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Theoria Medical

20 min read

Theoria Medical

Overview

Multi-state physician group whose providers see patients in nursing homes (in-person + telehealth); no Theoria-owned physical office locations. Operates under multiple legal entities organized by region and letter — internal codes Midwest H, Midwest M, Northeast H, Southeast H — used to scope payer enrollments, contracts, and AR. A separate billing entity, Complex Care Medical Group (used interchangeably as “complex care” inside Theoria, distinct from the unrelated Complex Care Solutions customer), took over Massachusetts Medicaid (and other) enrollments effective 2026-04-01. Top pain across the account is unresolved enrollment + AR with BCBS Michigan, BCBS Illinois, and Georgia Medicaid.

Key Contacts

Theoria (external)

Medallion (internal)

  • Amy Barfield — Senior Engagement Manager, amy.barfield@medallion.co (current account owner since Oct 2025; Theoria’s 3rd EM)
  • Amy Frana — Head of Engagement Management, amy.frana@medallion.co
  • Amanda Spadafora — Engagement Manager, amanda.spadafora@medallion.co (added recently; 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 (was 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 (per Amy Barfield)
  • Kelsey — former engagement manager; departure left a hand-off gap on Midwest M priorities

Active Work / Processes

Weekly cadence

  • 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 + Latoya (now departed) ↔ Amanda. Source: 15 portal access call.

Complex Care Medical Group entity transition (eff 2026-04-01)

Several payers transition from Theoria to Complex Care Medical Group (internal billing entity, not the Complex Care Solutions customer) 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. Effective dates of 4/1 are showing as “inactive” on some payers (e.g. Georgia Medicaid Midwest M) and need follow-up.

Internal entity codes

  • Midwest H — Theoria’s primary midwest group
  • Midwest M — secondary midwest group (Mercy?); separate enrollment per payer in some cases
  • Northeast H — northeast group
  • Southeast H — southeast group (Georgia Medicaid pending; effective 3/1/26 per Lori)
  • Per Svetlana on 4/15: Midwest M and Midwest H are actively enrolling separately; Southeast H is Georgia-focused
  • Many payer requests need both H and M enrollments — easy to miss one (e.g. HAP reconsideration was filed only for Midwest M initially, needed both)

Portal access build-out (Amanda + Carrie)

Status as of 4/15:

  • 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 already; 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; Latoya was logging in as Lori
  • Montana, Pennsylvania: explicitly dropped — not needed
  • New Hampshire, MO, KS: still working on
  • Portal account UX is “very loud” per Carrie/Amanda

Medicaid roster + retros work

Active per-state status as of 4/15 (from Svetlana’s screen-share):

  • Texas Medicaid — not yet billing (June start); enrollment needs to be in place before then
  • Georgia Medicaid Midwest M — denied 4/6 due to business license; Secretary of State certificate rejected again; ownership-staff complaint received 4/9 (treated as “board of directors must be listed” — owned 100% by single person; no board; tax-purpose corp election). Svetlana wants the email forwarded so she can respond directly; Medallion never surfaced it. See Georgia Medicaid.
  • Georgia Medicaid Southeast H — pending docs as of 4/15 (denial letter referenced, location unclear); effective date 3/1/26 showing
  • Illinois Medicaid Midwest H — only one location enrolled but provider shows yellow not partially-completed; LOBs auto-requested by Medallion 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 and others); should be flipped to partially-completed at provider level so healthy blues can release
  • 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). Also Ola/Olam — Latoya’s submission was completely wrong (used complex care + Midwest M + Dr. Drew Packy values); team redoing. See Massachusetts Medicaid.
  • Minneapolis/MN Medicaid — Missouri the issue; several “unable to reach” follow-ups since February; resubmissions needed
  • New Hampshire Medicaid — W9 finally submitted (took 10 days); Northeast H processing, Midwest M approved
  • Wisconsin Medicaid Midwest M — partial complete; Carrie did demo updates (some missed physician group, others missed NP group); needs 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 minutes for one — UX flagged); was originally missed in bulk upload. See Healthy Blue NC.

BCBS Michigan deep-dive

Top-AR plan for Theoria (~$500K open). Top six AR providers (per Amy Barfield 4/14): 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 the rule changes by provider type (NP vs MD). BCN is a separate plan-set that may not include Blue Plus. Amanda Spadafora is reviewing each provider one-by-one to confirm they’re enrolled at the right level on the LOBs they qualify for, and linked to all group networks. Some Blue Plus providers (Peters, LaDonna) are in-network under complex care but with 2026 dates of service — Theoria still needs the retroactive dates because billing is via Theoria not complex care. See BCBS Michigan.

