Transcript
Kelli Fawver (00:00) hey, Nicole. Hey, how are you? Oh, that’s… a loaded question to be honest and I know probably the same for you. So I know we had a I’ll say it was a tough chat with Mira last week. So, sorry about… that. I’ll just have to preface that. That is it was a hard conversation. But I think again once we get some stuff ironed out, we’re making progress. I’m not, I’m seeing light at the end of the tunnel, we’re going to get there. It’s just, it’s a lot right now. So I did have one specific thing that on the agenda I wanted to chat through. But before we dive into that, I think it’ll be pretty quick and easy but I want to make sure I understand the workflow for something new we want to venture into. But just recap, like anything that you wanted to cover from our conversations last week, the extended conversation with Mira and anything that we need to do to help, I know there’s a lot of tasks but anything that we can do to help move this forward?
Niccole Russell (01:18) I mean, I’ve been in communication with Mira over that call and we’re trying to work some things out on the back end. I do have as I emailed you a product ticket in to see if we could have those admins separated out. We’re in touch with the operations team as far as enrollment goes, I think, you know. And I did tell Mira that I had sent over what payer information that I have. It’s a new spreadsheet I sent that over, but I know it’s just trying to figure out where to enroll, what with the behavioral health.
Kelli Fawver (01:55) So, I think it’s more so not only because I know you gave that cheat sheet of like who to enroll? What like lucet blue crest, we get that. But, and that’s I’ll say that’s lower priority right? Where the pain really comes in is it requires three providers and we waste an enrollment, sending it to a provider that’s never going to get enrolled. Because again, we have one provider. They’re not having three to five providers. So it should never be sent as a provider enrollment. If we know there’s not three providers at that organization. It’s just again that bloat, so any again of that kind of cheat sheet. And I did try and mention to Mira that like again you’ve been providing absolutely what you’re able to exactly. And that’s just that’s not something that necessarily like medallion or us would have readily available. So I did make sure to call that out and say you have been really helpful during this whole process. I feel like since we transitioned from Naomi, I will say you’ve been very helpful and things have been going better. So it’s just again some of that refinement that we need to just fine tune, right?
Niccole Russell (03:13) Yeah. I get that. As far as the, what payers require group enrollment prior to providers, if they require a certain amount, I am not aware of the PE team having that information just like any in a docket somewhere. To my knowledge, that information would be added to our payer directory. And so if they had that, then it would be added into provider enrollment, hey group enrollment needs to be completed. Unless we have five providers. Other than that, it would be an individual enrollment something.
Kelli Fawver (03:55) Like that. But the issue is where, right? That’s we?
Niccole Russell (03:59) Didn’t have that we’ve.
Kelli Fawver (04:00) already submitted. So that, yeah, my suggestion would be, then if you have that, right, is there some way medallion can preface that more proactively? So when you submit, it knows, because, right, we’re charged anytime we submit that payer in there, we didn’t know until they send it out. And then we get that back. Why do we keep having to send this out? And again, we sent a bunch of these. We sent it in bulk in the beginning because we don’t know. So now I know moving forward to double check these and not submit at all. But when we submitted these, initially, we didn’t know, and now we’re getting all these returns of this payer needs three. This payer needs five. Again if you have that in your payer list, your payer repository, how can we get that more proactively? It has always been my question is great. You guys learned this down the line. We learned this down the line. We’ve been making cheat sheets, but how can we joint do this? Because you guys don’t have more knowledge than we do, but I get it. I don’t.
Niccole Russell (05:08) think we proactively house that information in a docket. I.
Kelli Fawver (05:12) know, and we’ve had this conversation multiple times. So I don’t want to beat a dead horse on again information you may not have, but those are the pain points we’re feeling. I get that again like we’re just like not necessarily feeling as guided as we anticipated through medallion. I think that’s the best way to put it. We anticipated more guidance on the credentialing process. And ultimately and again, I don’t want to beat a dead horse here because we’ve got other things. We’ve already reviewed this with Mira. We don’t need to keep beating this. But ultimately, we thought medallion was going to be more than just a document repository. And ultimately, that’s what y’all are right now. Yes, those documents are being sent. Yes, you’re sending, hey, we got this DocuSign that now, Kelli, you have to then tell the provider that’s more hands than we anticipated. We were hoping this would streamline. And ultimately, it’s adding more complexity to the process than simplifying it, right? So.
