Spillin Tea Across America: New Hampshire

[00:00:00] Hey Nyleen! Hi Shannon! How are you? I'm fantastic. I'm even better that we're together. I am so excited. Can I not tell you? And you know, our social media team keeps telling me how good our content is coming out now because we're together. Well, we're trying, you know, we're really trying guys. Yeah. I keep you entertained and learn a little bit about credentialing and why it's important and all this. You know, we started as an MSP and we're just really coming to the point of being podcasters at this point. Okay. Yeah. We're podcasters.

[00:00:29] If we work for free forever, it's like, at least we teach you something, you know? At least we have a platform. At least. Okay. Okay. So we do have an episode today. So New Hampshire told insurance companies they have 30 days to credential a complete mental health application, Nyleen. 30. That does not seem like a normal turnaround time. What's your turnaround time? Yeah. A good turnaround time is at least 45 days because we got to get it at through committee. So I'd say 45 days is a good turnaround. Yeah.

[00:00:59] I mean, they said 30 though. They's not 90, not 120, not we are waiting for committee. They want it all done and out in 30 days for mental health applications. Okay. Okay. And the law says treatment can be covered in network retroactive to the application submission date. Okay. Well, we know that, right?

[00:01:18] That is the kind of sentence that makes a therapist or a doctor or anyone cheer and McClaim's department, you know, start sweating maybe because they're excited. You know, they're like, I get it done. Yeah. Yeah. But when I found the question that no one likes, what happens if the payer simply does not do it? That's the question, right? Because some observers warn that the law may not have enough enforcement teeth, Nyleen.

[00:01:45] Wow. Well, and then you have some teeth, right? Because a beloved healthcare center ends up closing. About 1,400 patients had to find care somewhere else. It's always the rule, the rule organization. I know. And then the lawmakers fought over whether new facilities near critical access hospitals should even face special rules. So like all of this stuff is happening.

[00:02:10] And finally, New Hampshire's prosecutors say that stolen patient and doctor identities, you guys listen to this, were used in a transnational scheme. And it led, and it was, it was led and tied to nearly $3 billion. Did you just say billion? With a B. With a B? Three, not even 1 billion, 3 billion. Yeah. In intended Medicare losses.

[00:02:40] I mean, baby, verify the human and the business at this point. That's what we need to be doing. Well, let's spill some New Hampshire tea. Yeah. Yeah. Oh, yeah. Well, Nyleen and Shannon's sitting there talking about you while you pull up a chair. Yes. Welcome back to Credentialing Chronicles. We're together. Where we spill the tea across America.

[00:03:09] On the doctors you see. So we connect the headline to the provider file and then ultimately to the patient because that is the life cycle of the credentialing world. Yeah. So before we get started, let's do our little disclaimer, which is this episode discusses criminal charges, allegations, enforcement matters, and disputed policy impacts. Allegations are not findings of guilt and defendants are presumed innocent unless proven guilty.

[00:03:39] We rely on public sources available. The legend. Yes. September 2026. This is educational and commentary and our personal opinions, not legal or clinical advice in any kind of way. We have not credentialed or have been part of any of these cases. Yeah. Verify current law, agency guidance, and pay your requirements, you guys, before making an operational decision. I mean, we're not out here telling you what to do in your organization. Right.

[00:04:15] We're not out here telling you what to do in your organization. Because God forbid they all expire on the same time. That's right. And I mean, do you think that's a credentialing strategy or what are you thinking? Well, it's a little craziness. It is.

[00:04:44] Are there softwares to help us with that? Well, let's meet credential. Credential network or for short, CredNet. Okay. So, you know, yeah. So we kind of use it interchangeably. Okay. So tell me a little bit about CredNet. Well, their platform, you guys, it brings provider documents, expiration tracking, and pay your enrollment together in literally one place, you guys. That sounds amazing. Yeah. And it helps the team stay organized and keep the process moving. Wow.

[00:05:11] Well, and you know, with CredWallet, providers can upload their credentials, keep their information current, and connect with the organizations that they work with. So it's free with providers as long as your organization is with CredNet. Exactly. And you don't get any of the questions like, is this a scam? Am I, you know, is this spam? I mean, you know, as a CBO, we get some of the craziest, wildest things. And we do text doctors, and sometimes they'll be like, they'll send it to their manager and be like, is this serious? They even put emojis.

