Transcript
Janette (00:00) bye. Good afternoon.
Nichole Walker (00:05) How are you doing?
Janette (00:07) Good. How are you?
Nichole Walker (00:08) Oh, it is a Monday is all I can say.
Janette (00:16) I wonder if half the world feels that way on a Monday? I,
Amy Barfield (00:19) mean, I.
Nichole Walker (00:20) think this has been a struggle. Monday is what I’m going to say. This one’s been a little rough for sure. But normally… my Fridays are pretty crazy and Mondays are not too bad. But I guess because I took Friday off, God’s like I got jokes for you today, Nichole.
Janette (00:42) Bye, Amy. Bye.
Amy Barfield (00:44) Good afternoon. Good.
Nichole Walker (00:45) Afternoon.
Vikas Bhalla (01:29) Hey, Amy. Hi. Hello? Hi, yes.
Amy Barfield (01:53) Hi.
Derek Lo (01:57) Hey, Vikas.
Vikas Bhalla (01:59) Derek. How are you?
Derek Lo (02:00) I’m good. Thanks. How are you?
Vikas Bhalla (02:01) Good.
Vikas Bhalla (02:06) All right. I think we have everyone from our end, Derek.
Derek Lo (02:10) Okay, great. Yep. Well, first to kick this off, I wanted to introduce Nate Rosenthal, who’s our new coo?
Amy Barfield (02:18) Hey, how are you? Good to?
Derek Lo (02:19) Be here. Nice to meet you really.
Vikas Bhalla (02:21) Nice to meet you, Nate. Thank you for joining the call. Yeah, yeah.
Derek Lo (02:26) Vikas, so we can jump in and start to share some of the results that the team has put together and review them. Yeah, our goal is obviously to burn down these age lines faster than what you’ve been seeing and apologize that it’s not moving quicker.
Derek Lo (02:47) I think that with, the focus from the internal team and what Nate and I have been reviewing over the past few days, I think we’ve got a pretty clear plan to actually make some material movement pretty quickly on a couple of things. And so, yeah, I’ll hand it over to either Amy barfield or Amy frana, to review that. But yeah, we did put together a doc to review, thank.
Vikas Bhalla (03:13) You, thank you. Hi, Vikas. Hi, so.
Amy Barfield (03:19) In our top 10, we had medicaid independence, amerihealth, caritas, of district, columbia, John Hopkins, MVP, sunshine, health services for children for special needs, amerihealth of New Jersey and Pennsylvania and a better health of New Jersey and regal medical group, ipa. So I’ll be discussing just, what are some of the issues that we’re running into with each of those payers and what we’re doing currently to move forward with those.
Vikas Bhalla (03:52) So, when you say top your top 10, what do you mean? How you got to top 10?
Amy Barfield (03:59) Yeah, we did it. Kate conducted an audit with our QA team, and we saw that the top 10 payers that have the most issues, and these are the top 10 payers that have the most issues that I think will take a bulk of that aging.
Derek Lo (04:15) So the way that we did this is we looked at what are all of the payers sorted by age and since first submission date? And so we bucketed all the lines over 90 days. So that’s how we got to the cohort. We then looked at it, broke it down by payer. And that’s the top 10 that Amy is referring to. So that’s how we actually got there. It’s not, it’s not the, I mean, in theory, yeah, there’s probably a tight correlation between payers that have issues and these ones. But yeah, that’s like specifically that cohort. And then, Amy, do you want to share your screen on the document that we put together?
Amy Barfield (05:07) Here we are and we can share this with you as well. So this first one is New York medicaid. And we realize that there’s an E 10 issue. However after reviewing most of these, the provider enrollments are complete and the group enrollments are complete. We’ve held them open because of the E 10 issue, because you’re unable to bill, but the E 10 issue is not related to the provider enrollment. So we believe that we can close out or approve the majority of these lines. So you can see that I have sent everything over to Jeanette for signatures and a shipping label for that E 10 issue. And so she should be able to follow through with anything related to the billing part of this issue with provider enrollment. But as far as their enrollments go, the majority of them are completed. There are about 120 providers that are affected by this E 10 issue that we’ll be reviewing and approving those lines this week.
