Transcript
Simira Huggins (00:00) request those prescriptive authority licenses. But yeah, we tried to make that as detailed as possible for like step by steps on that. Yeah.
Erika Schmidt (00:11) That was super helpful. I think I reviewed that doc in conjunction with like a lot of like our raw data and works. I can kind of share my screen. I kind of outlined a quick agenda for today with some of the questions I have. Yeah, cool. Okay. So what I did was, yeah, kind of what Mary alluded to. We’re trying to beef up medallion to be a source of truth right now in medallion right now, like a little bit of history of how we manage the license, majority of our license is medallion, but we do have a legacy like Airtable that houses some of our license. And then the way roe operates, we have like our internal system which we call like the actual tool we call like Django, but that basically determines whether like patients could treat patients on our roe platform. So what we do is we kind of have to Daisy chain like if you are active in medallion like a human goes in and like activate it into like our care center Django application to determine whether we can route work to those providers or not. So obviously licenses being a huge compliance risk for many reasons. That’s why this project is really important that we want to be that medallion. So it’s true we can readily rely on it and that will kind of feed all of our downstream systems and tools. Our MDS and dos are somewhat more straightforward. That’s probably more where we just get into like gaps of like some licenses might live in like Airtable that we need to bring into medallion. But I think like the nurse practitioners because with all the additional state by state requirements that’s where things get a little bit more complicated. So kind of breaking out the by state licenses. What I’m trying to do is like create this like rules engine to basically be like, okay, does this nurse practitioner have a license in that state? Yes or no? And do they meet that state’s additional requirements? And then I’ll create like a boolean field that determines like can treat patients or something like that. Because to my understanding that doesn’t really exist in medallion right now, like it does have some of these additional configurations but it doesn’t like surface whether like from a clinical and legal perspective, whether that provider can treat patients in that state. So that’s what I’m trying to, yeah.
Simira Huggins (02:23) I think to answer your question there, as long as they have a license to practice in that state, it’s an active license that’s issued. Then they should be able to. Now, there are some compliance measures internally for roe to complete before they can start to do those things. But as long as the license is issued, then that should deem them ready to practice essentially well.
Erika Schmidt (02:43) That’s where we get into all like the prescriptive authority. So it’s like if, you know, have a license in that state, but you don’t have the additional extra prescriptive authority license then like we would deem them not able to treat patients in that state. Okay?
Simira Huggins (02:56) So that’s how you’re looking at it internally. Yeah.
Erika Schmidt (02:58) Mary, you know, better than me as I follow some of these rules.
Mary Pedican (03:02) Yeah. So what I was going to say is that the reason that we don’t do so, if the state requires prescriptive authority and the provider doesn’t have it, we, the biggest call out here is that we don’t do collaboration agreements… with our contractors. So, if a provider is not a salary provider and they don’t have prescriptive authority, then we wouldn’t turn that state on because we’re not going to issue a collaboration agreement. So that’s where our nuance that’s what makes us so different is that we’re not going to issue a collaboration agreement for anybody that’s not salaried with us. So if you’re a contractor and you don’t have prescriptive authority and the state requires you to have prescriptive authority to be independent. If you don’t have it, then you’re not going to practice in that state with us. And so that’s where we need to be able to say, okay, well, this provider has the state license, but they don’t have prescriptive authority and they are contractors. So that state is a no go for them. And so we can’t do that because prescriptive authority is not. And, and Erica has some examples here of how we’re trying to look at the data so that we can determine how we want to operationalize this workflow whether it be that we go in and we manually mark prescriptive authority or if it’s something that you all are checking and then checking the box and then just understanding how we can work together to make sure the data that lives in the system stays true to what it is. Okay?
Simira Huggins (04:27) That’s hopeful context. Yeah, I think if we have a request for it, then we would definitely make sure that it’s closed out correctly as a permanent license. And then if it does have prescriptive authority, we make sure that we represent that as well. And then again, that nursing RX guide kind of showcases exactly what that request will look like and platform if they do have prescriptive authority as well. So I happen to go through anything you guys have.
Erika Schmidt (04:52) Yeah. Okay. So for the first section, yeah, maybe go into some of the details. So for all the states that require RX authority on license. And I think in your doc, you kind of called out there’s like some states that should like automatically get it, like if you’re in a state that like, but then there’s like other states, maybe I can bring that up just to put.
Simira Huggins (05:11) That out there. Sorry? Okay.
Erika Schmidt (05:13) It. Okay. So RX included. So these are the states that you automatically get RX included on it. But then there’s like these are the states where you actually have to like click the additional button, but it’s still like it would still come up as RX included. That’s still the button you need to click, but you just need to manually click it.
Simira Huggins (05:33) Right. So when you so essentially, for those, there’s two pathways for plus RX selected, what’s in our platform, we call that pathway two. So essentially, what that means is when you apply on the initial application, there’s a question within the application that asks, do you want prescriptive authority? Yes or no? If you select yes, then that means the permanent license will be issued with prescriptive authority. If you select no or don’t check the box at all. That means the provider will just be issued a permanent NP license. And then they must do a separate process to obtain prescriptive authority. So that either means a separate RX auth request, and then they will obtain prescriptive authority with, you know, a separate application. If they don’t check that box. So two pathways there, so.
Erika Schmidt (06:20) If the provider decides not to check the box and they decide to go like the independent pathway? Like how would that show up in the data? So.
Simira Huggins (06:27) If they don’t check the box, then we will close out the license as a permanent license. We don’t check the RX included box.
Erika Schmidt (06:36) Okay. But like, how do you, but like using that example? So someone lives in California, they don’t check the box, but they end up going to like getting that, make it sound like there’s a different way they can obtain prescriptive authority. They go like a different route.