[00:05:39] And it's like, we're trying to be human here, guys. FYI, this episode is sponsored by CredNet. CredNet. And we thank you very much. And so if you are dealing with provider enrollment or credentialing, we would love for you to check them out. Credentialnetwork.com. Schedule a demo. And what do we do? Do we always sell? Tell them the pink lady sent you. Okay. Now back to the Granite State and a lot of tea that they have. Of course. So House Bill 507. You know I'm all about these bills.

[00:06:09] You are the legislation queen. And you look great today. Oh, thank you. Yes. So House Bill 507 became law in May of 2025. Okay. And took effect in January of this year, 2026. Okay. It requires health carriers to process complete credentialing applications from We're going to talk about mental health professionals within 30 calendar days, bringing them in line with the timeline already applied to their care. To primary care. Yeah. Yeah.

[00:06:39] And this is huge, you guys, because a licensed therapist can be ready to treat patients and still sit outside the network while people cannot find an appointment. And so credentialing delays become truly access delays. Yeah. Because if you can't find the doctor, then you can't see them. So the law also supports a retroactive in-network treatment from the date the complete credentialing package. Which is good. Was submitted. Yeah. That's actually really good. That protects the patient from being treated as like out of network.

[00:07:07] Now we all know, and if you don't know, now you know, you should check your out of network benefits so that in case you do see an out of network provider, you can see whether or not you have these benefits available. But anyway, so this protects the patient from being treated as out of network solely because the payer's review is still moving. Yeah. But every word matters in this, right? You guys. So complete application matters. What does complete mean? I mean, that's the question we're always asking.

[00:07:37] Who sends the acknowledgement that it's complete? And if the payer is truly asking for one more item on day 29, does the clock restart? So the process needs a defensible received date and a true deficiency notice. Well, and carriers must have written credentialing policies. We always talk about these policies. And anytime you get an accreditation survey, they're always going to say, like, what do your policies say? Right.

[00:08:06] And you have to apply those standards consistently throughout your organization. The speed requirement does not erase verification. We know this. Yes. Even though they tell you, get it done right away. That doesn't mean skip all the verifications you have to do. License. You have to have a willing provider. Of course. Of course.

[00:08:26] License, education, training, malpractice, sanctions, work history, and all these other elements are still required in order to ensure that you have a compliant review. Mm-hmm. So when you're looking at it, you know, I want the dashboard. I need the number received, incomplete, complete. That's true. Decided within 30 days. But 30 days seems like a really short time, Shannon. Well, I mean, you know, AQC, we complete files in 28 days or less.

[00:08:54] I understand that, but that doesn't mean that the facility that you're giving that file to is within that 30 days. They may have credentials committee in 15 days. So while you completed the file, it may take up to 45 days to get to the next credentials committee meeting, right? Well, it could. I understand. But if you're proactive with your client, then you already kind of have those committee days on the calendar. Mm-hmm. And so you're working within that time. Well, the concern raised— And you're constantly telling the provider that as well. That's true. We're trying to get you a committee.

[00:09:24] We need to make sure you're getting, you know, the organization's getting paid. Right, because committees usually only once a month. Only once a month, yeah. Right. So the concern raised after passage was obviously enforcement, right? So like we said, your committee meets only once a month. So as fast as your processing department works, it's something that you still have to talk about.

[00:09:41] A deadline only changes behavior if, again, the provider or the clinician can report noncompliance, can complete their application on time, and regulators can see the data and consequences then exist if, you know, or when a payer repeatedly misses a deadline or the clinician misses a deadline or the CDO misses the deadline, right? Mm-hmm. You ain't lying. Do not give me an annual average that hides a six-month outlier.

[00:10:10] True. True. Do not, baby. True. Yeah. I mean, because, you know, truly, our score, you know, very good law, but enforcement and measurement decide whether it becomes real access, you all, or just a beautiful sentence in a statute book, you know? Right. And then the truth is mental health practices are small, right? Small but needed and mighty. Absolutely. Absolutely.

[00:10:35] And I can imagine in a state like New Hampshire where, you know, it's not super, super, super populated state, they may have not have a credentialing department tracking every single call. Or payers should provide, you know, transparent status and one accountable contact or like one thing. This episode is also sponsored by Baton Health, you guys. Ooh.

