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Theoria Medical

· 5 Gong sources · 1 SF source

Theoria Medical

Snapshot

Multi-state physician group whose providers see patients in nursing homes (in-person + telehealth); no Theoria-owned physical office locations. Top pain across the account is unresolved enrollment + AR with BCBS Michigan, BCBS Illinois, Georgia Medicaid, and Medicare.

Commercial

  • Customer · Tier 1 · ARR $1.07M · renewal 2028-01 (Pending Renewal) — per SF diff, 2026-04-19.
  • Y1 of 2: Closed Won $2,136,850 — closed 2026-01-31 (006PO000005SV62YAG)
  • Current: Y2 of 2 — Closed Won $1,068,425 — closes 2027-01-31 (006PO00000JfPPJYA3)
  • Renewal: Theoria Medical - Renewal - 2028 — Pending Renewal $2,136,850 — closes 2028-01-31 (006PO00000JevJBYAZ)

Profile

  • Annual revenue: $1,517,000 — 269 employees — Industry: Hospitals & Physicians Clinics (per SF diff, 2026-04-19)
  • Operating model: providers see patients in nursing-home facilities (in-person + telehealth); no Theoria-owned office locations.
  • Entity structure: Midwest H, Midwest M, Northeast H, Southeast H — distinct payer enrollments per entity. Midwest M and Midwest H actively enrolling separately; Southeast H Georgia-focused. Many payer requests need both H and M enrollments.
  • Billing transition: Complex Care Medical Group (internal billing entity, NOT the Complex Care Solutions customer) effective 2026-04-01 for Massachusetts Medicaid and select payers.
  • Engagement managers: Amy Barfield is Theoria’s 3rd EM; took over Oct 2025. Amanda Spadafora added recently. Kelsey was an earlier EM whose departure created hand-off gaps on Midwest M.
  • Tech stack: ECW (eClinicalWorks) for billing, Sigma for Medallion’s internal release-flag reporting.

Operations

  • AR exposure flashpoints: BCBS Michigan ~$500K open; BCBS Illinois 1 year with zero providers enrolled; Medicare $100K+ write-off exposure across multiple providers; Georgia Medicaid ~$100K retro-related; Jessica Deal Medicare $40K already recouped + ~7,000 timely-filing claims pending.
  • Board-meeting deadline: Svetlana wants Medicaid 100% complete by 2026-05-07.
  • CMS Medicare hold case: 261-050-473 (opened 4/15, callback within 10 days).

Key Contacts

Theoria — Svetlana Vinokur, senior ops/RCM leader (svinokur@theoriamedical.com) — drives weekly sync, escalates on AR + write-offs, on-the-record on payer rejections; Lori Durkin, Senior Director Revenue Cycle Management (durkin@theoriamedical.com); Brittany Dees, credentialing/enrollment (bdees@theoriamedical.com) — handles revalidation submissions, healthsmart docs; Carrie Reding, credentialing (creding@theoriamedical.com) — works portal access, BCBS IL escalations; Juvy Patal, credentialing/enrollment (patal@theoriamedical.com); Daniel Dominic Roxas, Medical Biller / Payer Credentialing (droxas@theoriamedical.com); (Del Rosario), Clinical Administrative Manager (delrosario@theoriamedical.com); Rizal, attaches welcome letters into Medallion.

Medallion — Amy Barfield, Senior Engagement Manager (amy.barfield@medallion.co) — current account owner since Oct 2025; Amy Frana, Head of Engagement Management (amy.frana@medallion.co); Amanda Spadafora, Engagement Manager (amanda.spadafora@medallion.co) — Theoria-only currently; off Thurs/Fri 4/16–4/17; Brittani, Provider Enrollment Team Lead (brittani@medallion.co); Addie Oh, Senior Product Manager (monthly product sync); Linh Nguyen, Staff Product Designer (monthly product sync); Annette Hong, Product Designer (monthly product sync); Nicole, runs Medicare team (OOO week of 4/14; back Tuesday 4/22); Mandeep, owns portal-access work (Amanda blocked on his help); Mitch, internal escalation route for write-off accountability conversations.