Simira Huggins (06:50) Yes. So if they don’t check the box again initially, then they would go the separate route of having to submit in a separate application. And then it’ll issue in that way instead of how will.
Erika Schmidt (07:00) that show up in the data? Because it’s not going to be selected on their license, right? So.
Simira Huggins (07:05) Once the license is issued, it’ll be closed out in the existing license section as just a permanent license. It will not reflect RX included. It will not show anything prescriptive authority. It just will be a permanent license.
Erika Schmidt (07:15) Right. But like how, but since they went the additional pathway to get it, how do we show that they actually do?
Simira Huggins (07:20) It? Okay. So you’re asking if they don’t obtain it initially within that application and they go the separate route. Yeah. So then it’ll show up as a separate license within itself in the existing license section. Okay? So.
Erika Schmidt (07:34) It’ll.
Simira Huggins (07:35) be a permanent MP, and then it’ll be a prescriptive authority, existing license.
Erika Schmidt (07:38) So they turn it, they automatically kind of get into bucket number three.
Simira Huggins (07:41) Yes. Okay. So you will see prescriptive authority in that state if they have prescriptive authority. So it’s always going to be if they have prescriptive authority, we’re going to represent it. If they don’t it’s just going to be a permanent license.
Erika Schmidt (07:53) Got it. Okay. Does Mary, does that sense check with like how I know we were kind of creating this rules engine, but like for this pathway two, I might need to check like instead of checking if I’m like saying this correctly for these providers, if I determine whether they actually have prescriptive authority and they can treat patients in that state, I need to either check if they have RX included checked on their license or if they have a separate license. Okay, great. So I think those are the ones that Mary, I don’t think we flushed out on the rules engine.
Mary Pedican (08:21) But I think we did because if they have a license, so those are the ones where you would see either an additional license or something. So I think it’s still just understanding how the, how it’s entered into the system. I think it’s we’d have to look at a lab example for me to explain what I’m trying to say, but I think that if they go through pathway two and they get a license and you just get a regular license and then they go back in the state. But there are some states who don’t issue a separate prescriptive authority license, they would just get them like they would just update their current license to include prescriptive authority, but.
Simira Huggins (09:02) You have some that are like that. Again, that’s why that nursing RX guide is going to be your friend. It lists out the nuances. So sometimes you may have to go back in and edit the existing license to check the box for includes RX after they obtain it. Then it’ll show permanent NP license with RX. Now, if it’s a separate license or something like that that’s renewed separately, then that’s when you add a separate NP license and then a separate prescriptive authority license.
Simira Huggins (09:28) Either way you’re going to be able to determine if they have prescriptive authority or not. I recommend for you all to just filter by state and existing licenses. And then that should pull up either if they have a permanent license or prescriptive authority or both.
Erika Schmidt (09:41) Yeah. So it’s an, or, so this is an, or, versus the first one is these states only have it included. And then step three, pathway three is like all these states require a separate license, right? So.
Simira Huggins (09:55) Pathway three is separate plus already selected is checkbox, if not checkbox, separate. Cool. Okay.
Erika Schmidt (10:03) So following up to this point, so maybe going through some like live examples. So okay, for the first one. So what we’re seeing in our data is like… without the nuance of some states can be an, or like you can either have ours included or you can have a separate license. I didn’t know that distinction until now we’re seeing only about six percent of our providers who live in a state that requires prescriptive authority on license, actually having that like checkbox selected. So like here’s our happy path a provider where like I can see ours included in the license. But this was one a provider and I can go into it to show you where her license. She lives in a state that requires prescriptive authority on license. And I looked at her license and I see it, but I’m just not seeing it like in the data. So just figuring out like who’s the a here that like if I identify all these instances, like goes in and like updates, this is this medallion or is this roe and like, but also to take a step back, you know, why might have this got missed?
Simira Huggins (11:10) Let me pull this provider up. Did we have a prescriptive authority request for this provider? And again, going back to our point of we just kind of updated, you know, our resources for this. So you may see some discrepancies there. But did we have a prescriptive authority request for this provider? Emily?
Erika Schmidt (11:26) What do you mean by request? So?
Mary Pedican (11:29) Most of the time you guys are not actually, you don’t like we don’t request license for any of our contract providers. So you would only have actually done a license for the provider. If they were salaried. These are just providers who licenses are entered or pulled from a previous medallion profile. Like we have providers who, so that’s a workflow thing that I think we need to discuss is when we have a provider and either they’re joining and they already have a medallion profile or they’re brand new and they’re filling out their medallion profile and it’s pulling in from, I would assume you guys pulled in licenses from caqh. I don’t know how that all works. But when the provider’s licenses are entered, our team is not manually verifying or updating anything on a license record in medallion at this moment. So what is entered is done by either you guys or the provider. So we need to align on what the workflow will look like to ensure that it’s correct? I.
Simira Huggins (12:29) Think that’s the gap if it’s outside of a request, and it’s like a new provider, if the provider is entering that, they need to make sure that it’s entered correctly to show prescriptive authority. Like outside of a request, my team wouldn’t be going in and just adding existing licenses and making sure it has prescriptive authority that’s outside of our scope. So, when.
Mary Pedican (12:50) you all do PSV for the licenses because that’s how we get our credentialing packets in the PSV process. Is no one actually doing a primary source verification of the license, and then making sure that the record in the system matches what is on the license? Because I would think you should.
Simira Huggins (13:04) So that’s different, Kyle, do they have ilv? Yeah?
Kyle Rice (13:09) I believe they do. Hey guys. Sorry, I was a little bit late for today. Yeah. I believe that the credentialing team, when the requests go through either initial or recredentialing, they should be verifying and updating those based on the license type. So if she does have prescriptive authority, they should be verifying that either at the expiration date or the time of the credentialing events, whether it’s an initial or recred. I believe in this case, it would be a recred, for Emily. Okay.