Niccole Russell (06:16) I will say for payers generally, if you’re contracted with them, which I know you’re a third party as well, so you wouldn’t probably be privy to the information. But when you contract with the payer and you’re meeting with the rep to do the contract, normally, they provide that information. So, hey, this is how you would submit a group. This is where, because usually, when you contract my experience, usually, when you contract, you have a designated representative at the payer’s office right after we.
Kelli Fawver (06:48) Submit the application, right?
Niccole Russell (06:50) No, no. When you’re contracting with them, when you say, hey, I want to start submitting applications, claims being approved, that type of thing for the providers.
Kelli Fawver (07:02) Help me understand then the difference between contracting… and credentialing because I have asked providers because a lot of times right before we got into the whole credentialing aspect, we would always say, do you have a provider rep, right? Like they’d be like, what are my rates? I don’t know, ask your provider rep, right? Right? So, is there, and maybe this is a piece of the puzzle. We’ve been missing… when we’re getting a provider set up. Do you have a picture that you can pull up and help us kind of walk through this? I know you’ve given us a medallion, a bunch of different documents. We’ve gone through them on different calls. Like you do, we do the processes, but just looking at it like a blanket credentialing process. I heard contracting as one thing. And then credentialing is a different thing. So, is there a process that needs to happen before credentialing that the providers need to do?
Niccole Russell (08:03) Yes, because here’s the thing, if they do not, if they are not under contract with the payer, then that would be an out of network application, right? So they would not be in network. So to be in network, you have to be contracted with that payer. And I mean, I don’t know if the provider does it themselves, if they had someone else do the contracting part of it, but my past life, when we’re working provider enrollment, the client usually owns the tin. So, I know you’re this is where we differ here. But the client normally owns the tin and npi for the group.
Kelli Fawver (08:43) And so when we say client.
Niccole Russell (08:44) That’s where you’re yeah, that’s where your contracting comes in.
Kelli Fawver (08:49) And so when we say client just to refer, we have clients too, right? So this is everybody that we’re doing these credentialings for. So when I say client, we refer to them as clients, right? So, the client, they again, I’m confused on how this difference differs from credentialing because, right? We’re working with brand new providers. They’re trying to get set up with the payers. Yeah. So they need to first before they even credential there’s a first step that they need to do so.
Niccole Russell (09:27) Credentialing meaning provider enrollment?
Kelli Fawver (09:30) Provider, yes, getting set up. So, I know people call different things right there’s. The Edi enrollment.
Niccole Russell (09:35) So, credentialing is like documents for the, provider enrollment is the application?
Kelli Fawver (09:42) Yeah. And when, okay, yep. And so when we’re talking about what we’re doing through medallion today, we’ve submitted a shit ton of provider enrollments, correct? Yeah. So that’s what we’re talking about today for provider enrollment. Is there something that needs to be done by our providers before they start with medallion?
Niccole Russell (10:01) If they are not contracted with payers, then the claims do not get paid unless it’s an out of state enrollment or out of network enrollment.
Kelli Fawver (10:11) So, I thought that’s what a payer enrollment was, what we were doing with you guys was to get them contracted with the payers?
Niccole Russell (10:19) It’s to get the providers enrolled with the payers.
Kelli Fawver (10:23) So you have to set up a.
Niccole Russell (10:25) Contract with the payer. Generally, what happens is you set up a contract with the payer. And it lets whoever the representative is, it could be a specific representative. It could be a rep, that should I say, it should be a rep that only works with that specific npi intent. Or it could be one that has multiple npis intents group. And when you work with them, you set up a contract. Hey, I’m going to be submitting an application on behalf of a provider, and that’s why I say it’s a little bit different for you because the providers are the owners of the npi intent, right?
Kelli Fawver (11:10) Yep. And so my question is what is the difference between contracting… and payer enrollment? Because I’m hearing, I get it. But I think that’s what we thought we were getting into you. What I thought medallion did was getting the provider set up. They have nothing set up, right? And so we’re coming to you guys to say, hey, they want to get set up with medicaid, right? I think we’re missing maybe then some first steps that if the provider needs to take steps, the client, we’ll say the client, right? Right? If the client, the npi and tax id provider client, same thing. If they need to do something before medallion, can you help me understand that? Because I get what they’re you?
