Healthcare organizations deal with a constant stream of regulations, contractual requirements, operational decisions, audits, investigations, and changes in how care is delivered. With so many moving parts, one question comes up repeatedly for compliance professionals: When does an issue belong with compliance, and when does it require legal involvement? The answer depends heavily on the situation, the level of risk, and what the organization is trying to accomplish.

Medical billing and coding sits at the intersection of clinical care, documentation, reimbursement, payer requirements, credentialing, and compliance. Every claim represents a series of decisions about what service was provided, who provided it, where it was provided, how long it lasted, which code applies, and whether the payer has additional requirements that must be satisfied before payment.

Understanding Where the Medicare Advantage Guidance Fits The new OIG Guidance In Medicare Advantage gives healthcare organizations a more focused framework for understanding and managing compliance risks within the Medicare Advantage sector. The Medicare Advantage Industry Segment-Specific Compliance Program Guidance, or ICPG, does not replace the OIG’s General Compliance Program Guidance or the seven elements of an effective compliance program; instead, it adds Medicare Adva

California Medicaid, better known as Medi-Cal, is one of the largest and most sophisticated Medicaid programs in the country. Covering approximately 15 million beneficiaries across urban centers, rural communities, and everything in between, the program presents operational challenges that extend well beyond understanding regulations.

California Medicaid, known throughout the state as Medi-Cal, is one of the largest and most complex healthcare programs in the country. Serving millions of beneficiaries across diverse communities requires far more than administering healthcare benefits. It demands collaboration between health plans, providers, community organizations, government agencies, and compliance professionals who all play a role in ensuring patients receive timely, appropriate care.

The demand for GLP-1 medications continues to grow, and with that growth comes a new set of operational and regulatory challenges for healthcare organizations. While much of the public conversation centers on patient access and clinical outcomes, compliance professionals are spending more time evaluating the compliance concerns regarding GLP-1s that can affect prescribing practices, documentation, reimbursement, marketing, and organizational oversight.

When people talk about compliance at a critical access hospital, the conversation often starts with limited resources. While resource constraints are certainly part of the reality, they only tell part of the story. What organizations often overlook is that critical access hospitals operate in environments where leaders frequently carry responsibility for multiple functions at the same time, creating both challenges and opportunities that larger healthcare systems may never ex

When healthcare leaders hear the term "Information Security," many immediately think about technology.

Medicaid is often misunderstood as a single, uniform program, but every state operates differently. In this episode of Compliance Deconstructed, Jessica Zeff, Lorie Davis, and Elvan Baker unpack the operational and regulatory complexity of Medicaid programs, including provider enrollment, managed care structures, compliance expectations, and state-specific requirements. The discussion highlights why operational planning and regulatory analysis are essential for Medicaid succe

MIPS continues to shape how healthcare providers measure quality, manage costs, and approach compliance. In this episode of Compliance Deconstructed, Jessica Zeff, Lorie Davis, and Elvan Baker break down the Merit-based Incentive Payment System and explore how quality measures, reimbursement structures, interoperability, and compliance reporting impact healthcare organizations. The discussion also highlights the operational challenges providers face when navigating MIPS requi

HEDIS plays a critical role in measuring and improving healthcare quality across the industry. In this episode of Compliance Deconstructed, we break down what HEDIS is, how data is collected, and why closing care gaps matters for both patients and organizations. Learn how compliance, data accuracy, and proactive strategies can drive better outcomes and stronger performance in today’s evolving healthcare environment.

Starting a medical spa offers exciting opportunities—but also complex compliance risks. In this episode of Compliance Deconstructed, we break down how Managed Service Organizations (MSOs) work, why the corporate practice of medicine matters, and how to structure your business legally. Learn the risks to avoid, the roles to define, and how a compliant MSO model can support both growth and long-term success.

Healthcare professionals receive extensive clinical training, but many enter practice unprepared for the business, regulatory, and compliance realities of modern healthcare. In this episode of Compliance Deconstructed, we explore the education gaps clinicians often face when navigating billing, insurance rules, privacy laws, and operational responsibilities. Understanding these non-clinical skills can reduce burnout, strengthen compliance, and ultimately improve patient care.

AI tools are transforming how organizations draft policies and procedures—but are they creating new compliance risks? In this episode of Compliance Deconstructed, we explore the role of written policies in operational success and regulatory protection, and examine how AI can support policy development without replacing human oversight. Learn how to build documentation that strengthens compliance, efficiency, and long-term resilience.

Whistleblowing is often misunderstood in healthcare compliance. In this episode of Compliance Deconstructed, we break down what whistleblowing truly means, how it differs from workplace complaints or rumors, and why it plays a critical role in protecting patients and public funds. We also explore the False Claims Act, qui tam actions, retaliation protections, and how organizations can build a safe, effective speak-up culture.

In this episode of Compliance Deconstructed, the team explores why continuous learning is essential in healthcare compliance. From certifications to mentorship, peer networking to hands-on experience, professional development is more than a box to check—it’s a strategic advantage. Discover how staying curious, connected, and proactive can help you grow as a compliance leader while strengthening your organization.

ECRO and ISCA audits are among the most important—but least understood—compliance processes in Medicaid. In this episode of Compliance Deconstructed, the team breaks down what these audits are, how they vary by state, and how organizations can prepare. From data integrity to system capability, get practical tips for managing these audits and using them as opportunities for quality improvement.

Whistleblowing in healthcare isn’t always dramatic—it’s often someone speaking up about a concern before it becomes a crisis. In this episode of Compliance Deconstructed, we explore how building a strong speak-up culture helps organizations reduce risk, protect patients, and stay compliant. From documentation issues to patient safety flags, early reporting is a powerful tool when supported by trust and transparency.

Prior authorization is no longer just an administrative process—it’s a growing source of compliance risk. In this post, we explore how access delays, peer review practices, and automation can expose organizations to regulatory scrutiny. Using UnitedHealthcare as a case study, we highlight key lessons for compliance leaders looking to align prior authorization programs with today’s standards for transparency, governance, and patient care.

Compliance failures at one of the largest healthcare organizations in the U.S. reveal what happens when billing integrity, documentation, and company culture fall out of alignment. In this episode of Compliance Deconstructed, Jessica Zeff, Elvan Baker, and Lorie Davis explore the United Healthcare case and what it teaches us about navigating compliance in a high-tech, high-risk world.