Mary Pedican (13:35) So, when Emily was initially credentialed, this license was issued in 20 21. So she probably had this license. So when she was initially credentialed if this license was here and she had prescriptive authority when they did the primary source verification, the prescriptive authority is on the license. Is that what you’re saying, Erica, you can see it on the license but it’s not entered here like it’s it doesn’t show here that she has prescriptive authority. And that’s where we’re trying to get a clarification on what is your workflow when you do the PSV for a license, where it does show on, it shows there clearly. We all see it but it’s not, it doesn’t it’s not indicated in the system in any way. So to me. And what Erica’s saying is that’s a gap because that should have been entered when the license was verified. When whoever pulled this document and put it here. They should have checked prescriptive authority at that time. Now, I don’t know. I know you said the workflow has recently changed, but we’re going to have to go back and need to clean up every license for every provider to ensure where there is prescriptive authority that it’s accurately marked in the system to show that there is prescriptive authority either on the license or there is an additional license or our engine will never work, and we’ll never be able to use this as our source of truth for licenses. So.
Simira Huggins (14:52) I think Kyle, this is outside of licensing. This has something to do with credit.
Erika Schmidt (14:57) Not.
Simira Huggins (14:57) necessarily my team, I think we can take that back internally. This is not anything to do with licensing.
Mary Pedican (15:02) I think the reason that we wanted to have someone from licensing, which to us is like a rather the license is a new license or a credential license. I think that’s the flow when you all, but also someone from the data team so that we could understand how a provider goes through the flow. Most of the time. You guys are not doing that many new licenses for us Kyle we just entered a few, but there’s not a lot of new licenses that you all are doing. Most of it is providers come with these licenses or they get them and we enter them or they enter them. How does the flow work for a license where prescriptive authority is either necessary and on the license or an additional license? How should that be in the system?
Mary Pedican (15:45) And how do we make sure it is the same across every provider that’s licensed in the same state? And that is where we’re seeing a lot of discrepancies on the way it is entered across one state. You can see a whole lot of differences on the same provider type. Yeah.
Kyle Rice (16:03) I think what we need to do is just do like a high level review here. And then what I probably need to do is take this back with our credentialing team in terms of like the license instances. And if you guys have any additional provider examples, we can definitely, you know, support some cleanup there for this. And for the data exchange piece, I would need to confirm that as well with our team.
Erika Schmidt (16:24) Yeah. I could share this report if it’s helpful. So this is like the list of all our providers who live in a state that requires prescriptive authority on license. But like I’m not seeing this like RX authority checked anywhere. So this would be the complete like listing that we would want to reconcile against. So there’s like 300 providers and.
Simira Huggins (16:42) Just to confirm these are providers that held existing licenses outside of a request from medallion.
Mary Pedican (16:49) More than likely, yes, because we probably wouldn’t have any for these providers through. Okay?
Erika Schmidt (16:54) That makes sense. Then there’s just knowing the nuance that we talked about. I’ll so I think I’ll do is I’ll rerun the rules engine, knowing that those subset of states can have prescriptive authority on license or separate license that might reduce some of like the list right here. But like one that was like specifically called out is like I did see this one provider. Or actually there’s five instances of providers who have licenses in Idaho. And that is one of the states that like should automatically be applied to RX authority. And like they’re not on the list. So that seems like a specific call out for one that’s.
Simira Huggins (17:30) okay. So that just may be a bug, but we can take a look at that too.
Erika Schmidt (17:33) Okay. So I’ll take that as an extra item. I’ll clean up that report and send it back because those are the ones that definitely need to be cleaned up.
Kyle Rice (17:38) Okay. I’d love to get some additional visibility on that report, Erica, just if you send that over to me as soon as you get a chance, I can take that from there.
Erika Schmidt (17:54) All right. So now, sorry, no, go ahead. Oh, I was gonna move on to like our, the next section… Eric’s authority, second license.
Erika Schmidt (18:10) Okay. Perform like a similar exercise. These are when I’m specifically looking for a second license for that provider, determine whether they have arc’s authority. Again here’s our happy path example where this one provider in Colorado. I can specifically see they have a specific arc’s authority second license. And then this one, I… this one’s a little interesting. So it’s like these, I don’t know. I don’t know if this is like a roe thing or a medallion thing. But like we just don’t always have that second arc’s authority license like in the system. So like that begs the question. Do they have the second license and like whether like roe needs to give that to medallion or if this just wasn’t like properly like updated? So I’ll probably lean on, you know, Mary and the medallion team to kind of like help me investigate here. Okay. This, but this one is specific interesting because I did want to find some examples where this provider is active in Illinois on our system. So it kind of like indicates that they should have the second license, but I don’t know where to look for it. I.
Kyle Rice (19:13) Showed, so, I, Samara, correct me if I’m wrong here. I showed that for Garrett, he’s got full practice authority as part of his aprn license here. So would he not necessarily have that prescriptive authority? Samara?
Simira Huggins (19:22) So, no, with Illinois, they don’t issue that. They only issue a separate autonomous registration like full practice authority license. So that would need to be entered into platform. And then if they do require prescriptive authority, they would have to obtain a autonomous registration or full practice authority CSR. So that wouldn’t necessarily count as prescriptive authority if they have autonomous registration at that point. Yeah.
Mary Pedican (19:51) And so, for our requirements, the providers, so on his… can you go to his record in medallion? So I can look at the license copy?
Erika Schmidt (20:06) Yeah.
Mary Pedican (20:10) And if you can open that image, so I can look at that. So, you see how he has the full practice authority aprn, and then the full practice authority, controlled substance to us, that is what we’re indicating as on the license. And so he has what’s required in Illinois for us. Erica, when we were, if we were loading this provider, we would have went and looked at this image to say, okay, he has full practice and he has, we don’t even look for the controlled substance. We actually just look for the full practice authority. And as long as he has that, then we move forward with turning that state on for this provider. So.
