Written by: Ray Jorgensen, Co-Founder of PMG Credentialing

Too many healthcare leaders think credentialing and enrollment is simply an innocuous item on somebody’s “to do” list. That “someone” may or may not have expertise or skills, never mind connections, to assure success with basic credentialing and enrollment processes as well as HRSA compliance requirements.

Working closely with our client and their PCA, we recently resolved an issue for a large health center client in the Southwest. The CEO contacted our leadership team to see if we could loan their health center $1 million on a short-term basis due to credentialing/enrollment snafus. That kind of request will quickly get anyone’s attention.

A brief recap of how we got to this place:

• Jan 2023, written confirmation from state Medicaid that this client was approved and could start billing. PMG forwarded a copy of this communication to the client.

• The client initiated billing and 60+ days later realized nothing was getting paid.

• An incorrect license number had been provided which resulted in a mismatch in terms of approved provider type vs. billing provider type on the claims.

• Resubmitted application included, erroneously, a PO Box for a board member address which resulted in another delay.

• The final approval for updated application arrived late Summer 2023.

• Medicaid opted to make the effective date retro to latest app approval vs. initial.

• $1 Million worth of encounter rate service had been rendered between the time of initial approval and corrected application approval.

Medicaid was not necessarily responsive or helpful despite the health center communicating to them significant financial duress. Literally, if they didn’t get some short term cash flow, they don’t make payroll.

A full court press ensued over a 3-4 day period including:

• The CEO communicated via email to a senior leader at Medicaid who was a former health center CEO and had served on the state board with this CEO.

• PMG requested a backdating of all effective dates to original date of application (which state regulations clearly allowed).

• PMG sought support from CEO of the state PCA who was most helpful and empathetic.

• PMG also escalated an initial request for a “claims project” to afford reprocessing of the denied claims.

• The CEO met with the senior leader at Medicaid while she happened to be on site for a previously scheduled tour.

In the end, this collaborative effort mitigated a disastrous financial situation. Hitting Medicaid from all sides resulted in escalation of the problem to those who could get it fixed. Having the health center, PCA, and PMG leadership teams working together to get Medicaid to simply follow statute was not easy but rewarding in the end.

If you are uncertain regarding your in-house capabilities. Call the experts at PMG Credentialing. We support our clients throughout the process even (especially) when the road gets rocky.