Active Work

Recurring cadences

  • Tuesday Cred Hold sync — top-AR providers + payer-specific blockers (Lori, Juvy, Brittany, Carrie). Source: 14 Cred Hold sync.
  • Wednesday Theoria/Complex weekly sync (~60 min) — Svetlana-led payer-by-payer review, Medicaid + BCBS heavy. Source: 15 weekly sync.
  • Thursday weekly sync — same cadence; Friday is alternate slot. Source: 17 weekly sync.
  • Monthly product sync — Svetlana ↔ Addie/Linh/Annette on UX feedback. Source: 13 product sync.
  • Portal-access working call — Carrie ↔ Amanda. Source: 15 portal access.

Open programs — entity + Medicaid

  • Complex Care Medical Group entity transition (eff 2026-04-01) — Several payers transition from Theoria to Complex Care Medical Group on 4/1/26 — confirmed for Massachusetts Medicaid where Theoria-side Chidi enrollment is being stopped and only the Midwest M complex-care line continues. Some 4/1 effective dates are showing as “inactive” on some payers (e.g. Georgia Medicaid Midwest M) and need follow-up.
  • Medicaid roster + retros — per-state (as of 4/15) (Gong 2026-04-15 weekly):
    • Texas Medicaid — not yet billing (June start); enrollment must be in place before then.
    • Georgia Medicaid Midwest M — denied 4/6 (business license); Secretary of State cert rejected again; ownership-staff complaint 4/9 (“board of directors must be listed”; owned 100% by single person; no board). Svetlana wants the email forwarded.
    • Georgia Medicaid Southeast H — pending docs; effective date 3/1/26 showing.
    • Illinois Medicaid Midwest H — only one location enrolled; LOBs auto-requested include several that don’t apply (traditional Medicaid only).
    • Indiana Medicaid — many providers stuck “partial complete”; Amy clarified release is on PE team’s queue, not auto.
    • Kansas Medicaid Midwest H — partial complete; healthy blue holds caused by single non-enrolled location (Obermiller et al).
    • Kentucky Medicaid Midwest M — resubmitted; Midwest H status unknown.
    • Massachusetts Medicaid — Anna Kavitt partially completed; Chidi needs investigation (group enrollment requires fee-for-service, not ORP). Theoria-side stopped for Chidi (transitioning to complex care). Ola/Olam — prior submission was completely wrong (used complex care + Midwest M + Dr. Drew Packy values); team redoing.
    • Minneapolis/MN Medicaid — Missouri the issue; several “unable to reach” follow-ups since February; resubmissions needed.
    • New Hampshire Medicaid — W9 finally submitted (10 days); Northeast H processing, Midwest M approved.
    • Wisconsin Medicaid Midwest M — partial complete; demo updates needed; revalidation date >1 week after effective date (currently broken).
    • North Carolina Medicaid (Healthy Blue) — Svetlana submitted group + provider enrollments herself on 4/16 (took 30 min for one — UX flagged); originally missed in bulk upload. See Healthy Blue NC.

