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.