Special Series | Who Audits the Auditor?

[00:00:00] So every episode, really, we sit here and we spill somebody else's tea and we talk about everything we find in the States and so on and so forth. Or somebody else's fraud case, but somebody else's bod audit, somebody else's cut corner.

[00:00:22] True. State by state, you're right. Case by case. Somebody else's name on the file. Yep. But today we're going to be vulnerable and that's not how this always works.

[00:00:37] So I guess today it's mine, right? My audit, my file, my mistakes, right? Same table, same trays, same rules we hold everyone else to. Because if we're not willing to sit in this seat too, you know, me and Nyleen, you know, just us as a, you know, Credentialing Chronicles, you know, then we don't get to ask anyone else to as well, I guess. Right? We got to be honest.

[00:01:07] Mm-hmm. So today we're going to do a little bit different, same format, different tea. So take me back. Where were you when it came in? Tell me. Um, my office last Friday, um, I almost didn't open it. I was actually on the phone. I had about three things going on, literally.

[00:01:33] And then I, you know, saw the first line and, and the entire world stopped around me. And what was the first thing you felt like before you'd even read past the first paragraph? I, Nyleen, what if I cry? I don't want to cry.

[00:01:55] I, I panic. I mean, straight up panic. Um, you know, seven years I've been NCQA certified, um, and not this cycle. Yeah, I don't know, for about four seconds, my brain went, this has to be wrong. There is a mistake. Um, maybe they sent this to the wrong company.

[00:02:23] Well, girl, that's the denial talking. So what happened? Yeah, I mean, that's, um, exactly what it was. And it lasted about as long as it took me to actually read the letter. Um, because once I got past the first paragraph, it wasn't, you know, what, you know, it wasn't what I thought it said, you know? So what did you think it said?

[00:02:48] I mean, I thought it said we failed, like substantially operationally failed, like we were doing something wrong with clients or with data or with, you know, people's credentials. Um, that's the version of like denial that lives in my head, you know, after 11 years of telling other people, you know, what their findings are. And, but what did it, what did it actually say though? Well, there was some incomplete documentation submissions.

[00:03:19] Um, not a finding that we did something out of compliance, you know, so that that's, you know, that's a good thing. Um, a finding that we didn't submit everything they needed to see that we were in compliance. So, you know, it's a different letter, right? And so does that distinction matter or are you just trying to make yourself feel better?

[00:03:43] Because I do feel that this is an important topic that we as credentialing professionals deal with. And honestly, we could lose our jobs, uh, if this happens anywhere that we work or with any organization we're interested with. So does that distinction matters? What happened with that letter? I mean, it's a different letter than the one that I was scared of, right? I mean, it is still a denial. Um, I'm not going to sit here and soften that.

[00:04:13] I mean, it's, it's, it's a paper, but it's a paperwork gap. Um, you know, not it's a pro your company is a problem gap, you know? And I think it matters because of what I can do next. You know, if it's noncompliance, you know, I've got a much bigger problem, right? If, if my people are doing something wrong, you know, that's a much scarier fix in front of me.

[00:04:35] Um, if it's an incomplete submission, you know, my job is to go find what's missing, prove what I already know is true. Um, what we already have in practice and to get that in front of them the right way. And so, you know, those are two, two completely different Fridays that could have happened, I guess. So which Friday did you have? Well, I had the second one, which almost kind of, you know, made it worse, honestly,

[00:05:03] because there's no version of incomplete submission, um, that still doesn't trace back to me not catching it before it left the building. Right. Well, before we start then, um, do you want me to like protect you today? Do you want me to like hold something back today or do you want me to just bring it all out? Well, I think, you know, to be honest with our listeners, um, we said we were going to do this honestly.

[00:05:32] And I think, you know, no, I mean, let's do it honestly because people are going through this and that's why I agree to do this. Um, and hopefully it helps an organization or a person somewhere, right? Okay. You sure? Okay.