Open programs — per-payer

  • BCBS Michigan deep-dive — Top-AR plan (~$500K open). Top six AR providers (per Amy Barfield): LaDonna Peters, Patricia Blank, Miller, Claudia Romo, Ashley Poulos, Julie Tuffo, Melissa Miller. Specific quirk: Blue Plus plan (Medicare LOB) requires individual-level enrollment, not group — and rule changes by provider type (NP vs MD). BCN is a separate plan-set that may not include Blue Plus. Amanda Spadafora reviewing each provider one-by-one to confirm enrolled at right level on qualifying LOBs and linked to all group networks. Some Blue Plus providers (Peters, LaDonna) in-network under complex care with 2026 DOS — Theoria still needs retroactive dates since billing is via Theoria not complex care. Working session with BCBS-MI specialist + Lori + Carrie requested for week of 4/22. Status: Midwest H “nothing done since December”; Midwest M progress in Feb then stalled; Southeast H no records (Gong 2026-04-14).
  • BCBS Illinois crisis — 1 year, zero enrolled providers — Affected: Stanley, Islam, Haji, Sarpong, Fergani, Matthews. Islam originally enrolled telehealth-only — PE team submitting demo update to remove telehealth and link to requested locations. Haji flagged for resubmission (originally denied). Application closed 3/27 with no clear reason; group enrollment now done. Compliance risk: doctor currently holding BCBS IL needs to leave, but Theoria can’t release him without a covering BCBS-enrolled provider.
  • Medicare Railroad welcome-letter process gap — Multiple Mark Peterson-style providers have welcome letters Rizal manually attached, but lines haven’t been touched since February — Medallion automation isn’t processing them. Going forward Rizal will also email help@. Open: does each PTAN get its own Railroad number or is it just one (Amy unsure). See Medicare Railroad. (Gong 2026-04-17)
  • Medicare audit — never delivered — Svetlana recalls Nicole + Amy mentioning a Medicare audit that would deliver results to Theoria. She’s never received it. Amy to check.
  • Jessica Deal Medicare $40K recoupment + timely-filing crisis — CMS recouped ~$40K (likely more open) because file showed RN license when it should have had NP license — even though no Medicare enrollment lapse. CMS now denying every claim on timely filing and won’t reprocess in bulk. Theoria filing paper claims + individual appeals on ~7,000 claims. Svetlana asked Nicole to escalate within CMS for “special project” bulk handling. Amy to email director on PE side as interim while Nicole OOO; Lori sending claim count + date range (Gong 2026-04-14).
  • Medicare appeals denied — Appeals on Alexandra Wright, Willie Adams, and a third (Lily/Lilly Adams?) all denied — payer says “as far back as they’ll go.” Svetlana believes Lily Adams didn’t get even six months. Whitney Preston (Midwest M Medicare, outstanding since Jan 2026) and Rebecca Font (rejected again 4/16, original 6/30 submission) are escalation flashpoints — Svetlana on-the-record that any future write-offs on these two are on Medallion. Email to Mitch + Derek pending (Gong 2026-04-17).
  • Provider Partners TPA — Indiana + Missouri — Svetlana signed amendment 4/14 to add Missouri and end complex care on the Provider Partners contract. Amendment processed same week; Brittany originally tried to add it but Provider Partners isn’t in Medallion’s standard payer catalog. Theoria only needs IN + MO going forward.
  • Paramount Health — Michigan group needs un-stopping — Paramount Ohio is client-owned (Theoria handles directly via Sheila + Carrie). Paramount Michigan was incorrectly stopped — Svetlana submitted re-request for group + 3 providers + 1 location (Midwest H only). Amy reopened group + linked client-owned.
  • Aetna Better Health — work direct, client-owned — Switched to working directly with Janelle for Aetna Better Health on complex care. Aetna Better Health Illinois (both complex cares) and Ellen White complex care enrollment flipped client-owned for groups + providers. Theoria provides rosters directly.
  • UnitedHealthcare national contract approved — Approved for complex cares. Brittany filing appeal on closed-network Medicare/Medicaid LOBs. Svetlana confirmed (4/15) Theoria wants a national UHC contract. Multiple GD-numbered UHC contracts came in for individual providers without state context — Svetlana asked Amy to identify states + roster scope for: GD45801484 (Midwest H, community health plan = Medicaid), GD46079443 (Dr. Matthew), GD4673993 (Sarah Maria Garcia, possibly Kansas), GD46080831 (Midwest M).
  • Meridian Illinois direct contact established — Centene-owned Medicaid managed care, distinct from CDPHP (earlier internal notes mis-grouped them). Reached out to Svetlana directly, very confused. Asked her to send everything to one named contact. Carrie to provide Midwest M roster so Svetlana can submit directly. Midwest M only made client-owned for this work.
  • Healthsmart Solutions — DEA + board cert ask — Brittany received 30+ emails in one morning requesting DEA copies and board-cert wallet cards for every provider. Amy to check whether these are in the Healthsmart project plan (they should be sent with the application) (Gong 2026-04-17).
  • CMS Midwest H deactivation hold (4/15) — ECW reported Theoria’s Medicare payments on hold; Midwest H Medicaid (CMS) shows deactivation hold from prior incident. Svetlana opened CMS case 261-050-473 on 4/15; expects callback within 10 days, will re-call Monday if no contact. Medallion’s Medicare team previously confirmed with CMS director everything is fine, but hold flag persists.