Simira Huggins (20:44) Erica, in our platform, that will be entered as autonreg for autonomous registration.
Erika Schmidt (20:51) Autonomous registration. Okay? And this is where I get tripped up for the rules. Does that? And that would be under the RX authority field, autonomous registration, no.
Simira Huggins (21:00) That’s something separate. So, prescriptive authority and autonomous registration are separate. That autonomous registration just means the provider can practice autonomously. No collaborative or supervising physician and agreement needed. So, if you go to add existing license in our platform and then go to license types scroll all the way down and you should see where it says or you can type it into, but you should see where it says autonreg and then it’ll say dash, autonomous registration, that’s the license type, you would choose for that one.
Erika Schmidt (21:32) But if I’m in the system, how do we know that they have autonomous registration?
Simira Huggins (21:36) With the autonomous registration license type? But I’m.
Erika Schmidt (21:40) saying that they don’t have it, right?
Simira Huggins (21:42) It doesn’t reflect it. So that’s something that either did the provider put that in that’s something that we’re going to have to discover. And then again, this is not licensing. So that’s something that we’ll have to consult with credentialing for if this is credentialing.
Mary Pedican (21:55) Yeah, that’s what I was going to say, but if this was licensing.
Simira Huggins (21:58) Yes, if we had a request, you would see it as autonreg. Yeah.
Mary Pedican (22:02) That’s what I was going to say. It’s most likely not licensing. That’s the issue here. I think it is for all the providers that are going through credentialing, we’re either merging their profile or the licenses are being pulled in. And when they go through credentialing, they’re verifying the licenses, but they’re not updating the records to accurately reflect what it should, whether it be autonomous registration or prescriptive authority. They’re just verifying the licenses previously. That wouldn’t have been an issue for us because we just make sure that it has what we need on the license. So nobody spent time to like really clean up what the data should say. So what we actually need is someone, somehow, we’re going to have a project where the licenses are cleaned up to accurately reflect the rules. That, can you say your name smyra?
Simira Huggins (22:52) Smyra?
Mary Pedican (22:53) That smyra is stating that her team follows. Because if we would have gotten this license issued through you all it probably would have been entered in the system the right way. But because the providers are coming on board with these licenses, no one is doing the due diligence to make sure that they’re entered the appropriate way based on the rules that it should be across autonomous registration and prescriptive authority. So that’s why we see so many different cases across every provider.
Simira Huggins (23:19) Yeah. And I would, I will say like if we did have a request for the provider, our intake team would have probably called it too and updated those licenses. But again, since it’s just Craig, then there’s a gap. And so we need to, you know, address that gap. We.
Kyle Rice (23:32) Also might want to consider too, I’m just pulling some data really quickly here. Ad hoc. It looks like this provider, Garrett received his autonomous registration on February, his last credentialing event was on 1,216 20 25. So we would not have visibility into that license being updated to autonomous registration unless the provider had gone into the existing licenses section and updated that to that distinction type, but.
Mary Pedican (23:59) How did the image get there? If that wasn’t I mean, I don’t know. Did we put that? Did someone on our team add the image of the license there? Because either way we look at it when we add a new license or if something changes on a provider’s license, we count on medallion to be our… yes.
Mary Pedican (24:19) So, and you guys are doing PSV for us. This goes just all the way back to the fact that you only verify licenses up a third, 30 days, 60 days before expiration date. And that’s where this issue continues to come up because if this license was verified more frequently, that would have probably came up. And then it would have been flipped to accurately reflect what it’s needed there. And so that’s why I always say that we need the licenses verified more often than every three years, which is most of the time when a license is due for renewal so that it can be accurate.
Mary Pedican (24:55) Because if the provider doesn’t tell us and we don’t know that he has prescriptive authority in this state, we may have a collaboration agreement that’s in place that we don’t need or something that’s causing and we can’t rely on this data to be accurate.
Kyle Rice (25:10) Yeah. I’m just pulling the verification here. Mary, it looks like this was verified automatically through the Illinois state board of medicine. So I don’t know that would flag that if there was any license change since we just had the NP, it’s searching for the NP license type. And then if we had the autonomous registration in there, I believe it would pull the autonomous verification in automatically through the connection to the state board. I believe it’s a vapi with illinois’ license lookup.
Mary Pedican (25:39) So when you say it would have pulled it in should the system have automatically created another record for it or updated it to show that the check was there that it has autonomous whatever.
Kyle Rice (25:50) I don’t believe that the system would automatically pull it in since we just have the NP type in there. I believe it would have been Garrett’s responsibility to put the license in the existing licenses section as that autonomous registration in February when it was issued. Otherwise, the system is just going to pull against the NP license to look for that type. I believe. Yeah. And then just.
Mary Pedican (26:12) For our context, Erica, this is just another reason why I don’t feel like providers should, while we all want to say they should be responsible for their own data and they should enter it the right way. What provider is going to know or pay attention to the fact that they should check autonomous registration or enter the license the correct way every time. And if we don’t I don’t have a report to show me new licenses that were entered by the provider. So it’s just a lot of gaps when it comes to the way these licenses are entered and how they’re being maintained because anybody could provide, I could go in. I could have went in. Haley, could have went in like anybody could have entered the license but who’s making sure that the data is correct every time a license is entered. We don’t give providers instructions on how to enter their licenses the right way. They just do their best. So, I think.
Simira Huggins (27:04) Good starting point for this even though it is crid, we could just share this nursing RX guide. Let them utilize that. I think, yeah, there’s going to be a gap with you all knowing like when something changes with their licenses, but I think two providers receive notifications from boards on when certain licenses are issued and, you know, what happens there. And I think maybe let’s just start there too of just having them update it using the nursing RX guide. And then from our part, yeah, we’ll connect with crid to see, you know if we can get those gaps addressed too. Yeah, makes.