Svetlana asked for a working session with the BCBS-MI specialist + Lori + Carrie to walk the cred hold list provider-by-provider; Amy will set up after Nicole returns Tuesday 4/22. Latest status:

  • Midwest H — “nothing done since December”; new BCN contract Amanda submitted recently
  • Midwest M — progress in February, then stalled
  • Southeast H — no records pulling up

BCBS Illinois crisis — 1 year, zero enrolled providers

Affected providers: Stanley, Islam, Haji, Sarpong, Fergani, Matthews (Theoria). Islam was originally enrolled as 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 is now done. Compliance risk: the doctor currently holding BCBS IL needs to leave, but Theoria can’t release him without a covering BCBS-enrolled provider. See BCBS Illinois.

Medicare Railroad welcome-letter process gap

Multiple Mark Peterson-style providers have welcome letters Rizal manually attached in Medallion, but the lines haven’t been touched since February — Medallion automation isn’t processing them. Going forward, Rizal will also email the line through help@. Open question: does each PTAN get its own Railroad number or is it just one (Amy unsure). See Medicare Railroad.

Medicare audit — never delivered

Svetlana recalls Nicole + Amy mentioning a Medicare audit that would deliver results to Theoria. Svetlana has never received it. Amy to check.

Jessica Deal Medicare $40K recoupment + timely-filing crisis

CMS recouped ~$40K (likely more open) on Jessica Deal (Theoria) because they had her RN license on file when they should have had her NP license — even though there was no lapse in Medicare enrollment per the file. Now CMS is hitting Theoria with timely-filing denials on every claim and won’t reprocess in bulk. Theoria has to file paper claims + individual appeals on ~7,000 claims. Svetlana asked Nicole to escalate within CMS for a “special project” to handle in bulk. Amy to email director on provider-enrollment side as interim path while Nicole is OOO; Lori sending claim count + date range. Source: 14 Cred Hold sync.

Medicare appeals denied — Whitney Preston, Rebecca Font, etc.

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 said on-the-record that any future write-offs on these two are on Medallion. She’ll email Mitch + Derek directly. Source: 17 weekly sync.

Provider Partners TPA — Indiana + Missouri

Svetlana signed amendment 4/14 to add Missouri and end complex care on the Provider Partners contract. Amendment processed by Medallion 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. See Provider Partners.

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 a re-request for the group + 3 specific providers + 1 location (Midwest H only, not M). Amy reopened group + linked client-owned. See Paramount Health.

Aetna Better Health — work direct, client-owned

Theoria switched to working directly with Janelle for Aetna Better Health on complex care. Aetna Better Health Illinois (both complex cares) and the Ellen White complex care enrollment now flipped client-owned for groups + providers. Theoria provides rosters directly.

UnitedHealthcare — national contract approved

UHC 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 (Stanley, Sarah Maria Garcia, Dr. Matthew) 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

Meridian Illinois (Centene-owned Medicaid managed care, distinct from CDPHP — earlier internal notes mis-grouped them) reached out to Svetlana directly, very confused about state of things. They asked her to send everything to one named contact. Carrie to provide Midwest M roster so Svetlana can submit directly. Midwest M only is being made client-owned for this work.

Healthsmart Solutions — DEA + board cert ask

Brittany received 30+ emails from Healthsmart in one morning requesting DEA copies and board-cert wallet cards for every provider. Amy will check whether these are in the Healthsmart project plan (they should be sent with the application). Source: 17 weekly sync.

CMS Midwest H deactivation hold (4/15)

ECW reported Theoria’s Medicare payments are on hold — Midwest H Medicaid (CMS) shows the deactivation hold from a prior incident still on record. 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 had previously confirmed with the CMS director that everything is fine, but the hold flag persists.

Product research — LOB-level status indicators (Svetlana → Addie/Linh)

Svetlana’s #1 product ask: bring the existing green / yellow / blue / “stopped” color coding (currently only at the practice locations level) up to the lines-of-business level on each enrollment. Today the 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 was loaded into Theoria’s system but not reflected anywhere in the LOB display, so internal Medallion follow-ups are guessing. Addie’s team taking back. Linked to:

  • 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.

Product research — 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 is targeted by end of April 2026 and will hide closed locations from the list. Svetlana wants the option to also add closed/term locations on a per-enrollment basis (rare but happens — retro enrollments, missed locations on original submission). Two options surfaced: select-all-active vs select-all-everything.

Product research — 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 the internal payer directory has this info but PE isn’t always referencing it.

Revalidation date entry gap

Brittany pulls revals from Medallion based on stored revalidation dates → submits revalidation → PE team tasks her back asking for the letter. Issue: Medallion isn’t entering correct revalidation dates after enrollment completes, so the report is unreliable. Lori shared CMS monthly file link in Slack as a workaround for Medicare specifically. Svetlana wants the underlying Medallion data fixed for complex care going forward. Confirmed by Amy: revalidation date is based on initial credentialing date (so demo updates shouldn’t change it; if Brittany sees it changing post-demo-update, that’s a bug to flag).