Portal access build-out (Amanda + Carrie) — Status as of 4/15 (Gong 2026-04-15 portal):

  • Done: NC Tracks (Carrie’s user creding19 added under domain administrator; covers Theoria + complex care).
  • Renamed: Indiana — all locations renamed inside Medallion’s portal account so Carrie can ID the right “CCM Midwest H” etc. (4 still pending rename).
  • Working on: Illinois, Tennessee, Kansas, Missouri, Michigan medicaid (Carrie has access; provider-by-provider linking required, can’t bulk add — confirmation pending from portal helpdesk).
  • Iowa: paper apps only; revalidations can be done via portal account creation.
  • Kentucky Medicaid: not easy — Carrie must create own account, then call KY Medicaid to link Theoria’s Medicaid IDs (NPS ending 210, PAs ending 660, physicians/internal med ending 850); also pending CCM and H IDs (still in progress payer-side).
  • Georgia: Carrie still needs to call GA help desk to get access.
  • Montana, Pennsylvania: explicitly dropped — not needed.
  • New Hampshire, MO, KS: still working on.
  • Portal account UX is “very loud” per Carrie/Amanda.

Open Issues & Requests

Operational pain

  • BCBS Michigan ~$500K AR (most severe) — Six months of “nothing done” on Midwest H per Svetlana; Amy disputes “nothing” but agrees pace has been slow. Working-session with specialist requested for week of 4/22.
  • BCBS Illinois — 1 year, zero providers, compliance risk — Theoria can’t release the one BCBS-enrolled doctor without a covering provider; medication/operational bottleneck.
  • Georgia Medicaid Midwest M repeated rejections — Business license, Secretary of State cert, ownership-board questions all recurring; Medallion never forwarded the 4/9 ownership email to Svetlana so she could respond.
  • Georgia Medicaid retro dispute — Derek vs Svetlana on facts — Derek (CRO?) emailed Svetlana implying retro window is 60 days from effective date. Svetlana correct: it’s 60 days from welcome letter. Original Theoria letter dated 8/1, marked enrolled in Medallion 9/12, retro request submitted 9/25 (within 10/1 deadline). Medallion’s PE team initially gave Amy conflicting info (one said effective date, one said letter; later clarified to letter). Svetlana wants Medallion to pull what was actually submitted 9/25 and show GA Medicaid timely-filing proof. Amanda digging in; said GA “won’t go back” but Svetlana wants original submission re-pushed with facts. ~$100K AR exposure. Source: 17 weekly sync.
  • Medicare $100K+ write-off exposure — Multiple providers (Whitney Preston, Rebecca Font, Lily Adams, Alexandra Wright, Willie Adams) with Medicare denials Theoria is being forced to write off. Svetlana on-the-record: future write-offs on Whitney Preston + Rebecca Font are on Medallion.
  • System UX friction — Healthy Blue NC enrollment for one group + 20 providers took 30 minutes when one bundled facility was termed and had to be manually X’d off every provider (Svetlana, 4/17); pulls providers but not groups — locations under groups must be manually added one-by-one; provider-individual permissions in MI portal can’t be bulk-added.
  • Revalidation tasking back — PE team tasking Brittany back when she submits revals from Medallion’s own report, asking for letters Medallion didn’t trigger. Root cause = revalidation dates not maintained in Medallion post-enrollment. Brittany sending examples to Amy; Svetlana wants this fixed for complex care from the start. Per Amy, revalidation date is based on initial credentialing date (demo updates shouldn’t change it; if Brittany sees it changing post-demo-update, that’s a bug to flag).
  • Provider Partners not in payer catalog — Custom TPA in IN/MO; Brittany asked how to add to Medallion. Amy: Medallion doesn’t do custom payer names, will research whether TPA-line-of-business workaround applies.
  • “Santandra” (?) emailing wrong contact — Payer continues emailing the RCM-cred email at Theoria for a payer update; Brittany sent multiple emails to Amy. Possibly mis-identified payer name in transcript.
  • Molina Healthcare — wrong contact email — Molina (Ohio) reports Medallion is sending follow-up emails to their Ohio contract requests mailbox, which is for new contracts only. Molina asked Medallion to pause follow-ups while group is being contracted. Brittany sent the email.
  • Fareed Ahmad (WI Anthem) rejection — Family-medicine provider in Wisconsin — Anthem rejected with three reasons (1y US training, 10y clinical, geographic GP saturation). Provider qualifies on first two; appears mis-categorized as GP not family medicine. He’s a medical director at the facility. Amy to research; possibly a reconsideration letter or link-to-existing-group is the fix. Source: 14 Cred Hold sync.
  • Process residue — cap on what’s still broken — Several enrollment requests still show auto-included LOBs that don’t apply (e.g. Medicare Complete = Medicaid only, but other LOBs requested) — confuses Theoria and PE follow-up. Partial completions inconsistently filled (Svetlana’s June 2025 onboarding manager allowed loose habits now baked in). Approvals not always released to client view even after done — Brittani’s team works through release manually, slow. Duplicate enrollment lines in Illinois (one terminated, one active) caused by EFT term events.
  • Other open items (4/15 + 4/17) — Confirmation-of-effective-date tasks coming through for complex care all asking for hire-date — Carrie can address internally with different date convention. Priority Health (Michigan) — roster updates not loaded in Medallion despite Theoria sending; on hold. Louisiana Medicaid Midwest M — 7 enrollments on hold, 20 processing; Medallion sent enigmatic “received signature/completed agreements through mail” without attaching what was received. BCBS New Mexico, BCBS Texas, BCBS Wisconsin, BCBS Kansas — no movement noted. Theoria’s Massachusetts BCBS enrollment for Anna Kavitt now partially completed. HAP reopened with reconsideration submitted 4/13 (originally only Midwest M; corrected to both H + M).