Mary Pedican (27:40) sense.
Erika Schmidt (27:44) Okay. So, I think so it sounds like, yeah, there’s some, I think on the RX authority on license, I’ll share that listing out because that’s probably like a gap in how the license were originally like set up. So and then the additional I’m just kind of a little unclear of like who’s the a on like fixing some of these between medallion and roe, and then just like, you know, going forward a better process to make sure that these licenses are like up to date, so we can rely on the downstream data… for sure.
Kyle Rice (28:16) Yeah, Erica, let me take a look at the list and then just cross reference a little bit and then let me have as a takeaway just to see like provide some additional information like where the license was updated, if it was pulled in from either credentialing packet or if it was a provider driven update. I just think we just need to understand a little bit more of the root cause on where the data update had determined from, just to just resolve this and then take the next steps from there. Okay? And.
Simira Huggins (28:41) Mary, so.
Erika Schmidt (28:42) Our 10 90 nines, they all have the responsibility of updating all their licenses in medallion, all.
Mary Pedican (28:48) Providers are supposed to update and maintain their licenses in medallion. Sometimes they will email us in a copy of the license and we will go in and enter it for them. But I mean, that’s what I was going to say. We could change the process to, they don’t enter any licenses into their own profiles and we enter them. But I mean, we get emails at least 50 emails a day about either a license renewal or a license something. So it would have to be, how do we operationalize maintaining and updating every provider’s license in their profile for them?
Erika Schmidt (29:26) Okay. So it sounds like there’s a little bit of a gap in terms of like… there almost needs to be like a how to, we need to like operationalize a little bit. Like I have a license in that state especially as an arch practitioners, but they’re probably the most complicated and like how to appropriately like add the data into medallion. Cause it seems like it’s a little bit of like a free for all and people are like adding the data inconsistently and that’s where we’re kind of getting to these like discrepancies, if that’s an accurate summary. Yeah.
Kyle Rice (29:53) That makes total sense. Erica. So there’s a couple of different ways that they can update it. Like when I said, we can initiate a profile transfer. So if they have a previous profile with medallion, we can essentially copy that information over. We can import through a caqh import. If they, the provider keeps a caqh up to date, it’ll pull all the license information over there. And then the third and fourth is if the provider is completing licensure actions such as renewals, initial licensures, I think that’s specifically be aligned with the contractors. They may be up in the system updating those as well. And then if our team is completing any initial or renewal requests that’s when our team will take over and update those kind of internally within the existing licenses section.
Erika Schmidt (30:39) Okay. But I just think there’s also like a lot of complexity with these like state by states like how would we know, how do we know that Illinois requires this autonomous registration? And that indicates that they can treat… patients in that state. Like I don’t know if we have, that like rules engine we had for nurses, I think just talked about like on license and then separate license. But then we didn’t like really talk about the rules for this like third set.
Simira Huggins (31:08) So it’s not autonomous registration isn’t required. It’s something that you choose to obtain or not. So like if you want your providers to have autonomous registration in Illinois, then you would obtain it. So the license verification document is going to tell them we may not have a request again because we don’t have a lot of requests for you all. So that will be again something that’s on your end. So when the license is issued to the provider, they’re going to receive notification. Okay, autonomous registration and full practice authority is issued from that verification that’s what they should issue. Now, I can’t edit the nursing RX guide to include, okay, if you have autonomous registration, just enter it into platform as such. If that’s helpful for you all but kind of self explanatory, you would just enter it as autonomous registration within the existing license section. Again, it’s not a requirement for providers to have it’s just on how they intend to practice if they want to practice without a collaborative agreement and a collaborating physician, or if they do want that, does that make sense? It?
Erika Schmidt (32:13) Does, so, does autonomous registration kind of like trump all the others? Like you have that? And that’s what I’m trying to build out like there’s like rules engine in terms of like deterministically from the data be like, okay, they have a determined autonomous registration, then they don’t need this like separate RX authority when they.
Simira Huggins (32:30) Have autonomous registration, they can practice and prescribe autonomously. No, you know, collaborating physician, no practice agreement. So that’s the top of the line.
Erika Schmidt (32:41) Okay. It’s kind of like.
Kyle Rice (32:44) In terms of like the autonomous registration kind of like smyre said, like this is the autonomous registration as like the full tier like practice authority in that state below that kind of prescriptive authority. And then that like the MP license giving them like the levels to practice out and smyre, let me know if you disagree at all there.
Erika Schmidt (33:01) Okay. And then if I remember from the prior conversations though autonomous registration is an attribute that is not supported in medallion though. So I think we talked a little bit about or is it?
Kyle Rice (33:11) No, it is supported in medallion. It’s listed. I think Samara hinted on this a little bit earlier as a Eton reg underneath the license type. There. It is supported. And I believe there’s some states that will not grant the autonomous registration. And then it’s just an independent practice state. If I’m off the internet.
Erika Schmidt (33:29) So it’s a separate license type actually?
Simira Huggins (33:32) Yes, great. So you can request licenses from there, and you can also enter existing licenses for autonomous registration… Mary.
Erika Schmidt (33:44) What was the one thing that we talked about that they didn’t support? Do you remember… I?
Mary Pedican (33:52) Have no idea. I don’t remember exactly. It’s.
Erika Schmidt (33:55) something we were going to put in the notes section, but.
Simira Huggins (33:58) Then we.
Mary Pedican (33:59) were going to put in the notes if.
Kyle Rice (34:02) It was independent practice. I think that was ringing a bell right there?
