahead of potential disruptions.

Key Takeaways

• The Big Beautiful Bill aims to improve billing transparency but may unintentionally create new administrative hurdles.
  
  
• More frequent Medicaid eligibility reviews could increase the risk of coverage gaps for vulnerable populations.
  
  
• Administrative changes may shift focus away from patient simplification and toward compliance burdens.
  
  
• Proposed changes to student loan programs could deter individuals from entering healthcare professions.
  
  
• Compliance professionals should conduct risk assessments and plan proactively for operational impacts.
  
  
• Staying informed and engaging stakeholders is essential to navigating evolving healthcare regulations.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

Federal prosecutors aren't just fining companies anymore. They're putting leaders in the crosshairs.

In this eye-opening episode of Compliance Deconstructed, hosts Jessica Zeff, Lorie Davis, and Elvan Baker unpack the Hertel & Brown case and why owners (not just businesses) are facing the consequences.

Throughout this episode, they reveal how a network of billing scams, data manipulation, and oversight failures resulted in criminal charges for not only executives but also the compliance officer.

Healthcare fraud can include overbilling, upcoding, billing for services not rendered, and data tampering, all of which are deliberate strategies rather than simple mistakes. This episode explores how organizations can detect red flags, improve internal controls, and build a culture of accountability to prevent systemic fraud.

A pivotal moment in the discussion highlights the concept of “impossible days,” where clinicians were allegedly billed for more hours than they actually worked…pretty much an unmistakable sign of fraud. The hosts also emphasize the importance of strong EMR audit trail reviews and avoiding shared login credentials, which can mask unauthorized actions.

You’ll also discover the legal consequences for individuals involved in fraudulent schemes, underscoring that corporate shields do not protect against personal liability. Practical tips are offered for building a resilient compliance program that not only meets legal standards but also supports ethical, transparent healthcare operations.

Key Takeaways

• Fraud is often systematic and intentional, not a one-time oversight. Look for patterns, not just isolated errors.
• "Impossible days" are a critical red flag, where billing exceeds physical capability and must be investigated.
• Compliance officers carry personal liability and must be qualified, empowered, and proactive to avoid complicity.
• Weak internal controls and oversight failures are common gateways for fraud to persist undetected.
• Shared EMR credentials and data manipulation present major legal and ethical risks in healthcare organizations.
• Regular audits, employee training, and a culture of compliance are essential to detect, prevent, and report fraud effectively.
  
  

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

In this episode of Compliance Deconstructed, hosts Jessica Zeff, Lorie Davis, and Elvan Baker take a deep dive into the world of Risk Adjustment Data Validation (RADV) audits. These audits have become an increasingly high-stakes area of focus for healthcare compliance professionals navigating today’s regulatory landscape and this conversation will help you understand them on a deeper level.

Throughout this episode, your hosts cover the purpose and impact of RADV audits, including how CMS uses them to ensure billing accuracy and recover overpayments. With annual audits now planned for every Medicare Advantage plan, the pressure on healthcare organizations to maintain accurate documentation has never been greater.

You’ll also learn how RADV audits are conducted, from record sampling to final closeout meetings, and why internal review and proactive documentation are vital. Jessica, Lorie, and Levan also explore the real-world challenges of responding to multiple audits at once, highlighting strategies to stay ahead of the curve.

Additionally, this episode looks at how emerging technologies like AI and data analytics can streamline the audit process. By leveraging the right tools and team, organizations can better manage risk, reduce financial exposure, and maintain compliance in a rapidly evolving environment.

Key Takeaways:

• RADV audits are used by CMS to validate diagnosis coding and ensure proper reimbursement.
• The audit scope has expanded significantly, now including all Medicare Advantage plans annually.
• Inaccurate coding can lead to major financial recoupments and increased compliance risk.
• The audit process includes multiple phases, from sample selection to dispute resolution.
• AI and advanced analytics can help identify vulnerabilities and improve audit readiness.
• Proactive planning, training, and documentation are critical to navigating RADV audits successfully.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

Jessica, Lorie, and Elvan (your favorite Compliance professionals) are back with another installment of Compliance Deconstructed and In this insightful episode, they explore the growing role of Artificial Intelligence (AI) in detecting and preventing healthcare fraud. With healthcare systems facing persistent issues of fraud, waste, and abuse, AI offers new tools to identify patterns, flag anomalies, and streamline compliance efforts.

The discussion dives into how AI can both help and hinder fraud detection, acting as a powerful tool for compliance or a potential risk when exploited by bad actors. Real-world examples illustrate how AI identifies unusual billing patterns or fabricated documentation that may warrant further investigation.

Jessica, Lorie, and Elvan emphasize the importance of human oversight in AI-driven systems, especially to prevent bias and ensure ethical use. They also discuss the risks of using AI in processes like prior authorizations, where automation must be carefully balanced with clinical judgment.

To wrap up, the episode offers a practical guide for healthcare organizations looking to implement AI responsibly. The key message: AI is not a silver bullet, but with careful deployment and continuous monitoring, it can significantly enhance fraud prevention while safeguarding fairness and patient care.

