Medicaid and Medicare Updates

Medicaid and Medicare Updates

  • Approvals:

    • Medicaid was approved.

    • Medicare has been approved.

    • TRICARE has been finalized.

    • All submissions started from October 1 and extended through October 16.

  • Reason for Date Gap:

    • Approval of Medicare and Medicaid was necessary prior to processing subsequent plans.

    • Required identifications:

    • Medicaid ID

    • Medicare ID

    • These IDs are prerequisites for obtaining Medicare Advantage or Medicaid Health Maintenance Organizations (HMOs).

  • Progress Tracking:

    • Plans are moving along as anticipated.

    • A plan-by-plan update will be provided in the following week.

Engagement with Fort Myers

  • Current Status:

    • No engagement yet with Fort Myers.

    • There is an intention to reach out to a contact in Tampa to identify the Fort Myers representative.

    • Goal: To reconnect with the Humana networks in the Southwest Florida area.

Updates on New Patients

  • Margaret Johnson's Case:

    • Critical Updates:

    • Medicaid status is still pending.

    • Medicare has been approved (effective with Aetna and UnitedHealthcare).

    • Application for DEA (Drug Enforcement Administration) is in progress.

    • Challenges:

    • As a new graduate, she had to complete additional steps, particularly with the DEA application, which is more comprehensive in Georgia than in other states.

    • Anticipations:

    • Expect Medicaid approval imminently, likely within the week.

  • Automatic Credentialing:

    • Upon Medicaid approval, Georgia Medicaid can automatically credential with five Medicaid CMOs (managed care organizations) and HMOs provided all documentation is in order.

Medicare Submission Details

  • Application Process:

    • Once Medicare is approved, all necessary Medicare Advantage and commercial applications will proceed.

    • Inquiry regarding the date of Medicare approval is pending.

    • There is a capability to backdate approvals by 30 days, ensuring effective billing.

  • Engagement with Other Agencies:

    • Updates regarding the doctor for Pinellas, Doctor Miller:

    • Medicaid was approved recently.

    • Commercial applications are currently in process awaiting a DEA number clarification.

    • Important Note:

    • DEA licenses are state-regulated, meaning practitioners need to have them for every state they practice in.

    • Verification of existing DEA status is crucial as there is no public database for this information.

Updates on Nurse Practitioners

  • Current Status:

    • Two payers still pending:

    • TRICARE Prime

    • Humana Military

  • Network Engagement for Nurse Practitioners:

    • Recent communication with Andrea from Penelo indicates that Optimum, TRICARE, and Humana are out-of-network; however, letters have been found to clarify acceptance.

    • The approval process involves checks against active Medicaid IDs, as many payers will not process applications without validated Medicaid enrollment.

General Remarks on Florida Healthcare Network

  • Market Presence Analysis:

    • Sunshine Health has a limited presence in West Florida but is more substantial in South and East Florida.

    • Notable military associations with certain networks (e.g., MacDill Air Force Base).

  • Cultural Insight:

    • Discussion included regional pronunciations, showcasing the local dialect and connection to Florida geography.

  • Miscellaneous Details:

    • Team collaboration noted with multiple members facilitating patient credentialing processes and updating statuses accordingly.

  • Conclusion Remarks:

    • The group's collaborative nature is emphasized as they continue to track patient progress and application statuses.