Kristen Hanly (06:08) Hi, everyone. I have a question on this. Sorry. So, Amy, so you’re saying we can release these enrollments but we’re sure that they’re going to be OK even though the E tens for the groups are not complete.
Amy Barfield (06:23) Well, the E 10 issue and maybe Nichole, you can give a little more insight into that is a billing issue. So, the E 10 is a billing form to connect to be able to bill. It’s not a provider enrollment issue. So the enrollment segment is complete. OK. Yeah. OK. So once the E 10 is you should be able to bill freely for those providers in your groups.
Janette (06:51) Excuse me, Amy. It’s Jeanette and you’ve confirmed that out of these 120 providers, they’re already actively enrolled with medicaid.
Amy Barfield (07:01) That’s what we’re currently going through. The majority of them are. Yeah. So we’ll see those and we can review that on our Wednesday call as well to see what they’ve been able to complete out to see what is still pending to give you a true number.
Janette (07:12) OK. Thank you. Yeah.
Amy Barfield (07:16) Amerihealthcredis of DC, we do have a contact that has been sending us rosters monthly. The payr portal has been down since 20 24. And so this rep has been working with us to get this just to have some kind of contact to be able to get updates on these enrollments. We have, our manager has a relationship with this person knows her personally. So she’s reaching out to see if we can get some of these resolved quicker… John Hopkins health plans. I think I sent you an email on Friday, Jeanette, if you, or, and Kristen, if you had any open Ar with that, they told us that you can bill without being credentialed as in network providers. So, one of the things that we’re wondering, is it even necessary to submit enrollments for John Hopkins? If you can bill as in network without credentialing or enrollment? Yeah.
Janette (08:21) Amy, I replied this morning to you that it does require individual enrollment as a matter of fact. I believe some of these doctors are top payer denials as well. And I included that information on there. Oh.
Amy Barfield (08:37) Interesting. Okay. Thank you for sharing that. They’re telling us that you can continue to bill as in network as that’s processing, but we’ll continue those enrollment applications, thank.
Kristen Hanly (08:47) You.
Amy Barfield (08:50) For MVP. So for MVP, we, the rosters are showing that the… rosters show like four locations. One of the locations that are on these rosters are not even, it’s not even in medallion, the three that we have, the one that you’re contracted with mamaronec. I can never say that correctly. That location doesn’t even exist for you guys anymore, correct?
Kristen Hanly (09:17) No, but, we are open with mamaronec.
Amy Barfield (09:21) You are okay. So when I looked into, looked in medallion, most of our lines are stopped for the group. So we just need to reconcile and make sure that we have your behavioral health locations and tax id in medallion the way that it needs to be so that we can process those provider enrollments. Does that make sense?
Kristen Hanly (09:47) So, is that, so, are you, referencing mamaronec for BH, or uc? Because for BH, no.
Amy Barfield (09:54) Right? For BH, okay. So then, okay.
Kristen Hanly (09:57) So then, no, yeah, for BH, mamaronec is not one of the, facilities at the moment. Okay?
Amy Barfield (10:05) So, we just need to make sure we have all the correct BH locations listed. And so we can review that on our Wednesday call and make sure that we have the proper request so that we can move forward with that correctly?
Janette (10:19) Okay.
Amy Barfield (10:20) Sunshine health. Most of the providers are partially completed, with this payer, I know there was a, so, with ambetter, a lot of our provider, a lot of the providers are enrolled with ambetter, and you can have all lines of business with ambetter, whereas sunshine health is only medicaid, but they work kind of one and the same. So, I think there was a question of, do we need both or can we approve the other close out the other if they’re enrolled with ambetter? And we know that we need five locations for each provider, we can only submit five locations for each provider. And a lot of these, requests have more than five locations. So, what I would need from you, Jeanette or Kristen is, you know, review like your Ar, see what your top five locations are for each provider. And then we need to match that in the request so that we’re requesting those locations, but they’ll only allow five. So the locations only has three. And then the other tax id number has like nine. Okay?