[00:10:57] Faster primary source verification helps credentialing teams move qualified providers through the process without sacrificing defensible evidence. And it's helping that time. So if you're in New Hampshire with a 30-day clock ticking, Bataan Health might be what you need. Absolutely. Because a 30-day deadline still needs trusted data and still needs primary source verification. So learn more about Baton Health by clicking through the link provided in our show notes, batonhealth.com. All right.

[00:11:25] So New Hampshire has also been planning a community engagement requirement for its Medicaid expansion program. Now, we have talked a lot about Medicaid and Medicaid growing, and it's called the Granite Advantage. Well, legislative proposals in 2026 addressed hours, qualifying activities, exemptions, and, of course, documentation. Everything. They was looking at everything. So New Hampshire has a little history there. Here. Okay.

[00:11:51] A prior work requirement rollout was suspended years ago, you all, after tens of thousands faced potential coverage loss. So that history should be in the implementation file, right, as a lesson learned, not treated like ancient news. Right. So the federal rules now require states to implement what's called the work requirements, which I think is pretty clear. Great, great, great. Yeah.

[00:12:17] But states still make operational choices about verification, notices, exemptions, and support. New Hampshire also has also sought reentry navigation help for people leaving incarceration. Oh, that's interesting. It's really good. Yeah. Who need Medicaid enrollment and ongoing compliance support. You know, and that's really just smart, right? Because the hardest cases are not always people refusing to comply, Nyleen. Right. You know? It's not that they don't want to. It's just...

[00:12:46] It's hard. Yeah. And they are people with unstable housing, which we know. They're changing a job. There's no easy document access, you all. You have to get a social security to get a driver's license. I mean, it's a process. You know, behavioral health needs or a transition from jail to community care, it's where this services is really needed. Well, credentialing teams may think eligibility is somebody else's problem. True. Because we do know that's all different rules. Mm-hmm. They break it all up. Yeah.

[00:13:15] Everybody's in charge of something else. But coverage churn changes provider panels. Mm-hmm. Okay? Denials, uncompensated care and continuity. Mm-hmm. If patients repeatedly disappear and return, quality and finance needs to know, obviously, like, why these changes are happening. Because at the end of the day, and we're talking payer moment credentialing here, guys.

[00:13:42] So, we're talking about access to health care and enrolling a provider and Medicaid and then patients having Medicaid. So, that's just a little tidbit. We're kind of talking about provider moment on this episode. Yeah. A person should not lose coverage because one system cannot see information that another state system already has, right? Mm-hmm. I mean, you train staff, verify consistency, document the basis, and you give a real appeal path to people.

[00:14:11] So, well, yeah. And then New Hampshire gets credit if it uses its earlier experience to prevent avoidable losses. It gets no credit for repeating the same paperwork failure with a newer portal. I mean, we really should be learning from our lessons and making things better in the credentialing world. I mean, really. Yeah. And we're talking, yeah, credentialing payer moment world here. You know, Medicaid, access to health care, patients needing it, how patients are getting Medicaid.

[00:14:39] I think it's an important understanding overall, understanding both ways kind of thing. No, yeah, you're right. So, let's talk about fall 2025. One of the community health services locations in Franconia. Franconia? Is that? Franconia. Franconia. Yeah, Franconia. It's closed, you guys, after more than 20 freaking years. 20 years.

[00:15:08] That's crazy. That's crazy and sad. It's scary that our health care facilities have to close after providing care and... It was so crazy. I dropped my mic. I'm sorry, but Lord. Care and community to our services. Yeah. I think that, unfortunately, with all these new changes, we may be seeing this more often. But, Shannon, tell me what happened. Well, Mommy, Public Resource reported said that roughly 1,400 literal patients had to find another source of care.

[00:15:38] That's horrible. The organization apparently cited financial pressure, which who wouldn't, right? We all have it. Right. Including Medicaid and federal funding changes. So, closing the site reportedly saved about, yeah, $250,000, right? While the system faced a projected shortfall around $500,000. So, they had already lost $250,000. They didn't want to lose an additional $250,000. So, you're talking about serious financial impacts, which you can't keep a business running

[00:16:07] if you're losing half a million dollars. Well, like you said, it faced a projected shortfall of $500,000. Yeah, that's half a million. That's a lot. That's half a million, yeah. So, those numbers are tiny, though, in comparison with a large hospital budget, you all, right? Well, but where are we talking about? True. In a rural town. You're right. I mean, they do decide whether a 70-year-old patient drives a few minutes or loses the relationship entirely. Yeah, I understand that.