[00:05:55] I guess if I wanted to be protective, I wouldn't have sat here on the camera with my plain background like you have asked for. Okay. So let's say it. Say it how you said it to me on the phone. I mean, I built a company off the back of catching other people's mistakes, right? Um, so 11 years, you know, women own the only one like it in the country. Like I have worked so hard for that title.

[00:06:28] And NCQA came into my, you know, house and found four things that I could not prove in my own operation. Um, not didn't do, not couldn't do, but I just couldn't prove it with paperwork. And, and I, we didn't add that paperwork. We didn't submit it correctly. And there's a difference. And it almost destroyed me to say that out loud. So which one hurt you the most to hear though?

[00:06:56] Honestly, the one that wasn't even mine to fix, right? I mean, my vendor is still sitting on a backup policy document. You know, a piece, you know, it's the piece of paper in Eileen, you know, I'm, I'm the one whose name is on the certification. You know, that one still isn't closed and it's, and it's not closed right now while we're literally filming this. Okay. I'm not letting you talk in vague terms. Really. I want four things and say them.

[00:07:24] I want all four right now, nor warm up. I want you to tell me exactly the details. So let's start. We talked about four things. So start with number one. So number one, um, no vendor confirmation of our backup plan.

[00:07:44] So, you know, we use a credentialing software and we have asked for the policy showing that they back up the data, you know, that there's a backup in place and they still haven't gotten it to us. And, and, you know, I couldn't, they, there was a period. My data manager has been asking for it. They're escalated the ticket.

[00:08:07] Um, we had the one from when we were first certified seven years ago, but they wanted the renewed one and, and, and I couldn't produce it to them. Um, so that's number one. Okay. Number two. Um, so in having a lot of things to do, I asked a staff member, you know, to submit some monitoring reports into our system.

[00:08:32] Um, and only the heading headers on the page went out, not the four. And so, you know, nobody caught it before it hit the surveyors desk. And so, yeah, I don't know. It's, I don't know. Cause we have so many monitoring reports. We do it every month. It's, but I think she was trying to protect the data that was on the, the provider information. And so she wiped the report clean and just kept kind of those headers.

[00:09:03] Number three is something that is so unbelievably crazy, but race and ethnicity is part of data collection now with the new policies. And that language was not existence in existence, you know, because why do I need to ask providers their race? Yes, but NCQA says I do. Um, so, you know, we have already corrected that. We've already put it into place.

[00:09:34] Um, and there is a little caveat on there that says the providers, if they don't agree to give it, you know, then they can check if they don't want to. Four. Was two out of our SMART goals got rejected because they weren't measurable or timed down the way that NCQA needed them to be stated on paper. So which one of those is a, we didn't know better problem.

[00:09:57] And which is a, we have a sloppy problem because I think anybody that's accredited is going to start trying to measure these things and use this as an example. As they should, right? Because once you get three or more things wrong, then you get a denial and that's why we have the denial. And so when you look at it in your question, when you say, you know, which is a, we didn't know better would be the form.

[00:10:27] Um, because I did read the language about the form, but I think it's an industry wide blind spot right now. Um, more than half of the CBOs in this country do not have this language form right now and everybody's getting dinged on it. Um, so, you know, that, that, that's going to be that. My sloppy moment is the, is the monitoring reports. Um, that's the sloppy moment. Yeah. Yeah.

[00:10:56] I mean, that's a verification that I could have completed faithfully, you know, and went in there. We do this every single month. I mean, we have all of this data to show that we do it. Our clients get it every single month. And yeah, it was just the, it was just the headers, you know, and it killed us. I mean, the smart goals, that's writing, that's fixable. It's an afternoon. Once you know the formula, you know that they have a specific formula and they change things.

[00:11:25] And so we didn't write it in the, in the correct formula. And, and, you know, the back of the verification, that one isn't on my sloppiness. I mean, that one is our literal credentialing software vendor who has had my emails for months, you know, my data managers emails, and literally still hasn't provided us this policy so that we can give it to them. You know, you know, something that this brings to mind as you bring it up is that with all these

[00:11:54] NCQA new requirements that are coming to us, I think software vendors need to be made aware that these are things that their clients need. They need certain kinds of reports. They need data. They need certain required fields like this race and ethnicity. We didn't even know.