Niccole Russell (11:52) Say I’ve never been in contracting, so I can’t say what I’ve been on contracting calls, but I don’t know the full scope of contracting. So being in provider enrollment in my past life, what generally happens is you’re meeting with a payer, trying to figure out the specifics of that contract. Is there going to be group enrollments? Is there going to be provider enrollments? You find out rates of that sort, how they pay the claims? So there’s a lot of different steps that go into contracting that I am not familiar with. So I don’t want to speak on that but I can just say from my experience, you know, if I’ve sent a, again not here, my past life, if I’ve sent an application to a payer and said, hey, I need this provider enrolled, they come back and say, well, we don’t have a contract. It would be out of network payment for that provider, which can be done, but it’s a whole different form, right? So when I say as far as contracting, they should have that information. Usually, when you’re in that contracting deal with the payer, they provide all of that. So this is what you would do for group enrollment. This is what you would do for provider enrollment. This is how many providers you need for group enrollment? So, and for us, we are just individually enrolling either the group and, or practices or the provider? We are not contracting with them. Now, if we send an enrollment application and the payer comes back and says, hey, you’re not contracted with us? How would you like to proceed at that point? It would be if they offer out of network, they would send us that form or they would say, hey, if you want a contract here’s, our contract, you need to sign and date this. And then you would be tasked with that information.
Kelli Fawver (13:50) Okay. Well, because I think… I’m trying to get a little bit more insight here. I’m just searching online too because I think that’s been the piece of the puzzle that we’ve been missing and it’s.
Niccole Russell (14:08) so I can say for all of them like hours when.
Kelli Fawver (14:12) I’m researching here just and again, maybe Aba is different than the rest it says. And this is just again, based on what I’m looking at online, it says the most common workflow is credentialing starts and then contracting follows or overlaps. So you submit an application to join a payor network. The payor reviews your entity, the providers, the credentialing part, the enrollment, which right?
Kelli Fawver (14:35) You guys are helping with. And then they offer you a contract if you’re approved. And so sometimes it’s parallel where it goes at the same time. But it says there’s rare cases where the contract needs to be sent. But usually from what I understood in Aba… it says the true and.
Niccole Russell (14:58) Aba could be different. I have not worked with Aba providers prior to medallion. So I can’t say for Aba specifically, just generally speaking that’s how that’s the experience I have with provider enrollment. Yeah.
Kelli Fawver (15:14) Because how it’s breaking it down and I’m thinking about it is right? Is the credentialing is like, are you qualified, right? Do you have all of your documents? Do you have your W9? Are you a qualified business? And then the contracting is like, okay, now that we know that you’re a business, how much do you get paid? What are those actual terms of the qualifications? Some get paid more, some get paid less.
Kelli Fawver (15:37) So it’s all based on that credentialing contracting. And then we do the fine tuning of connecting of what we call Edi. Yeah, we call enrollment on our end of like, okay, now that you are credentialed with what medallion takes ownership of, right? Where you do the paperwork, the W9 you get them established with the payer?
Niccole Russell (16:03) Right? And.
Kelli Fawver (16:04) then we do the payer then goes, hey, we’ve got your W9. Okay. You guys want to become on network? Okay. Well, we’ll give you rates of 100 dollars for unit and then they go. Okay, great. So we covered medallion, does credentialing contracting comes in during that with the payer when they’re looking at the W9 and the documentation, all that jazz. And then we help with the connection. After that. You don’t need to worry about that. We do the clearinghouse, all of that connection. We’re well versed. We actually come from a clearinghouse. I used to work at a clearinghouse, Annette built the clearinghouse. We’re very well versed with Edi connections, payer enrollment. In that sense, we need help with the credentialing where providers go. Hey, I’m a brand new provider. I’ve got my W9. Who do I go to? And that’s again, what we thought medallion was helping with. So.
Niccole Russell (17:03) Yes, medallion is helping with that, but I’m just saying as far as pay as far as payer specifics… it’s usually covered in the contract, correct? And.
Kelli Fawver (17:15) we know that the rates and everything like that.
Niccole Russell (17:18) Yes. So, when the rates are covered, that’s kind of when the, you know, if they’re location specific, if they’re county specific, things like that are covered. Usually during that process. So our team was not aware of because we don’t do contracts, our team was not aware and we haven’t done that. The optum Aba would be my guess because it was not in our payer directory that, hey, we need five providers for this group. So none of us were aware until we came across that instance. Now, it’s been updated, we’ve got that. But unless… our team has come across some sort of instance like that, we would not know that ahead of time.