Janette (11:30) So, for sunshine, I actually just worked on this whole project with the provider relations department and they linked. I want to say maybe 98 percent of our providers for both ambetter and for sunshine, and gave us a retro effective date to the original contract. So, anything moving forward, you guys would need to add them on the loap, and it needs to be checked off for both ambetter because it’s a different product than, it is the marketplace product, but it needs to be added for both sunshine and for ambetter when you’re selecting the loap for each provider, and.
Amy Barfield (12:06) I think they’re doing that for ambetter now, I can verify with our team to make sure that that’s happening. Do you have the roster that they approved to where you’re saying that they have the 98 percent?
Janette (12:20) Yeah, I believe, I believe I sent it to you last week as I was sending them all the rosters? Okay? I’ll.
Amy Barfield (12:27) have them look at that. I bet we can close a lot of those out. And then… as far as the five locations moving forward, when you make those requests, can you ensure that only five locations are requested?
Janette (12:45) Yeah. I’ll have to work with the operations managers just to see which locations they’re primarily at. We just did this with an exercise with Maryland as well. So I’ll do the same thing for sunshine. Okay. Perfect. Health.
Amy Barfield (13:00) Services for children with special needs. We believe there is a separate application process but there was some conflict information on whether it was needed or not. I did send you an email, I think Friday and you may have responded this morning. I haven’t looked at it on if you had any open Ar, there was where they, it’s a medicaid product. And so it’s like an auto enrollment or it has to be requested at the same time. So, do you know if you have any open Ar with?
Kristen Hanly (13:31) Yeah. I responded this morning. So we do have open Ar, but I don’t think it has to do. I think it has to do with how we’re billing the claim. So my team is going and sending these claims for reprocessing under the rendering provider because right now we were only sending it out under the group npi. Okay? And none of our claims have been paid that way. Okay? That’s how we were originally told to bill and I don’t think that is correct because we are getting denials submitting under the group for non par.
Amy Barfield (14:05) Right. Okay. We did send out an email today for more clarification on that application process. So once I have info on that, I can share with you on Wednesday as well.
Amy Barfield (14:22) Okay. Amerihealth Pennsylvania in New Jersey, let’s see. So the peer portal has been down since… August of 20 25. This is also where we receive updates. We do have a contact with amerihealth that we’re working with closely to get those rosters as well. The peer portal is used for status updates or not status update. Well, basically showing us if it’s completed or not. What we’re having trouble with is getting statuses throughout the enrollment process. So our team’s working with that rep to get those updates more regularly and to get rosters. Do you have any questions about that? Well, just to?
Nate Rosenthal (15:17) Provide just a little more context on that too. So I think before October, it sounds like the peer portal did allow you to check the status, and then after October, it did not allow you to check the status of in progress applications. And so we’ve been working to figure out what is the correct process of getting those in process status updates, which currently is not the peer portal. And I think we probably had a more robust update in the independence blue cross section. I don’t know that we covered that above.
Amy Barfield (15:50) Did we miss that one? Oh, yeah, we totally missed it. Yeah.
Nate Rosenthal (15:55) So maybe this might have just some additional context too. So maybe we can talk through this one at the same time.
Amy Barfield (16:05) Yeah, this is the one, this has been our major blocker. And Nichole, do you have additional insight into this? Because I know this has been a big blocker across the board.
Nate Rosenthal (16:18) So, not.