Feature requests

  • Search practice locations by street address — SF case (500PO00000VoWCYYA3, Committed - Current Quarter/P2): ability to find a practice location by entering a street address. (SF 2026-04-19)
  • Auto-assign tasks to specialists after user removal — SF case (500PO00000RCuriYAD, Submitted - Needs Review/P2): when a user is removed, tasks should auto-assign to the relevant specialist. (SF 2026-04-19)
  • Report builder export — single value per cell — SF case (500PO00000NBEAYYA5, Closed/P2): current export puts licenses and practices in a single cell, making filtering/pivot tables impossible; each cell should contain a single value. (SF 2026-04-19)
  • Group enrollment primary-doctor field — SF case (500PO00000NBCzzYAH, Committed - Future Quarter/P2): when a group enrollment requires a doctor linked to it, add a field to track who the primary doctor is for that group enrollment. (SF 2026-04-19)
  • Demographic update aggregation on new practice additions — SF case (500PO00000NBGCHYA5, Committed - Future Quarter/P2): when a demo update adds a new practice to a group/provider enrollment, platform should automatically identify and aggregate existing demo updates in intake/pending-dependency status. (SF 2026-04-19)
  • LOB-level status indicators — Svetlana’s #1 product ask: bring existing green/yellow/blue/“stopped” color coding (currently only at practice-locations level) up to lines-of-business level on each enrollment. Today LOBs are a single line with no per-LOB status — Svetlana can’t tell at a glance whether a provider is enrolled with traditional Medicaid vs Medicare Advantage. Concrete example: BCN-Michigan contract effective 4/1 loaded in Theoria’s system but not reflected in LOB display, so internal Medallion follow-ups are guessing. Addie’s team taking back. Yellow = processing / not received; Green = at least one enrollment received; LOB-level green should fire when any location has that LOB completed; locations stay yellow until each completes that LOB. Source: 13 product sync.
  • Select-all active locations — Svetlana wants a select-all on the practice-location dropdown that selects only active (not terminated/archived) locations. Linh confirmed terminated-practice-location release targeted for end of April 2026 and will hide closed locations. Svetlana wants the option to also add closed/term locations on a per-enrollment basis (rare — retro enrollments, missed locations on original submission). Two options surfaced: select-all-active vs select-all-everything (Gong 2026-04-13).
  • Initial enrollment checklist + uploaded packets — Svetlana asked product team to require a standard checklist when PE submits initial enrollments, and to upload the full submission packet into Medallion so everyone can see exactly what was sent. Amy noted internal payer directory has this info but PE isn’t always referencing it.
  • Accurate revalidation dates stored in Medallion — underlying data fix tied to the tasking-back pain above. Svetlana wants fixed for complex care going forward.