Kelli Fawver (18:00) So then we’re not getting that ahead of time. So like I get this is a learning lesson for the situation. But then like we’re still doing like a workaround on our end. And again, I know we’re beating a dead horse and I do want to make sure we get to, the topic I had and I’ve got a hard stop. But again, it’s like great now that we’ve learned these lessons, how do we do these more proactively so these aren’t lessons again and again. And for other Aba providers, we just have a way to know. Yeah, optum requires three to five providers. We won’t if you.
Niccole Russell (18:34) Have a specific payer that you’re like, hey, I want to enroll this provider. Is there a group enrollment? Is there a requirement for a lot of amount of people? I can go back to the PE team and ask them. I can look at our payer directory, see if they may know, and then if not, it would just have to be researched.
Kelli Fawver (18:52) I mean, that’s a great workaround for now. But again, I think again like thinking about greater scale that would be nice because again, it seems like we’re running into these scenarios and we don’t want to always have to again thinking about streamlining processes. I don’t want to have to reach out to you every single payer because I will Nicole, if you’re open to that, I will say, hey, I need, these are the payers that we’re working with. I need any upfront payer expectations. And if that’s what we need to do for that proactive kind of band aid. But that’s.
Niccole Russell (19:22) that’s why I said it’s usually in the contract because the way medallion works is you and you enter the request line within medallion, but it’s based on your payer contracts. So you should not you, but whoever owns that TN should know how to enroll. And so based off of that, that’s kind of where your request lines come in, we’re typically my.
Kelli Fawver (19:46) question there then is if they knew how to enroll, why would they hire us and you, right? Like why are they.
Niccole Russell (19:53) doing?
Kelli Fawver (19:53) That, it’s.
Niccole Russell (19:54) for the enrollment, it’s not because they, it should be outlined in a contract, right? So when you contract with that payer, you still hire somebody else to do the job. You’re not going to do it yourself, especially if you’re a provider, you don’t have time to do that, right? So, and to me, when I say clients generally, the providers work for a specific client. And then we, my past life would work for that client doing their provider enrollment, yeah.
Kelli Fawver (20:23) Right. And see us, it’s so small. We work client provider. It’s all the same thing because, yeah, it’s one provider that owns the clinic that does all the work. It’s not multiple big groups sometimes, but again, usually it’s a woman our age that is starting a business. And here she goes trying to do it. So, yeah, I think a lot.
Niccole Russell (20:47) Of it, I will say on our end as far as clients meaning you, the different clients that we have, I know you have your clients, but generally speaking, on our side, the clients are aware of what their contract is with the payers. So they know how to request those lines within medallion. Well… and.
Kelli Fawver (21:09) I think that’s the discrepancy because our providers don’t right? They’re coming to us. They say I need a group. It’s it’s me the provider, and I guess when you say they know how to enroll, right? They… again, it’s just them. Yeah, I mean, if.
Niccole Russell (21:26) they’re not contracted with the group, we would do the enrollment and then the payer would come back and say, hey, if you were doing a group enrollment, hey, this group is not contracted with or the provider is not contracted with, the group is not contracted.
Niccole Russell (21:41) So we can’t do that enrollment this way. So you would get a task, right? So either they would do a contract request, which I have other clients out there. We’ve tried to do enrollment for and the group is not enrolled with the payer. So they have to sign a contract to be able to be enrolled with the group. So every payer is different. They all have different requirements. And I think that’s probably where the disconnect is, you don’t have that information because it’s not your group or team, your mpi or team. Okay. Well.
Kelli Fawver (22:17) Yeah, definitely understood there that we only have limited access. And again, I think because… again, our providers, they don’t do the contracting themselves. It’s like the payer, right? It’s like, yeah, now that we’ve got all your W9, all that information. So maybe we just need to do a little bit more research on how then they may need to do the first step of contracting before even initiating with a medallion. But I don’t think in Aba that’s how it happens, but I’d be curious to again, any other suggestions that you guys have on, I guess requirements before it gets to medallion, that’s what we need? What are the requirements before we start doing our tasks? Yeah.
Niccole Russell (23:01) I can look into that and see, I know again contracting is a big thing. But I’m not sure kind of how that works on your end because I’ve never been in contracting, but, okay. So I’ll check with my team on that. What question did you have?