[00:12:15] So the question becomes, is our vendors keeping up to assist us and users, us CDOs, us, you know, people who are in charge of accrediting. Are they assisting us in helping keep up with these new requirements that just came out? What do you think? Or if it's a spot check, because, you know, my last rounds of recertification, and this was a recertification.

[00:12:43] This was not, you know, initial certification. You know, they didn't, nobody requested it after initial certification. And then this auditor requested it. And so, you know, it's a spot check. So I think at the moment that I asked my vendor, hey, can I have your backup policy? I think I should have it within 24 hours, you know? And I think that that's just something like when you're looking for vendors, you need to ask those type of questions.

[00:13:11] And you need to, you know, say, send it to me yearly at this point to keep yourself safeguarded. Oh, for sure. That is a really good suggestion. So Shannon, you audit people for a living and you've told clients to their face what they're doing wrong. Why should anybody trust the credentialing expert who didn't pass her own audit? I mean, let's just be honest. Damn. Damn, Nyleen. Damn, Nyleen Flores. I just made it.

[00:13:43] Woo, Nyleen Flores. Well, they shouldn't blindly, right? I mean, let's be honest. That's actually my point about this whole thing and why I wanted to become public. And I didn't want to do this in secret with shame, right? Because nobody should trust anybody blindly, including me, including the organization that certified me before, right? I mean, including the one reviewing me now.

[00:14:10] I mean, that's the whole business that we're in, you know, as MSPs is prove it or it didn't happen, right? Hmm, that's a good answer. And not a dodge, which is I asked why they should trust you, meaning Shannon, meaning AQC, meaning an organization that may or may not have lost their accreditation because of these changes with NCQA. Dang. Dang.

[00:14:39] Well, I mean, every consultant in this industry has had a bad audit. I'm the only one filming hers, Nyleen, right? I mean, bad audits happen, right? I mean, ask anyone in this industry. They'll all tell you. I mean, a story off the record after a couple of margaritas at their favorite Mexican restaurant, right? Eating salsa. You know, I'm telling mine on camera to help people, right?

[00:15:07] I mean, we talked about this. We figured out if we wanted to do this. And I guess, you know, the world that we're living in now, being podcasters, right, it led to us doing this and really making it like a teaching moment for me and for anybody else that could be going through this. So I figure if I'm going to go through this, right, I'm going to use this to help others that may go through it as well, I guess.

[00:15:36] Well, are you scared that certain clients are going to leave you for this? Well, I mean, honestly speaking, I'm terrified. Many of my contracts, they say, you know, that I am contracted to stay certified. But only if I show up when I, if I only show up when I'm winning, I'm not actually credible, right? I'm just saying that I'm credible, right?

[00:16:05] Okay, so we're not doing a redemption story or what are we doing? No. No, no, girl. No, you know, I mean, I like to, I like to be transparent. No, we're doing an autopsy, right? We're going to cut it open. I mean, we're going to show people what's inside. And don't sew it back up until it's actually fixed, right? Okay. So then how are you going to tell your clients? Or how did you tell your clients?

[00:16:32] Because I think at this point, once we release this to our special tier people, what are you doing? Yeah, you know, I just found out last Friday. And so I've written emails and I'm working on a corrective action plan. And that's how I, you know, plan to present this to my clients, you know, and how anybody should, I guess, you know.

[00:16:58] I mean, fortunately, many of my CVO clients have been with me for, you know, over five, six, seven years. I mean, longer. So they know the quality of the work that's produced by AKC. And ultimately, the plan is to reapply. I mean, we will be reapplying within the next two, three months. Okay, that's good. So I think that's a very good plan.

[00:17:22] So, okay, thought or proved where did it live going into that survey? So meaning like, what were you thinking? And what was proven? And where do you think you're going to go? So we're going to go through all the aspects of it. Well, thought. I thought it lived, you know, improved, but it didn't.