[00:16:37] Especially me living in a rural community. You do live in a rural community. Yes, and you saw the deers in my backyard, too. I see the deers. I see how you have no DoorDash. I don't have any DoorDash where I live. I see how you have no doctor right now. I have no doctor down the road. So, this is really important to me because around the same period, reports warn that several New Hampshire hospitals face serious financial risk. And I don't want to lose my little rural community because you know what? The other day when my daughter had a stomach ache, I was able to take her to my little rural community hospital. So, that's really important to me, right? Yeah, no, I could imagine.

[00:17:07] Lawmakers also debated that there was this House Bill 223, which would have reduced special notice and consent restrictions for certain facilities located within 15 miles of a critical access hospital. So, like 15 miles, like my hospital isn't even within 15 miles. Like I have to drive maybe 20 miles, I would say. Yeah. And that is a rural critical access hospital. And it is very much needed. You know, the problem is bills like this did not become law.

[00:17:37] They just get reviewed, but they don't become law. So, these rural hospitals, eventually, if you can't sustain it, then they're going to just close. Yeah. And that debate is really hard, Nailene, right? Because you're talking about your favorite ASCs. Yes. I mean, there's dialysis, urgent care, and specialty services, you know, can improve the choice that people have when they're available. Yeah. But an ASC isn't open overnight.

[00:18:06] No, it takes time. You're right. If new facilities take profitable services, you all, while the critical access hospital keeps the emergency room inpatient coverage and 24-hour obligations, the whole rule system weakens. I mean, it can, but you're talking about access versus sustainability, right? But not really, right? Sustainable access is the goal.

[00:18:30] The state has to model where referrals, revenue, staffing, and emergency coverage can be provided and move where a new facility opens. You're true. That's so true. And, you know, credentialing capacity matters, you all. At a rural hospital, they may have one medical staff. Tell me about it. Professional managing appointments. Tell me about it. Expirings. Say it again. Privileges. Again. Peer review. Do they even know what that is? And service. I mean, they do know what that is.

[00:18:58] I mean, of course, because we're going to have MSPs at every rural critical access hospital, but we'll talk about it later. Exactly. Now, let's add a telehealth provider or competing facility, and the network of files becomes way more complex, Nailene. And this is where credentialing by proxy and shared services and a regional CVO support system and MSPs in a community matter, right? But accountability must be written. And again, who verifies, who decides, who monitors, who reports an adverse action?

[00:19:27] And can I tell you a little bit about my personal experience with rural healthcare is a lot of these people have lived in this community. So what happens is education is sometimes limited and information is sometimes limited. So we as MSPs, again, need to encourage education throughout different kinds of facilities. So let's talk a little bit about New Hampshire. Yeah, and I'm just going to say it.

[00:19:54] Follow Credentialing Chronicles on all platforms because rural hospitals, you all in healthcare, does not fail only when a hospital closes. It can fail, you know, one departed clinician at a time. We've seen that. One unfilled position or shift. That's true, Shannon. Yeah, and one delayed privilege at a literal time. This episode is sponsored by HFT Pathways, the cloud-based platform helping ambulatory surgery centers bring scheduling, clinical, financial, and patient workflows all together.

[00:20:24] Schedule a demo today at hstpathways.com and let them know what Credentialing Chronicles sent you. Let's talk a little bit about what happened in 2026 in June of this year. New Hampshire prosecutors announced money laundering charges against two alleged associates of a transnational criminal organization tied to a nationwide healthcare fraud scheme with, girl, $3 billion. These poor hospitals are closing over $500,000.

[00:20:52] You're talking about a $3 billion in intended losses. Nyleen. Well, according to the government, the scheme used stolen identities of New England patients and doctors to submit literal fraudulent Medicare claims for DMEs, durable medical equipment always.