Decisions & Commitments

  • 2026-01-01 — Theoria Medical PLLC assigned all contractual rights and obligations to successor entity Theoria Management LLC (continues operating as “Theoria Medical”); Medallion notified Oct 2025 with 90-day advance notice; silence by 2025-12-15 treated as acceptance. Source: SF diff, 2026-04-19.
  • 2026-04-13 — Terminated practice-location feature targeted for end-April 2026 release; select-all (active vs all) to land with it. Source: Linh in 13 product sync.
  • 2026-04-13 — LOB-level status indicators (green/yellow/blue) added to Medallion product team’s backlog for follow-up discovery.
  • 2026-04-14 — BCBS-MI Blue Plus enrollments must be done at individual (provider) level, not group, with NP-vs-MD distinction; Amanda Spadafora confirming each provider’s enrollment configuration. Source: Amy Barfield in 14 Cred Hold sync.
  • 2026-04-14 — Lori to send Medicare claim count + date range + take-back letters for Jessica Deal so Amy can email CMS director for special-project escalation.
  • 2026-04-15 — Provider Partners contract amended to add Missouri and end complex care; only IN + MO needed going forward. Source: Svetlana in 15 weekly sync.
  • 2026-04-15 — Paramount Michigan re-opened to client-owned for Midwest H only, 3 providers + 1 location.
  • 2026-04-15 — UHC national contract requested by Theoria (yes from Svetlana).
  • 2026-04-15 → 2026-04-17 — Latoya Pough (previously Theoria’s primary cred contact at multiple working calls — BCBS MI, portal access) departed by 4/17; Svetlana asked Medallion to remove all access. Carrie now covering Latoya’s portal-access work. Open: Medicare surrogacy/AI process Latoya owned needs reassignment. Source: Svetlana in 17 weekly sync.
  • 2026-04-17 — Medallion to set up Theoria + BCBS-MI specialist working session week of 4/22 to walk cred-hold list with Lori + Carrie.
  • 2026-04-17 — Aetna Better Health Illinois (both complex cares) + Ellen White complex care enrollment flipped client-owned for groups + providers.
  • 2026-04-17 — Massachusetts Medicaid Theoria-side stopped for Chidi (transitioning to complex care Midwest M effective 4/1).
  • 2026-04-17 — Going forward, Rizal (Theoria) will email help@ after attaching welcome letters for Railroad Medicare so Medallion’s automation queue actually picks them up.
  • 2026-04-17 — Svetlana on-the-record: future write-offs on Whitney Preston + Rebecca Font are on Medallion. Email to Mitch + Derek pending.

Source History

  • 2026-04-13 — Theoria Monthly Product Sync — select-all active locations, LOB-level status indicators, BCBS-MI as concrete pain example
  • 2026-04-14 — Theoria Cred Hold Weekly Sync — BCBS-MI top-6 AR providers, Jessica Deal Medicare $40K recoupment, Provider Partners IN/MO, Fareed Ahmad WI Anthem rejection, BCBS IL closures, Georgia Medicaid retro denials, Ohio Medicaid task loop
  • 2026-04-15 — Complex weekly sync — exhaustive payer-by-payer Medicaid + BCBS review, Provider Partners amendment, Paramount MI re-open, UHC national contract ask, GD-numbered UHC contracts unmapped, BCN MI February-Dec stall on Midwest H
  • 2026-04-15 — Portal Access Theoria Working Call — NC done, IN renamed, MI partial, IA paper-only, KY individual call-in, GA help-desk pending
  • 2026-04-17 — Theoria Weekly Sync — Latoya departure, Healthy Blue NC submitted 4/16, Whitney Preston/Rebecca Font denials, BCBSIL crisis, GA Medicaid retro 60-day-from-welcome-letter dispute, Mass Medicaid FFS requirement, Medicare Railroad welcome-letter gap, revalidation date gap, system UX 30-min enrollment, Healthsmart 30-email DEA/board-cert ask
  • 2026-04-19 — SF diff bootstrap — ARR $1.07M Tier 1, 2028 renewal pending, revenue $1.52M/269 employees, 5 SF cases (feature requests), entity assignment Theoria PLLC → Theoria Management LLC eff 2026-01-01

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