Nichole Walker (16:19) More context. But to give the context on this one, we have escalated it to independent blue cross, which also is amerihealth, they’re two in the one in the same, their portal changed in October as Nate said. So before October, you were able to check statuses, you were able to view enrollments, you know, approvals, effective dates, all the things when the portal changed in November… this feature is now gone off of the website. We have escalated it numerous times to the actual payer. They know that the portal is broke. We got confirmation from them that they’re saying the only way you can check this information is by the portal, but they also know that their portal is down at the time at this time, which has been down now for what? Six, seven months. We did do an exercise on Friday. We have like I said, escalated it to the director of the organization of independence blue cross. We have not received any information back from them yet. But as of now, like this is a, and this isn’t just for you guys as an entity. This is across the board, we have numerous clients that this is affecting it’s, affecting anyone that has this payer as a whole, just because their website, like I said, when they revamped it, this is an option that went off. But when you call them, they will tell you if the provider is enrolled, they will not give you effective dates or id numbers. So that’s where we’re having the discrepancy of fully making sure the providers are enrolled with what locations with effective dates and id numbers? Because we cannot obtain that information at this time due to their website being down.
Janette (18:02) Nichole, you’re probably getting more information than we are because they won’t even give us an effective date when we call because I’ve called on a couple of these providers. I just reached out to our provider relations representative asking her for assistance. And I’m just curious. Has anyone reached out to a state level to file a complaint with the state insurance commissioner’s office? Because this is, you know, it’s not just affecting us as a provider, but across the board. I’m just curious if anyone’s went that route with your clients, of course, right?
Nichole Walker (18:32) I don’t I do think that this is something that Nate not talked about. This is the next step that we need to do because it is affecting numerous people. They will and do, like you said, they will not give us the effective date. They will just tell us if they’re enrolled. But again, you know, you can’t submit a claim without an effective date and an id number. We did find out that the id number is the mpi number, but it’s kind of hard to put claims through. If we don’t know an effective date. I mean, we could probably try to guess and get things submitted, but they will not give us any other information other than they are enrolled. Yes or no. They won’t. If we ask if this location is enrolled, they’ll tell us just to use the payr portal, which again, then we go round and round telling them your payr portal is broke. Yes, we know it’s broke. So we do see Emily Frye on this list. I did get confirmation that Emily Frye was enrolled, but no other information, no effective dates. No locations. I do know that this is a big one for you guys because she has a lot of held Ar.
Janette (19:32) Again.
Nichole Walker (19:32) on Friday, I did get confirmation. All they did tell me is that she was enrolled but no other information that I could provide. Yeah, I.
Janette (19:39) think Emily Frye is just one of the many providers that we have pending. In fact, I just went and looked and I have roughly 37 providers that are payr processing in medallion and it’s still no update on it.
Nichole Walker (19:53) We have called and confirmed all 37. I actually thought it was 42 but maybe some got approved. We have called and we’ve gotten confirmation again, a confirmation with a reference number that they’re approved, but again, they won’t give us effective dates. We do know the id number is their npi number. So I mean, we could put them in with a date we submitted them and see if you guys can at least release a claim so you can receive some sort of payment on them, but again, only with, and if we don’t have it in like writing from them that these providers are approved just when we call and, they do provide a reference number though.
Kristen Hanly (20:31) But.
Nichole Walker (20:32) I do think that it would be worthwhile for us to try to release for you guys to try to release the claims with their npi number as the id number, just to see if you guys can recoup some of your money at this time.
Janette (20:46) Kristen, do you want to go ahead and try doing that?
Kristen Hanly (20:49) I… okay. We don’t put like, I mean, we have the provider’s npi number on the claim, but we don’t bill like with provider id numbers. Okay?
Nichole Walker (21:00) So that’s so whenever I, in a roundabout way, I did because, you know, some payers require an actual id number like, you know, blue cross blue shield of Florida. You know, they require that to be on the claim, but they, this payer did indicate it is, they only go by the provider’s npi number. So you, I was just saying you wouldn’t have to have an additional id number to be able to bill out?
Janette (21:23) Okay. Nichole. Another question. When was the last time you guys verified if you guys had access to the payer portal?
