Credentialing & Billing Operations – Weekly Sync Notes

Weekly cross-functional credentialing/billing huddle (participants: Michelle, Jay, Amir, Joanna, Martha, Stephanie, Ferris, etc.)
Core goals:
• Track credentialing progress for every state, entity, payer and individual NP/MD.
• Decide which payers can be billed under RTM (Remote Therapeutic Monitoring) vs. RPM (Remote Physiologic Monitoring) vs. standard E/M.
• Re-prioritise P-levels (P0 > P1 > P2) after two facility churns and multiple new installs.
• Identify where billing must be held (to avoid denials) and where back-billing is allowed.
• Hand off all data wrangling/dashboard work to Jay to free up clinical-ops staff.

“Preset” = current BI tool, but UI is disliked; Jay to evaluate alternatives or augment with Google Sheets.
Monday.com boards:
• Master Credentialing board (insurance rows, P-level, status columns).
• IPVB column toggles when visits can start.
PracticeSuite: source of detailed claim/encounter data; payer IDs stored here.
Shared Drive/Google Drive contains IPD money notes; Jay still lacks permissions—temporary screen-cast solution.
Slack used for ad-hoc requests; several relevant messages dated 10 July.
Key linkage work Jay will build:
\text{Preset Insurer}\leftrightarrow\text{Monday Insurer}\leftrightarrow\text{Facility}\leftrightarrow\text{Live\/Churned}
Need a mapping table for inconsistent payer names (e.g., “Medicaid”, “Medicaid CT”, “800 Medicaid”).

Each entity and each individual clinician (NP/MD) must be credentialed with every payer seen.
Historic issue: company originally billed almost everyone out-of-network ⇒ mass denials.
Medicare is relatively easy and back-dates to effective date; Medicaid does not back-date.
Billing logic summary:
• If credentialed → bill immediately.
• If Medicare pending → can hold & back-bill after approval.
• If Medicaid pending → visits before approval = unrecoverable .
Ongoing decision tree RTM vs RPM vs E/M driven by payer policy:
• Example: Blue Cross Blue Shield (BCBS) MI does not cover RTM, so team switched to RPM and now expects 150 $per CPT$ 90905 $vs previous$ 59.
• Need to verify actual collections post-switch.

Original priority spreadsheet used data window Feb 2024 → current.
Two top-volume facilities recently uninstalled ⇒ previous P-levels now inaccurate.
Jay will automate priority logic inside the sheet:
\text{If Submitted Claims} > 1000 \Rightarrow P0
500 \le \text{Claims} \le 999 \Rightarrow P1
\text{else} \Rightarrow P2
Additional column to capture date range of volume snapshot to avoid future confusion.

California (largest pain-point)

Medi-Cal addresses mismatched; applications had to be withdrawn because virtual lease flagged ⇒ resubmit once physical addresses in Inland Empire & Sonoma found.
Kaiser split required: NorCal ≠ SoCal. NorCal still RTM; SoCal moving to RPM.
LA Care, Inland Empire Health Plan, Health Plan of San Mateo et al. are Medi-Cal managed plans → apps submitted; waiting.
VA Community Care: submitted May, follow-up July; 30–60 day wait.
Medicare: Martha (SoCal) still pending; Stephanie (NorCal) hold; Shah signature outstanding.
Billing hold list: Humana, IAT, Medi-Cal managed plans, Kaiser (until split), any IPA requiring onsite service address.

Tennessee

New York

Only Lawrence MD pending (Medicare) because Dr Nagawala has not signed; visits may occur but billing must hold until signature.

Michigan

Dr Barry credentialing in progress as “backup” (no facilities yet) ⇒ low urgency.
BCBS RPM switch date needs to be tagged for analysis.

New Jersey

Horizon BCBS is commercial, not Medicaid; separate “800 Medicaid” managed plan exists.
800-page paper packet mailed; waiting response.

Connecticut (Coming Next Month)

Two new NPs start Friday; avoid touching CT claims until rostered.
Need payer ID cross-check (Anthem BCBS CT vs Anthem national) to know if grouping required.

UHC often fronts for AARP; UHC data must include AARP alias.
Scan Medicare Advantage appears in data as “IPA BT”; Jay to trace.
ING Insurance: appears as “physician group” rather than standard plan; likely direct facility contract.
Medicare SCAN, Medicare Advantage and VA plans may reimburse RPM even if not credentialed for IPV—requires case-by-case confirmation.
Example cost–benefit guidance: if extra 9 San Mateo patients unlocked but payer unlikely to reimburse, added visits only increase clinician cost. Use formula
\text{Net Gain} = \text{Reimb per visit} \times N_{visits} - \text{Clinician Cost per visit}
and proceed only if \text{Net Gain} > 0.

Build “Revenue Before vs After IPV” dashboard
• Filter by insurer, state and clinician.
• Needs “Date of First IPV” field (month-granularity acceptable) manually populated for now.
Auto-flag high-volume churned insurers so Monday priorities drop automatically.
Map all payer name variants to a unique ID (PracticeSuite payer ID ideal key).
Provide weekly export summarising:
\begin{aligned}
&\text{Total Submitted Claims},\
&\text{Total Collected},\
&\text{Avg Days to Payment},\
&\text{Top 10 Denied Reasons}
\end{aligned}
Chase Michael for PracticeSuite extracts; ingest to same G-Sheet if preset import too slow.

Access: Jay still blocked from Drive → temp screen-share.
Credentialing lags reduce attainable visits; Ferris demand of 2{,}500 visits may be unrealistic if Humana, Kaiser SoCal, etc., excluded.
Facility churn complicates existing analysis; any new dashboard must reference live facilities only.
Manual holds create complexity for Michael (billing lead): must know exact dates & payers to suppress.
Multiple 1-hour payer helplines (e.g., Anthem) drain ops time; could be off-loaded to junior staff.
Ethical/financial caution: do not conduct visits solely to hit volume if payer won’t reimburse—company pays NP but loses revenue.

[ ] Grant Jay G-Drive access or move IPD money notes into shared folder.
[ ] Populate “Date Initial RPM/IPV” column for each insurer (Michelle + team; tag team).
[ ] Split Kaiser entry into “Kaiser NorCal” & “Kaiser SoCal” on Monday board.
[ ] Re-calculate P-levels using updated claims; add “Snapshot Date Range” column.
[ ] Stephanie (NorCal) + Martha (SoCal) Medicare → HOLD billing until approved; notify Michael.
[ ] Withdraw current Medi-Cal apps; resubmit once physical addresses secured.
[ ] Jay to produce first pass “Before vs After IPV” revenue chart by next meeting.
[ ] Remind Michael: continue to hold all Medi-Cal claims; Medicare can be back-billed.
[ ] Confirm if Anthem BCBS national and BCBS CT share same payer ID (PracticeSuite lookup).

(End of prepared study notes.)