[00:17:52] Right. So what did you think was happening? You know, I thought that the full rapport was what went up to NCQA because that's what goes to every single client every time. I mean, I trusted that submissions literally matched, right? The deliverables. And I didn't check that upload myself. And when the auditor came back, there was some confusion. And it just, you know, it was serendipity. I mean, right?

[00:18:23] So what was actually happening? The document uploaded for that survey element was the header page, the summary. I mean, not the full body. Our clients never, it was never the full report with all the providers. So that one submission, you know, it didn't match up. And, and, and CCUA, you know, didn't want to see the full reports after they wanted to see it at that time. And they didn't end.

[00:18:50] And so, and I said, well, I got two years of reports I can give you for all these clients. And they said they didn't care. So who owned that submission? Well, I mean, a team member, right? Directly. Cause I asked for some help because, you know, I do, I do run a company. We do work on, you know, it's, we do a lot. So, and this is the first time I've ever kind of asked for some help in this area. But ultimately I own everything that leaves AQC, right? I mean, that's what I've always done. Right.

[00:19:19] So did you, do you feel like your team failed you? No, no, no, definitely not. Right. Well, careful because, you know, you're the president. So things to think about. No, no, no. I mean, that's why the answer is no. I mean, the team didn't fail. Nobody failed. I mean, my oversight structure failed to catch one wrong file going to one wrong place, you know, um, with one wrong information, you know, which humans do.

[00:19:47] And I built a company that assumed good people wouldn't miss things. And when we do, we kind of build that, that portion of human error into it. And that was my mistake because ultimately I should be checking everything, you know? Um, and I, and I work hard to make sure that there's an audit process. And to catch, you know, the errors in the files. And I just didn't even think to kind of go back in and check everything. Right. And it cuts me deep.

[00:20:16] It cuts me deep. Um, but again, this is why I wanted to use this as a teaching moment for all of us. Um, you know, because it could happen to any of us. Right. Yeah. And, you know, as two business owners, we always try to say, we want to delegate, delegate, delegate. And sometimes we feel like we have to take on the responsibility a hundred percent of everything that happens because things like this do happen.

[00:20:43] And the reality is at some times, you know, we can't do it all and we do need assistance. And so I know we do this. How many times did that sentence run through your head during the survey? Like, what are the results? Oh my goodness. What's going to happen? Was everything done correctly? Did everybody in my team do what they were supposed to? Like, how many times did that run through your head? I mean, yeah, right.

[00:21:10] More than I want to admit on the camera with you today. I mean, you know, I knew that we were shaky going into it and, you know, it's just been so much. And so I, you know, I believe that by the latter submission that it was okay and believing and proving are not the same thing. Right. And I have said that to a hundred clients and now today I have, I am walking down that hall myself, you know? And so why are those words so dangerous?

[00:21:39] Well, I think because they feel true, but that that's what makes them dangerous. Not that they're lies. It's just that they're honest feelings standing in for evidence. Your gut isn't a document, right? Your team's word isn't a document. If NCUA asked for it and it's not sitting in the system, you know, with everything that they want, I mean, the, I think the goal is to give more information, um, not minimal information.

[00:22:08] And so, you know, providing more of what they want, um, would be good advice for the future. So what do you tell an MSP who catches themselves either saying it or in a situation like this? Well, stop talking to yourself, boo, and go get your receipts. That's it. You know, that's the whole lesson. And check, check again that you have more, you know, of what, what, what they're asking for. I mean, truly, because, um, you know, the backup, if I, you know, it, it more aggressive,

[00:22:38] you know, more, you know, I, I could, I could, I'm still trying to get that, but it's like, I need to get even more aggressive with this vendor. Um, because as a credentialing software company, you should have a backup plan. Um, and so, I mean, you know, it's just, you know, and, and, and the report, like it needs to be fully generated report, not just the headers, you know? So with a situation like this, uh, we've talked about it. We know what's going on.

[00:23:06] We see what it is. So let's talk about the cost, not the standards, not the scoring. Like what did it actually cost you and your organization so that people know or employees or whoever's working with us for us, for any hospital, for any organization, what does this actually cost? I don't know if I could tell the price over. It's a little, it's over $35,000. I could tell you that.