Mary Pedican (34:05) Yeah. Something about that we verified that the provider met the requirements in that state and they have independent practice. But if you’re saying that in the states where they have autonomous practice. So, like for example, in Florida where you can have autonomous practice, they should have in Florida, it should be autonomous practice, it should be a Florida license. And then an autonomous practice license. Or will that not be two separate?
Kyle Rice (34:38) I don’t think.
Simira Huggins (34:40) That’s a separate because most of the time when autonomous practice gets issued, it trumps the MP license itself. So it’s just autonomous practice. Does that make sense? Like with Illinois? So Illinois will inactivate the previous licenses. So they will inactivate the previous permanent MP and the previous CSR, and then it goes into autonomous registration. So you don’t have that permanent MP anymore. You’re just autonomous.
Mary Pedican (35:08) So only in states where the autonomous registration license is the highest level of license that the MP can hold will, and it’s a separate. It’s actually like a separate license, will that be different, but in Florida, you can be, you can still hold, you can have autonomous, an autonomous license or you can have a, but it doesn’t it isn’t too separate.
Simira Huggins (35:34) So it will be separate, but it’s going to trump the license. Does that make sense? Like, okay, this provider has an MP. Now, they want to go and get autonomous practice. It’s going to be two separate things. But like it trumps the whole license. So they have autonomous, they have the MP, autonomous registration license itself. And let me see if I can pull up an example for you all to see. So.
Mary Pedican (35:57) Like Virginia is another example where their license has to say autonomous practice with RX authority.
Simira Huggins (36:04) So, Virginia, on the verification, if you see on the verification, it’ll say prescriptive authority under that, it’ll say autonomous practice or autonomous registration or something like that under the license. So it’s just saying the overall license is autonomous. This provider can practice autonomously, they can prescribe autonomously, but again, some states will keep the license number the same. It’s just about updating the existing license within medallion, if that makes sense?
Mary Pedican (36:32) So, is this the details that you’re going over now? Is that in that guide you shared with us? No?
Simira Huggins (36:37) I will add it for you all. This is just specific to prescriptive authority since this is kind of like something that we really changed. Autonomous registration hasn’t really changed for us. We always represented it the same, okay?
Mary Pedican (36:48) Because what we would need to know is in states where autonomous registration is separate, where should we see it separate versus where we should not? And then I think we can build a rule engine. Erica, correct me if I’m wrong that if you are in this state and you should have both, then you will see both and they’re good. But if you’re in this state and you only have one, then stop because this provider, you may need to do an additional check or don’t turn this state on for this provider.
Simira Huggins (37:12) Yeah, I think for us, we do a little bit of cleanup. So, like if an autonomous registration license is issued, they already had a permanent MP before, but now they issue autonomous like separately, we remove that MP, and then they just have the autonomous registration license. And I think that may be what your team needs to do, but I’ll add that information and send it over to Kyle. Once I have it, you know, go ahead and mapped out for you guys. But I think there’s just going to be, you know, something that the providers have to do on their end. Once autonomous practice is issued, because it is a separate thing within itself. You just have to know how to represent it in platform. Again, it may be editing the existing license because it has the same license information. It has the same license number. We just need to change the actual license type to autonomous practice.
Erika Schmidt (38:04) Is that like the RX authority, autonomous registration box that would be checked?
Simira Huggins (38:09) So, it’s not a box that you check. It’s always going to kind of be a separate application. Yeah.
Kyle Rice (38:15) It’s a different license type. Yeah.
Simira Huggins (38:18) If you enter it in platform, it’s always going to be a separate request. Got it. Okay.
Erika Schmidt (38:24) And does every state, like can I take a general rule of like you have autonomous practice?
Simira Huggins (38:30) No, only certain states have it not offered by every state. No. Okay. Some states require you to still have a collaborative agreement, collaborating physician.
Erika Schmidt (38:40) And that doc, will you have that spelled out yep?
Simira Huggins (38:43) I’m going to spell out the ones that we assist with. We don’t assist with all autonomous registration states. So that’s something that would have to be managed internally by ROA, if you want that. Okay, I think.
Kyle Rice (38:54) There’s a list. I think it’s about. I want to say maybe 26 states that offer full practice authority for that like autonomous registration. There’s a couple states with like reduced practice. I know we highlighted on like Illinois, North Carolina, Virginia, and we have those restricted practice states that are always going to require that collaborative agreement or prescriptive authority. I have a pretty good resource from the aanp Erica that I can send you that might help kind of give you a little bit more of a visual on this after, if that works for you.
Erika Schmidt (39:23) Yeah, that’d be helpful. And then in the states you don’t support like what does ro, do? Is there a way for us to update it in the system manually ourselves or?
Kyle Rice (39:30) For this, in terms of like licensure or just trying to like?
Erika Schmidt (39:35) You said you don’t support it in every state? What does that mean?
Kyle Rice (39:37) Just meaning we don’t support like the application process for that. I believe like Georgia is one that we don’t do offhand. And then I think there’s one other, but I’m just not recalling it. We just wouldn’t either support the initial application for that state for full practice authority.
Erika Schmidt (39:54) But if a provider comes to us with it, can we upload it into our system?
Kyle Rice (39:58) Oh, yeah, absolutely you can.
Simira Huggins (40:00) And like, and yeah.
Erika Schmidt (40:03) We can still upload it and it’ll still reflect the same as like any other provider, yes.
Mary Pedican (40:09) Sounds good.
Erika Schmidt (40:13) Okay. I think I have a little bit more clarity. I think that additional doc will be helpful just for us to like look up. And yeah, I think for… I think, Mary and I, we can sync after this call. Maybe we need some time just to kind of go through like the nuances of like the process, but I think this is like a process gap where we have a lot of providers who are uploading the information, but maybe we’re not doing consistently and just figuring out who the a is on making sure this data is entered appropriately and it sounds like medallion doesn’t support that in our current process since our providers upload their data independently?