Kelli Fawver (23:18) Yeah. Last thing is caqh, we want four providers and I want to make this. Let me just, I’ll pull up medallion that way. I don’t want things to get lost in translation. Yeah. And I feel like sometimes maybe I misspeak, I don’t know, I want to make sure we’re looking at the same picture. Yeah… we have providers that they are already contracted and credentialed and enrolled. We’ll use all the terms. They have everything done. We’re billing for them. Everything is set up. We’re done there. Okay. They want just caqh management. So they say we’re all set up. We’re credentialed medallion had no part in that. Okay. Not whatsoever. This is a provider. We’ve already done everything for. Okay. And they say we want you to manage caqh. Is there a way we can? Because I know we can add that caqh management onto a new payr application. Okay. How do we start a caqh management but not request the credentialing in the enrollment phase?
Niccole Russell (24:30) So, you have to request those lines. So if you just enter a provider in the system and check the caqh management box, we’re going to do that. So you don’t have to enter a request line for enrollment or anything like that for us to manage the caqh. Okay?
Kelli Fawver (24:50) Oh, so to clarify, you… will manage caqh and that will fall into that separate bucket because that is a separate charge for that, that’ll go into that caqh management bucket for that provider. And because it’s caqh there’s not necessarily specific payr’s associated. We would not need to create lines or payr requests.
Niccole Russell (25:18) Not unless you wanted a payr request. Two totally separate things that.
Kelli Fawver (25:22) makes sense because I was like, wait, how would I make sure that we don’t get charged for that line? But that’s only for requesting caqh management is built into that profile and that’s total. Okay, perfect. Okay. Do you?
Niccole Russell (25:37) Remember where the caqh management box is?
Kelli Fawver (25:41) I do, right? When you add them in like the, when you add them in as a staff member, there’s, the box there. You can show me quick just to make sure. Yeah.
Niccole Russell (25:51) Let me, let me share my screen with you. So it’s.
Kelli Fawver (25:55) all the way over here, right?
Niccole Russell (25:57) Yeah. If you’ve already added them in… you can scroll all the way over here to the right and.
Kelli Fawver (26:08) Just check it yep. But the note is, I can’t uncheck it right? Once it’s checked.
Niccole Russell (26:12) Once it’s checked that’s it. Now. I think if you accidentally check something… or if you did no longer want it, we would have to do that internally. So it’s not that it’s that’s it and that’s done, you are unable to check it. So we would have to go internally on the back end and have the team do that.
Kelli Fawver (26:34) Okay. Yeah, absolutely. So perfect. So that helps clarify it. I’ll just create those providers. I don’t need to associate them to any payers that makes sense because it’s just caqh help me understand then for… the fee, I’m just trying to pull up like our actual agreement because is that a one time fee or a recurring fee? Then since it’s caqh management help me understand?
Niccole Russell (27:04) I don’t know how the fees work. That is out of my pay grade.
Kelli Fawver (27:09) Okay.
Niccole Russell (27:10) Mira would be the one to ask as far as any specifics on consumption.
Kelli Fawver (27:15) Okay. Cool. Thank you for clarifying that. And I know she mentioned that too last week that any sales go to her. I’m sorry, I shouldn’t have gotten into the.
Niccole Russell (27:22) No, that’s okay. That’s okay. I mean, if I know the answer, I don’t mind answering but I’m not familiar with the consumption part of it.
Kelli Fawver (27:29) For sure for sure. Yeah, because I was just curious, I’m like because it’s caqh management. I wasn’t clear on that. So perfect. I will go ahead and get these set up. Then I’ve got a group of providers that we just took on. It’s. An established org that’s coming on. So I will get those providers added then probably end of the week. Great. Okay. This was very helpful. I will look into my end too more on the contracting because I hope that doesn’t halt anything that we’ve been doing. I believe that’ll just kind of go down, you know, as the providers are getting credentialed, they get established that provider rep, but I’ll keep my ear to the ground there. Anything else? Yeah. And I’ll look.
Niccole Russell (28:10) into it on my side to see if I can figure out any information.
Kelli Fawver (28:21) That’s stupid.
Kelli Fawver (28:30) Oh… I think we froze for a moment there, I think so.
Niccole Russell (28:35) I was just going to say I’ll look at it on my end as well and see if I can come up with anything. But that’s just my past experience with enrolling providers.
Kelli Fawver (28:48) Cool. All right. Well, thanks for all of the conversation today. Keep me in the loop Nicole, and we’ll go from here all.
Niccole Russell (28:55) Right. Will do. Thanks, Kelli. Take.
Kelli Fawver (28:57) Care bye.