[00:23:34] I don't think I could tell you the actual price, but ultimately, right. I mean, it's cost my sleep. Um, I don't know if I'm looking fresh for you today. Mug shot. Um, it's, it's really costed my confidence, right? Um, I mean, you're such a great friend to me. I'm able to talk about this. You make me feel comfortable. Um, but I mean, truly it's costed my confidence. I built this reputation, you know, over 27 years in this industry.

[00:24:01] And for the last week, you know, I generally didn't know if I still even deserve my company, if I should come out of the bed, if I should stop crying, you know, I'm in the shower. My husband's telling me, you're not a loser. Stop calling yourself that, you know, um, I'm scared. I was scared to tell everybody. I mean, it's, it's, it's shameful. Like you said, anybody in a, in a corporation would have been fired.

[00:24:27] Um, and so, you know, it costs me the time I really don't have, um, because now I need to rebuild these four areas. I need to get them done because, you know, we're trying to, um, you know, reapply within the next, you know, 60 days, you know, to, to get the process rolling. And I guess, you know, I'll see my pride. Now I'm sitting here telling everybody, right? I had to tell you Nyleen. I know. I know. So which one hurt the most Shannon? What do you think?

[00:24:56] I say the pride, you know, not because I'm vain because I grew up, you know, truly like with nothing. Um, you know, I was emancipated at 15, you know, I built every piece of this organization myself, you know, nobody's ever handed me a client list or my reputation. I mean, in, in the, in the contrary, people have, you know, given me the evil eye, you know? I mean, I, I feel like, you know, I worked for every file, you know, every, every client

[00:25:26] to prove myself. And so when something threatens that, you know, for any of us, we know that as entrepreneurs, it doesn't just feel like a business problem, right? Like I can't separate it Nyleen, right? I mean, it feels like it's coming for me. I mean, you know what I'm saying? It feels like it's the one thing that I know I've worked my entire life for, you know, I've earned it. I, I've, I understand because girl, I know all about earning.

[00:25:55] Oh Lord, do I know anything about earning? So talk a little bit about how you earned it. Well, yeah, not like with a safety net, right? I mean, when you don't have people to catch you, you learn, you know, really fast that your name is the only thing that you have in everything. Like if somebody says Shannon Reyes, I want them to smile. I want them to think, oh my God, she's going to keep my patients safe to make sure the providers are good.

[00:26:19] You know, so I built this company and I lean like so solamente on my name, you know, on every page and that's it in my hands, you know, and, you know, for one report in one Roman, you know, that isn't good enough because I didn't write the goals right or I didn't push hard enough to get the policy. You know, it's, it's a hard thing to sit with.

[00:26:44] Um, when it's the only thing you've ever really owned, you know, was, was the things that you work for, you know, and you're still sitting here on camera and you're talking about it. So I'm really thankful to you because I think that MSPs don't get a chance to talk about real raw things or a situation where they went through this either for their organization or as an employee or as a business owner.

[00:27:10] Well, yeah, because I mean, hiding, you know, never once fixed anything, you know, um, not as a kid, you know, not now. I mean, it's just not for anybody, right? What's done in the dark comes to light eventually, right? Mm-hmm. So what would hiding have look like? Well, you know, quiet correction, fix the, the, the stuff, you know, don't say a word,

[00:27:35] hope nobody asks, hope nobody verifies me, you know, go to NAMS, feel paranoid. Everybody knows. And I haven't, you know what I'm saying? Um, I mean, that's what everybody tells you to do. You know, I feel if I get past NCQA and be certified multiple rounds and then fail, you know, get denied, it literally equates to I'm a loser, you know? Um, but my faith and my family. No, I don't say that.

[00:28:04] No, I mean, y'all are keeping me on track. Everything's on track. We're going to reapply. We're getting the four things fixed. You know, we're going to fix it. We're going to fix it. All right. So this one then doesn't get a vow today. No, no, no, no, no, no, no. So your software company has had the request to update the report that you need. Yeah. I mean, yeah. And you know, if I don't get the document every single attempt I made, you know, we're going to escalate it in writing.