Kyle Rice (40:51) Yeah, it just depends on the modality in which they’re uploading it. Like I said, there’s I think like four or five different ways that we can receive the information from the provider, Erica, if you could, if you could send me a copy of that spreadsheet whenever you get a second, I’d just love to take a look at that and see what the gap is and then just take that back with the team. And then if we need like as I say, if we need another call to, you know, support, like any additional questions, I could kind of help run that and get you guys squared away, but I would just like to just take a look at some of the data that you guys have pulled from there, do some cross comparison.
Erika Schmidt (41:20) Okay. And using Garrett as an example, just to circle back to this, how did we know he had autonomous practice?
Kyle Rice (41:25) We, I just took a look at the verification. If you, so if you go to the right on your screen, Erica, you should see the three dots on the right. Keep going. Yeah… that’s right. Yeah. And you can yep click, right? Yeah, view verification or if you click that bottom there view file and then the autonomous registration should be on the PSV. So.
Mary Pedican (41:50) My last question is, so when a provider enters a new license, does it automatically go into the PSV process or? Yes? Okay. And so when it goes into the PSV process, would, will you guys complete the PSV and then update what’s on the license record or that’s not?
Kyle Rice (42:10) How.
Mary Pedican (42:10) it works? You just verify that the license actually exists, but you’re not going to make any updates to the license because I think there’s a few different things like there is, I got a new license. I entered into medallion, what happens next? Or something changed on my license? I don’t update it in medallion at all. But now I have independent practice. I think that’s two different scenarios. And so I would want to understand what happens when they enter their own license and then how that flow looks. And when something changes on the license, what the flow looks like for that? I guess there’s not anything that’s going to verify that the license changed because you won’t verify until expiration. So the provider would then have to notify us or go in and manually make the change. Yeah.
Kyle Rice (42:52) Exactly. I’m happy to put together like a flow chart for you to kind of show you what happens. I believe with the initial entry, like specifically for the providers that we migrated, their licenses will go through that initial verification again for any new licenses entered. But I can put some documentation together in a visual for you if that helps give you guys some additional visibility into that. Okay?
Mary Pedican (43:14) And.
Erika Schmidt (43:16) when you say just to circle back, you were saying it’s because there’s… the full practice. Is this what you’re referring to? Like how we knew they had autonomous practice? Yes. But then there’s a handful of providers who don’t have their license in the system. So like then we just don’t know, right? Like… not every provider uploads their license. Yeah. If.
Kyle Rice (43:37) there’s any licensure, not uploaded the system, we wouldn’t have visibility into that, until they enter essentially got.
Erika Schmidt (43:44) It. Okay. So, Mary, is that like another gap that we have to identify? Like all the providers who don’t have a license?
Mary Pedican (43:51) So, I’m sorry.
Erika Schmidt (43:52) Not every provider that I’ve qa’d has a copy of their license in the medallion. Do we know if we have all those provider licenses in some regard, they’re.
Mary Pedican (44:02) probably in the air table, but if they’re not, I mean we don’t really use the copy of the license for anything. So as long as it verifies through the board when they enter it, which every license just to make sure I’m right? Kyle, is, if the license is there, it has at least been verified once. And then it’ll be verified again. So every license, as long as it’s checked and verified through medallion, we don’t need a copy of the license for anything. So we don’t always get it. Like if they renew their license, sometimes the renewal date will just come through and we’ll update the date, but we won’t put a new copy of the license in the in medallion. No.
Kyle Rice (44:35) They’ll always be. So if you enter, like if you were to go into Garrett blakers right now, and if you just entered like a dummy license for like Minnesota or something like, that would go, you’re gonna see that you’re gonna see it initially enter and then pop off, it’s not gonna be visible once it answers our verification queue. So, our team will essentially verify it against the state board. They’ll pull a new updated PSV on there. And then I believe they should make any updates to say if it’s like autonomous registration, if it’s prescriptive authority in regards to that major. Okay.
Erika Schmidt (45:02) That’s a good question. So, like automatically, all the licenses entered in the system get automatically verified against the state board. But like how do we check all these like different nuances? Like if I add RX included, like how does that get checked against the state board or not? Like all those additional attributes that we’re talking about. So.
Kyle Rice (45:21) They should be pulling the license to check for all those attributes. I believe we either use a combination of the state board and nercis to verify if they have prescriptive authority included or not autonomous registration or anything additional linked to like their NP license, yeah.
Erika Schmidt (45:35) But what’s the workflow? I enter my license, Minnesota. I say I have RX included, right? It goes to the state board. I’m guessing we just do like a web crawl and just like check against the state board, whether like it has that activity.
Simira Huggins (45:47) Like, you know?
Erika Schmidt (45:49) That provider’s license, but like who checks the specific attribute, whether like RX was included or not.
Kyle Rice (45:54) In terms of like the provider or the person entering the license? Well?
Erika Schmidt (45:56) Like, okay, they have a license, it’s what’s.
Simira Huggins (46:00) the process who’s they, so like the, are you saying like the provider is entering the license? Yeah?
Erika Schmidt (46:05) The provider enters the license. It sounds like you have a process where we check whether there’s a license actually for that provider in that state, right?
Kyle Rice (46:13) Yes.
Erika Schmidt (46:15) And then, but like I’m assuming what is the exact attributes we’re checking it’s just the state.
Simira Huggins (46:22) Like if it’s an act like, what are the details on the license? Exactly? What I’m.
Erika Schmidt (46:27) trying to understand is like we’re finding inconsistencies… where like all the attributes that the provider has on their license aren’t included in medallion. So it’s like, correct.
Simira Huggins (46:36) If the provider’s entering the license, you want to make sure that everything that’s on that verification is in medallion for the fields. If it’s an active license, make sure that status, is there license issuance date, license?
Erika Schmidt (46:49) Expiration date?