Cap on what’s still broken in process

  • Several enrollment requests still show with auto-included LOBs that don’t apply (e.g. Medicare Complete = Medicaid only, but other LOBs were requested) — confuses both Theoria and PE follow-up
  • Partial completions are inconsistently filled in (Svetlana’s June 2025 onboarding manager allowed loose habits that are now baked in)
  • Approvals not always being released to client view even after they’re done — Brittani’s team works through release manually, slow
  • Duplicate enrollment lines in Illinois (one terminated, one active) caused by EFT term events

Pain Points / Open Issues

BCBS Michigan ~$500K AR (most severe)

See dedicated section above + BCBS Michigan. Six months of “nothing done” on Midwest H per Svetlana; Amy disputes “nothing” but agrees pace has been slow. Working-session with the specialist requested for week of 4/22.

BCBS Illinois — 1 year, zero providers, compliance risk

See above + BCBS Illinois. 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; effective Medallion never forwarded the 4/9 ownership email to Svetlana so she could respond. See Georgia Medicaid.

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 on 9/25 to the GA Medicaid portal and show GA Medicaid timely-filing proof. Amanda was digging in; said GA “won’t go back” but Svetlana wants the original submission re-pushed with facts. ~$100K AR exposure on this issue. 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. Mitch + Derek to be looped in via email.

Latoya Pough departed mid-resolution

La Toya was 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 covering Latoya’s portal-access work. Some open Medicare surrogacy/AI process Latoya owned needs reassignment.

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; one-at-a-time

Revalidation tasking back

PE team is tasking Brittany back when she submits revals from Medallion’s own report, asking for letters Medallion didn’t trigger. Root cause = revalidation dates not being maintained in Medallion post-enrollment. Brittany sending examples to Amy; Svetlana wants this fixed for complex care from the start.

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 it’s a TPA-line-of-business workaround. See Provider Partners.

Sandantra (?) emailing wrong contact

“Santandra” payer continues emailing the RCM-cred email at Theoria for a payer update; Brittany sent multiple emails to Amy on this; Amy to follow up. 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 the follow-ups while group is being contracted. Brittany sent the email already.

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.

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 a different date convention for complex care
  • 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 (was originally only Midwest M; corrected to both H + M)

Decisions & Commitments

  • 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. Source: Addie in 13 product sync.
  • 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. Source: Lori + Amy in 14 Cred Hold sync.
  • 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. Source: Svetlana + Amy in 15 weekly sync.
  • 2026-04-15 — UHC national contract requested by Theoria (yes from Svetlana). Source: 15 weekly sync.
  • 2026-04-15 — La Toya removed from all Theoria systems (departed by 4/17); Medallion to ensure no re-grants. 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. Source: Amy in 17 weekly sync.
  • 2026-04-17 — Aetna Better Health Illinois (both complex cares) + Ellen White complex care enrollment flipped client-owned for groups + providers. Source: Svetlana in 17 weekly sync.
  • 2026-04-17 — Massachusetts Medicaid Theoria-side stopped for Chidi (transitioning to complex care Midwest M effective 4/1). Source: Svetlana + Amy in 17 weekly sync.
  • 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. Source: Svetlana in 17 weekly sync.
  • 2026-04-17 — Svetlana on-the-record: future write-offs on Whitney Preston + Rebecca Font are on Medallion. Email to Mitch + Derek pending. Source: Svetlana in 17 weekly sync.

Key Facts

  • 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
  • Billing transition: Complex Care Medical Group (internal entity, NOT Complex Care Solutions) effective 2026-04-01 for Massachusetts Medicaid and select payers
  • Engagement managers: Amy Barfield is 3rd EM since the account began; took over Oct 2025. Amanda Spadafora added recently as EM. Kelsey was an earlier EM whose departure created hand-off gaps on Midwest M.
  • AR exposure flashpoints:
    • BCBS Michigan: ~$500K open (source)
    • BCBS Illinois: 1 year zero providers enrolled (source)
    • Medicare: $100K+ write-off exposure across multiple providers
    • Georgia Medicaid: ~$100K retro-related exposure (source)
    • Jessica Deal Medicare: $40K already recouped, ~7,000 timely-filing claims pending
  • Board meeting deadline: Svetlana wants Medicaid 100% complete by 2026-05-07 (board meeting)
  • CMS Medicare hold case: 261-050-473 (opened 4/15, callback within 10 days)
  • Public partnership / referenceability: not directly stated
  • Tech stack: ECW (eClinicalWorks) for billing, Sigma for Medallion’s internal release-flag reporting

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; Svetlana = 3rd-EM context; complex care 4/1 effective dates
  • 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

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