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.

It’s Episode 2 of Compliance Deconstructed and your favorite trio of Compliance professionals are back to take a closer look at how artificial intelligence (AI) is reshaping the landscape of healthcare compliance. With the ability to automate routine tasks, analyze vast data sets, and flag potential issues, AI offers exciting possibilities for improving both efficiency and effectiveness in compliance operations.

But alongside these opportunities come critical risks and ethical considerations. From algorithmic transparency to potential bias in sensitive areas like compliance hotlines, the introduction of AI raises important questions around trust, accountability, and the need for ongoing human oversight.

Your hosts Jessica Zeff, Lorie Davis, and Elvan Baker explore why training and education are essential for compliance professionals seeking to implement AI responsibly. Understanding both the technical and ethical dimensions of AI is critical to building trust with stakeholders and ensuring that new technologies align with organizational values.

As AI continues to evolve and further cement itself as part of our everyday operations, compliance professionals must remain proactive and informed. By balancing innovation with integrity, organizations can embrace the benefits of AI while mitigating its inherent risks...all while leading the way in ethical, responsible compliance practices.

Key Takeaways:

• AI can enhance compliance by automating tasks, analyzing data, and improving efficiency.
• AI tools can assist with policy development, monitoring, and even supporting better patient care.
• Ethical concerns such as transparency, bias, and accountability must be addressed early and often.
• Human oversight remains essential, particularly in sensitive areas like investigations and hotlines.
• Training and education on both technical and ethical aspects of AI are critical for success.
• Establishing oversight mechanisms, such as AI committees or governance boards, helps ensure responsible AI use.

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

In the premiere episode of Compliance Deconstructed, your hosts Jessica Zeff, Lorie Davis, and Elvan Baker dive into the foundational principles that shape effective healthcare compliance programs. Whether you're a newcomer to the compliance world or a seasoned professional with years of experience under your belt, this episode offers a comprehensive, yet accessible overview to help you confidently navigate the regulatory landscape.

The conversation is built around the Seven Elements of an effective compliance program - core building blocks that support ethical behavior and regulatory adherence. Each element plays a critical role in establishing a strong compliance culture within healthcare organizations, from leadership and training to communication and corrective actions and everything in between.

You’ll also discover the importance of policies and procedures as more than mere formalities. These documents serve as operational blueprints, guiding day-to-day behavior and ensuring consistency across departments. Learn why they should evolve with your organization and how collaboration enhances their effectiveness.

Additionally, Jessica, Lorie, and Elvan explore how compliance is a shared responsibility that extends far beyond the compliance office. By fostering a culture of integrity (driven by leadership, supported by open communication, and embraced by staff at all levels), organizations can build trust, prevent risk, and stay aligned with their ethical mission.

Key Takeaways:

• The Seven Elements of Compliance are the foundation of any effective healthcare compliance program.
• Leadership commitment and accountability are vital to a strong compliance culture.
• Policies and procedures should be living documents, regularly reviewed and updated.
• Collaboration across departments improves the quality and relevance of compliance policies.
• A culture of compliance depends on open communication and ethical behavior at all levels.

Compliance is not just a department. It’s everyone’s responsibility, every day.

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

Welcome to Compliance Deconstructed, a podcast brought to you by Simply Compliance.

Hosted by Jessica Zeff, Lorie Davis, and Elvan Baker, this podcast is set to break down and deconstruct many of the various complex aspects of Healthcare Compliance. From the 7 Elements to Medicare to AI's role in today's healthcare landscape and everything in between, you've discovered the best resource for elevating your knowledge in the healthcare compliance space.

Whether you're new to the industry or a seasoned professional, you'll find useful information to help you better understand what's happening at many levels of healthcare compliance.

In this trailer, Jessica, Lorie, and Elvan share their passion for Healthcare Compliance and why they've chosen to build a career in this space. In addition, they're sharing some clips from upcoming episodes of the show.

Click play to join us today, and be sure to follow and subscribe so you're notified any time new episodes go live!

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