Simira Huggins (46:51) License number. If they have prescriptive authority, check the box for prescriptive authority upload communication. I think that’s how you’re going to know if they, if it says full practice authority, autonomous registration, just make sure that license type is reflected on the existing license first upfront. That’s what I’m saying, like if providers are doing this, like at least make sure they have that information there.
Erika Schmidt (47:10) Roe checks.
Simira Huggins (47:11) Roe, if roe is doing it, add in that existing license, then roe needs to make sure that information is there. If it’s on the verification, there should be no reason to like really leave it out so, that is as accurate as possible.
Erika Schmidt (47:27) For sure. I think I got excited when you say you do the independent check against the state board. But like, what is that independent check you’re checking against with the state board? I?
Kyle Rice (47:36) Can take that one so that’s just that’s going to check against the provider, demographic details. So, their first name, last name, middle name, if applicable on the verification, it’s going to check against the license type. So, if a center is an NP, aprn with prescriptive authority, it’s going to check in regards to that. It’s going to check against the license number. And then it’s going to check against the status. So whether it’s active inactive, whatever that status may be. And then if it is prescriptive authority on there, it will check against that as well.
Erika Schmidt (48:09) Okay. So it does check prescriptive authority against the state board, yes.
Kyle Rice (48:13) Okay.
Erika Schmidt (48:14) But then how do we get into all these instances where like we’re missing some RX included?
Kyle Rice (48:19) Yeah, that’s what I want to take a look at that list for because it could have been off cycle. There are. So the way our monitoring works, it’s only going to check two weeks before expiration on one day before two weeks before one week before on expiration, and then one week post expiration in which it pulls in that data. There might be a like Mary said, there is a little bit of a gap there where it’s not checking continuously. It only comes up on the expiration date or when a new license is added. So, I just want to take a look at that data to see to kind of cross reference. If it was, you know, in between cycles, it was in between a credentialing event just to get a little bit more visibility into that.
Erika Schmidt (48:56) Got it. Okay. Sounds good. So, yeah, I’ll provide that listing. Was it also helpful to provide the listing of all the providers that we don’t have the second license for that we assume they should, oh, yeah. The first authority second license?
Kyle Rice (49:12) Yeah, I’ll take a look at that as well. Okay. Sounds.
Erika Schmidt (49:15) Good. Okay. I think I’m like 80 percent clear. I think there’s still some. Yeah, I think some of those like independent practice and autonomous registration just sometimes just adds a little bit of extra complication. But Mary, I think we can maybe further discuss that. And then just like ironing out the process for roe for like new providers versus like just maintaining your license, perfect. And.
Kyle Rice (49:39) Then, yeah, I will share that autonomous registration guide with you as soon as Samaya gets a chance to update it, I’ll take a look at the data that you guys sent forward and do some cross referencing and provide you guys some insight there. And then if we want to set up like an ad hoc call for next week for any discrepancies or any additional questions. I’m, happy to do so as well. Sounds good.
Simira Huggins (49:59) Perfect. Thank you. Awesome.
Kyle Rice (50:04) Alrighty. Guys. Anything else, Mary? Or Erica?
Erika Schmidt (50:08) The only other?
Mary Pedican (50:10) Thing I had was that we are doing an audit of licenses that are not in medallion… that we do have record of. And so I don’t know if we ever discussed this before, but we want to be able to load all of those licenses and they need to be loaded. The right way. We just discussed all of this. So is there a way to get support from your team with loading those licenses? Because we have quite a few licenses that are not in that we need to get loaded for all of our providers so that we can get away from this air table that makes my skin crawl. So I would love to see if there’s any support we can get with getting those licenses added. Because as we all know, Haley’s not here anymore. So it’s just Mary. See.
Kyle Rice (50:54) I’m always on team Mary. So definitely understand where you’re coming from. Let me know. Do you know about how many licenses there are? We could definitely loop in our TSM team to help do like a data set import for any of those licenses that are not identified in medallion.
Mary Pedican (51:08) We will know closer to the end of this week or maybe on Monday, how many exactly there are and we can, and I can let you know how many and then you can tell me what we need to do. I don’t know for sure right now, but it was quite a few.
Erika Schmidt (51:19) Yeah. I can style that up against what we don’t have if we just gave you all the license though, just throwing that out there. Can you check against what we already have versus net new? Yeah, I.
Kyle Rice (51:30) can do like what I can do is I can just do a, I can just pull your licenses, do a vlookup for anything that’s not outstanding on there, but we can do a upload with our TSM team. I believe we’ll just need to provide an import template for you guys, and then we can pull those licenses in for each provider for anything that’s not listed currently.
Erika Schmidt (51:50) Okay. If you were just going to do a vlookup, I can do that. I didn’t know if the system has the ability to like automatically determine. Yeah.
Mary Pedican (51:56) You remember it’ll, put duplicates in there too. So we don’t want to like send them something that’s already there. And now we got 17 Minnesota licenses for providers. So I was thinking we probably need to identify what’s not there and only send what we need to have loaded. Perfect.
Kyle Rice (52:11) Yeah, just let me know the number and I can kind of help guide us down that pathway to get there.
Erika Schmidt (52:15) Okay. Yeah. Early next week, I’ll have probably the exact number, perfect.
Kyle Rice (52:18) That sounds great. Thank.
Erika Schmidt (52:19) You cool. All right. Sounds good. So, yeah, I’ll provide you the delta of the new licenses plus the discrepancies we have by risk authority. And then if you can send me that doc you have on autonomous registration, that’d be, really helpful. Yeah, kind of go from there.
Kyle Rice (52:34) Perfect. Sounds like a plan. Thank.
Mary Pedican (52:36) You. Thanks.
Kyle Rice (52:37) Guys. Bye, thank.
Mary Pedican (52:39) You. Bye.