Nichole Walker (21:30) Nate and I actually did that on Friday. We went through because we were actually trying to verify Emily fry for you guys since, you know, that was the email that came in with the high number. And we actually verified josh who is on my quality team. Him. And I actually looked at a couple other clients also just to make sure that just your payer portal wasn’t updated. We couldn’t get in across the board, but Nate and I personally did do your account on Friday and.
Nate Rosenthal (21:57) Just to clarify so you can log into the payer portal and you can actually see like fully approved providers… in there, but you just can’t see anybody in progress and what the current status is. So.
Kristen Hanly (22:12) Nate, I don’t mean to cut you off, but I did check the payer portal. They told, I think it was Spencer Jeanette if I’m not mistaken, that works in Pennsylvania, but they told Spencer that if we use like the allowance finder, I think it’s called in payer portal, we could see what providers are active like on our, you know, linked to our groups and Emily fry does not come up.
Kateland Sanders (22:41) Yeah. We looked into the, we looked into the same thing. And so, what we’ve done is we did log a formal escalation. It’s the bullet number two under independence with independence. They did respond to me and they said we need to be using the pns contact tool. We did, we did do that process and we were able to find direct reps that are supposed to be working on pmps. And so we’ve reached out to them and we’re waiting to hear back how they want us to handle this. But to your point, they don’t show in the portal until they’re completely done. And then it still doesn’t have all the information you need. Yeah.
Kristen Hanly (23:14) That’s great. Okay.
Nichole Walker (23:15) So whenever I called, I personally called on Emily on Friday, I think the reason why they were telling me she was enrolled because she’s enrolled at a location. But again, they won’t tell me which locations. And because you guys have more than one location, they won’t show up on the portal until they’re enrolled at every location. So it’s just really hard to get any information out of them. And, you know, I know that this is a high priority especially for you guys. The amount of revenue that is, you know, holding for her. So, you know, that was why again, I know she’s approved at a location. I just can’t tell exactly what location for you to be able to release the claims for her?
Kristen Hanly (23:53) Not a problem. All right. I’m going to also reach out. I have two other contacts that I’m also going to try and reach out to and see if we could get anywhere with them.
Nichole Walker (24:02) Thank you for your help with that. Yeah.
Amy Barfield (24:05) Kristen, I know sometimes like on the payers or on the claim side, if you call claims and ask them, was this provider eligible during the time of service? Sometimes they’ll give you an effective date. So I don’t know if independence will let you do that since they’re giving you.
Kristen Hanly (24:22) I don’t even think.
Nichole Walker (24:23) If I.
Kristen Hanly (24:24) Recall, correctly, they won’t even give us claim status over the phone. They tell us to go to the payr portal. So, I know that was a struggle because our website gets locked a lot and they couldn’t obtain claim status over the phone. Not anymore, at least, okay.
Amy Barfield (24:40) Okay.
Kristen Hanly (24:47) Let’s see.
Amy Barfield (24:50) So, Aetna better health in New Jersey. We were originally told there was a facility contract and that we could close these or complete them with the facility effective date later. We learned that is not the case. And so, they had to be all reopened and submitted. So that’s the reason for the long aging and why they’re in this 90 plus bucket, there’s about 20… 20 enrollments here on this payr… for regal medical group. I’ve been working, trying to get in contact with the payr, and this has been a discussion with, Jeanette and I, over our last couple sessions as well. Trying to set up a meeting with them on their processes,
Nichole Walker (25:41) They have a,
Amy Barfield (25:41) new portal or they have a portal, but setting up the portal is a little tedious, but, our, QA josh and QA is gonna work on setting up that portal this week. It’s not the submission process. They have a 15 page submission process, but the portal does allow us to check statuses, and so, once he gets that set up, we should be able to work through, and see if we have any approvals from those as well.
Amy Barfield (26:11) Any questions… or anybody want to add anything else?
Vikas Bhalla (26:22) How many enrollments are pending, post? 90 days? That is?
Amy Barfield (26:31) Fun. We have a total number down here. Do you know that off the top of your head, Kate?
Kateland Sanders (26:39) I believe it’s 864.