[00:28:32] And if I have to, I'll find an alternative way to demonstrate the backup exists. Um, because, you know, again, I mean, this is the one area that I can't control, but I refuse, you know, to let someone else's slow email response or urgency in the matter, um, you know, hurt me again, you know? So that's not a threat towards the company. That's just facts of like real situation of what's happening.

[00:29:01] Yeah, no, it's facts that every MSP needs to understand. I mean, I don't want the document to take it and read it and publish it and sit at Barnes and Nobles. You know what I'm saying? Like NCQA is asking for the document to sit at Barnes and Nobles and read it with a cup of coffee. I don't want it. You know what I'm saying? I mean, you know, I mean, it just is what it is, you know? Okay, Shannon. So what are you doing tomorrow?

[00:29:27] Girl, what I'm going to be doing until I pass NCQA, I'm going to be auditing my own operation the exact way I would audit a client's cold, no assumptions. You know, I don't want to hear no, we did it, you know, every one of those four areas gets literally a documented fix with a date and owner and a process that I can verify anytime, anyway. Okay. So what are you never trusting without a verification again?

[00:29:56] Well, I thought I had trust problems. I thought I had trust problems before. No. Okay. I thought, you know, you know, as a woman, I don't know, maybe other women. People ask me that all the time. So I understand, girl. So I understand. Tap in, tap in, because maybe we're different. I don't know. But people say, you know, oh, let people help you. Oh, blah, blah, blah, blah. That's the problem. And then you say, you know, I feel like I have to do everything myself.

[00:30:24] You know, we say that as women. And so, you know, you say like, well, what are you never trusting? You know, I mean, anything, everything. You know, I'm trusting my husband. What you doing? I'm verifying what you doing. No, I'm just joking. I'm just joking. But I mean, it just, it sounds extreme, right? But I mean, that's the job now, right? I mean, Nyleen, everything, right? So, yes. So let's get down to the nitty gritty. Are you going to reapply?

[00:30:54] Yes. Yes. That was never a question for me. Okay. I mean, the only question, yeah, totally, was whether I do it quietly or I would do it in front of our community, right? That's what, you know, when we talked to, you were the first person I told, you know, so, and we talked about what we were going to do and we wanted to share this with our community. I mean, even the public, I mean, when people fail, what do they do in healthcare, you know? And so, as you know, I decided to take everyone along on this journey.

[00:31:24] It's going to be what a four part series we said. And so, you know, this is our denial part. And then we're going to do the, what, the reapply, the cleaning up and doing the everything right. And then we're going to do the reapplying and then finally getting approved again. And then you're going to teach. You're going to teach everybody what you did, what you did to fix and what you did to correct and how you got recertified, correct? That's what we're going to do.

[00:31:53] I mean, you know, everybody truly is one missed report away from exactly where I'm sitting today. You know, I mean, I hate to say that and I'm not saying that to scare anybody, right? I'm saying it because, you know, I teach this from a slide deck on a presentation and now I'm teaching it from a finding from me going through it. And I think it's a much better teacher, right? Because now I actually know what it feels like.

[00:32:20] And I can tell my clients, like, I've been there when, when these are mistakes that are happening and everything else was a hundred percent. Every file came back a hundred percent. So, okay, Shannon, so we don't know how this ends. Not yet. No client information, no attacking anybody's team, no pretending that this didn't happen. No, we're going to show you. We're going to take you along.

[00:32:43] Um, I mean, you know, what, what, what you're getting instead is the real thing in real time, including the parts that I, I can't control, you know, like a vendor who still owes me a document and you know who you are if you are listening to me. So what's next? Well, who was auditing the auditor, right? Okay. Okay.

[00:33:11] So, all right, Shannon. So stay tuned for part number two. We're going to let you guys know how the reapplication process goes, recertification process goes, and we will go from there and keep you guys informed. Stay tuned, stay credentialed and not. Canceled and make sure you bring your receipts, honey.