✅ Key Takeaways

• AI can rapidly analyze claims data to detect unusual billing patterns and potential fraud.
• Criminals may also use AI to commit fraud, making it a double-edged sword.
• Natural Language Processing (NLP) enables AI to review documentation and identify inconsistencies or deceptive language.
• Bias in AI systems is a real risk and must be addressed through diverse training data and human oversight.
• AI in prior authorizations can speed up approvals but must be carefully monitored to avoid inappropriate denials.
• Successful implementation of AI for fraud detection requires a step-by-step approach, including data quality, oversight, and transparency.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

We’re back for Episode 5 of Compliance Deconstructed and today, Jessica Zeff, Lorie Davis, and Elvan Baker explore how recent fraud investigations and emergency response funding missteps impact healthcare compliance. They emphasize the importance of understanding fraud, waste, and abuse regulations to reduce risk and protect patient care quality.

Throughout this conversation, the ladies discuss the Department of Justice’s investigation into United Healthcare for alleged upcoding practices to inflate reimbursements. This case highlights the critical need for transparency and the potential consequences of manipulating patient data.

Even smaller providers are subject to the same level of scrutiny from regulatory bodies like the DOJ and OIG. Real-life examples show how individual practitioners have faced prison time for submitting fraudulent claims, reinforcing the importance of personal accountability.

Proactive compliance is a recurring theme, including tips for building a compliance work plan and reviewing the OIG Work Plan regularly. This episode addresses the significance of emergency preparedness, especially when handling federal funds during crises like the COVID-19 pandemic.

Key Takeaways:

• United Healthcare is under DOJ investigation for alleged upcoding and Medicare fraud.
• Fraud, waste, and abuse violations can lead to substantial penalties and reputational harm.
• Small providers and individual clinicians are not exempt from regulatory oversight.
• Proactive auditing and documentation demonstrate compliance intent to regulators.
• Emergency preparedness must include clear protocols for managing relief funds.
• Creating and maintaining a compliance work plan helps identify and mitigate organizational risk.
  
  

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

In this insightful episode of Compliance Deconstructed, Jessica Zeff, Lorie Davis, and Elvan Baker break down the often-misunderstood concepts of fraud, waste, and abuse in the healthcare industry. With real-world examples and expert commentary, the team explores how these terms differ and why the distinctions matter for healthcare professionals and organizations alike.

Throughout this conversation, you’ll gain clarity on what constitutes healthcare fraud, including how intent plays a central role in determining fraudulent behavior. The discussion covers deceptive practices like billing for unprovided services, upcoding, and illegal kickbacks, all of which carry serious compliance implications.

This episode also shed light on healthcare waste, describing how inefficiencies, poor planning, and unnecessary procedures can drain resources without malicious intent. Abuse is examined through the lens of inappropriate practices that may fall short of fraud but still violate standards and inflate healthcare costs.

Whether you're a compliance officer, provider, or administrator, Episode 4 delivers practical tips and clear definitions to help you stay on the right side of regulations. By understanding the nuances between fraud, waste, and abuse, you'll be better equipped to spot red flags and strengthen your organization’s compliance posture.

Key Takeaways:

• Fraud involves intentional deception to gain something of value, usually financial.
• Waste results from poor planning or inefficient use of resources, not necessarily involving intent.
• Abuse includes practices that violate standards of care or billing, even if unintentional.
• "I didn't know" is not a valid defense in cases of fraud. Professionals are expected to understand compliance obligations.
• Real-world examples help illustrate how similar actions can fall into different categories depending on intent and context.
• Implementing monitoring systems can help organizations detect and reduce all three: fraud, waste, and abuse.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

It’s time for Episode 3 of Compliance Deconstructed and today, Jessica Zeff, Lorie Davis, and Elvan Baker break down the recent Medicare final rule updates effective January 1, 2026, focusing on what was left out, positive changes, and how compliance professionals can navigate the evolving regulatory environment.

A key focus of discussion are the absence of clear AI guidelines, coverage decisions on anti-obesity medications, and prior authorization requirements continue to create challenges for healthcare organizations.

The conversation also highlights some encouraging developments, including the elimination of cost sharing for adult vaccines, caps on insulin costs, and expanded access to behavioral health providers within Medicare Advantage plans. These changes aim to improve patient access and promote preventive care.

Jessica, Lorie, and Elvan also cover practical strategies for compliance teams to manage these ongoing shifts, emphasizing the importance of education, clear communication, and cross-departmental collaboration. Proactive engagement helps organizations implement new rules smoothly while maintaining compliance.

To conclude, your hosts underscore the value of networking within the compliance community to share insights and tackle uncertainties together. As you’ll learn, staying informed and connected is key to successfully adapting in this dynamic Medicare landscape.

Key Takeaways:

• Clear guidelines on AI usage in Medicare remain unresolved, creating ongoing compliance risks.
• Anti-obesity medications are still excluded from Part D coverage, raising questions about equitable patient access.
• Prior authorization requirements remain unclear, adding complexity to administrative processes.
• Elimination of cost sharing for adult vaccines enhances access to preventive care.
• Capping insulin costs aims to improve medication adherence for beneficiaries with diabetes.
• Expanded Medicare Advantage coverage now includes more behavioral health providers, improving mental health access.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.