Amy Barfield (26:41) Thank you.
Amy Barfield (26:46) We have 192 and 90 to 120, 359 and 122 40 and two, two and 240.
Vikas Bhalla (26:57) Plus, why would, I can understand, 90 to 120 payers are not responding, all the payer issues we are talking about, why would something be pending for a year, 240 plus?
Amy Barfield (27:12) I mean, with the independence issue that has been one of, the blockers?
Vikas Bhalla (27:22) And that’s the, yeah, are you?
Amy Barfield (27:25) Finding, certain things that, are rising in this 240 plus bucket… iqa, Kate? Yeah. So.
Kateland Sanders (27:35) We, we have went back in and audited everything that’s aged. And so, I think, to your point, vicus, like, the ones in the 240 plus are the ones that maybe had an error, had a process issue, had to be resubmitted, and those are processing. Now that audit has been done, we are escalating now that we know everything is with the payor correctly. Now, we are escalating these because it is just processing time. At this point. We’ve made any corrections that they needed,
Vikas Bhalla (28:02) And, and kind of.
Kateland Sanders (28:03) Started escalating these, but, I do think a lot of these were in that original audit we sent over. I believe it was like two months ago, we have re audited those as we continue on. But I do think a lot of those either had had issues, or needed to be resubmitted or additional information submitted. So.
Vikas Bhalla (28:21) Can you confidently say everything that was done in the last 30 days has no errors? I can,
Kateland Sanders (28:28) check with the quality team. I know we’ve been targeting anything over the 90 days and then they were working down from that to audit those. So I can follow up with them and see where we’re at on the ones below 90 that’s.
Vikas Bhalla (28:39) yeah, that’s the concern. Maybe I have a hard stop. So we should talk about this next week, you know, and, you know, and drake and Nate, you know, that’s my concern. You know, we keep auditing, keep going back to correcting some of these things. And, you know, like, I have examples, I was gonna send it to you. I got it late from my team. So I didn’t send it to you. There are many of those enrollments where you all made two errors, three errors, and especially with the payers, which is, which takes three months, six months, you know, these kind of errors can lead it to a year and, you know, and Derek, we, you know, we don’t have anything in our contract because it’s a financial implication to us. I, I’m I lost 2,000,000 dollars because of this far more than I pay medallion today. All right. So, so I’m, you know, I know we are gonna make progress with all of you engaged Aya, you know, with all the lists you have, but I still don’t have confidence you all have processed buttoned down that today, what is being done? You are not making an error. I don’t have that confidence, I,
Derek Lo (29:47) fully hear you on that. I think we can commit to, you know, next week coming, with a tighter response on that, with actual data, and a plan on how we can give you confidence there. Cause, yeah, fully appreciate it and understand that. And, yeah, if you don’t mind sending us those examples, we will definitely dig into those, ASAP too.
Vikas Bhalla (30:08) Of your audit report, right? It is in your audit report, right? But, but when I was like, if you look at the state I sent you, our bad debt in those states is 20 percent, like we’ll be out of our business if we had a 20 percent bad debt, and especially when payers are not increasing even a dollar pay off reimbursement, right? So, so, so, so let’s talk next week. So, one thing about, so let’s follow up on this next week. Another thing I’ll request is if you could, you know, take a look at this 800 odd enrollment and give me a view by state. And as you are doing priority of these payers, you know, you are following up if you could also prioritize the four states which is critical.
Vikas Bhalla (30:51) I sent you two, which was, Delaware, Pennsylvania. And then if you can add two more, Maryland and DC to that because these are the state as I’m saying like north of 20 25 percent bad debt because of high, high number of credentialing related denials. Yeah, understood. So, there might be a long tail here, which we might be missing from the top 10 list. So we want to make sure they take care of that, so.
Derek Lo (31:21) Yeah. Okay. Well, we know your part’s up. Thank you guys.
Vikas Bhalla (31:24) Thank you. Bye bye. Thank you. Bye.