[00:21:13] One link DME company, you guys allegedly, received at least, literally, $20.5 million from Medicare and supplemental insurers. Well, the New Hampshire case focused on laundering alleged proceeds. The government described it as the largest healthcare fraud. Always the largest. Money laundering prosecution. It's just, wow. The government described it as the largest healthcare fraud-related money laundering prosecution in the state's history.

[00:21:43] Of course, it's that state. We're just talking about New Hampshire, and unfortunately, it's not just New Hampshire, because we've seen it in pretty much every state. Every state. And so, obviously, everything is still an allegation, because this is just happening this year. But, I mean, DME fraud, and I'm talking about it at NAMS. We're going to be talking about DME and provider enrollment and all of that. But it's crazy how much it's being used, and we're seeing this in every state. Yeah, I mean, the fraud is crazy.

[00:22:13] And this is why checking a license is not identity proof. Of course not. You know, a fraud operation does not need the real doctor to participate if it can steal the doctor's name, NPI, and identifiers. I mean, let's be honest. You know, all they have to do is create or acquire a billing entity and route payments somewhere else. That's really scary.

[00:22:33] And then credentialing and enrollment teams should validate, obviously, the natural person, authorized official ownership, managing employees, practice address, bank account, and contact channels. And as much as we complain about getting copies of all of this information, this is why it's important, because people out here are trying to steal money, you know? And people get mad. A real provider attached to a fake business is still a fake enrollment story. Very true. And providers need to monitor themselves, you all.

[00:23:02] I know that you think we're scamming you and we're asking for your documents, but it's really not us. You know, you need to monitor other things. Check PICOS. Check your NPPES. Pay your directories. You know, credit activity where appropriate. And even unexpected correspondence. True. If claims appear in a state where you never practice, do not assume it is a payer typo. Like, assume it's fraud. Right.

[00:23:28] So the government's data analytics can catch impossible geography, right? Sudden volume, product patterns. Organizations can do the same before law enforcement arrives. I need you guys to check the data, the licenses, the certifications, all of the things. You have to use care, right? Because a flag is not guilt, you guys. I mean, sometimes if this was happening, the provider doesn't even know it's happening. You know, it's not the provider's fault.

[00:23:57] And so, you know, you confirm identities, dates, orders, delivery records, patient contact, you know, supplier relationships and payment flow. Yes. Yes. And can I just say, I'm going to give you guys a little bit of information.

[00:24:13] So we have to, as people working in the office, if you prescribe a DME, you do need not only a proof of delivery that are a patient signs that they received the item, but you do need a prescription. You need a prescription signed by a healthcare professional. So I don't know how they are doing this, Shannon. To be honest with you. I come crazy with you for one brace. I don't understand. Docs, like protect your licenses, your NPIs.

[00:24:41] And unfortunately, a lot of credentialing is happening overseas right now. And I'm not saying that as not offering. Well, it's not that we don't want to offer people jobs. We want to let you guys know that your information is public. So doctors, protect yourself. Don't just give your data. Ask them if your credentialing is going across these. Absolutely. Who's doing your billing? Why are they doing their billing? What are you signing off on? Is anything weird coming on your faxes or your inbox?

[00:25:10] And have an amazing manager that can really tell you what's going on. If we have any advice, please, please, please. And really, the T is not merely that the fraud happened, right? It is that healthcare identity has become financial infrastructure. Even our identity, right? I mean, somebody steals my phone number and calls me 100 times a day. Right. I don't even know. It comes from all over. I know. You get spam calls all the time. I'm in a different state. They use that number to call me from the state.

[00:25:40] I'm like, wow. I know. So, you know, protect provided data like money, you guys. Because the criminals are already protecting it like money. Like the doctor's names and NPIs that they already have. Yeah. You know? For sure. For sure. So, Monday morning, first audit the 30-day credentialing clock. Mm-hmm. Pull 20 mental health applications and identify the receipt. Complete the date. Deficiency notices. Decision. Bam. Confirm the contract load. Direct D-date.

[00:26:09] And now I get a first paid claim. Mm-hmm. True, true. And second, test retroactivity in network claims. Okay. In network. Got it. Versus out of network. Yeah. Okay. Did the system reprocess services, right? From the complete application date? Or did the applicant and patient absorb the delay? Right? I mean, that's what we're asking or no. Yes. And so, then you're going to map the rural workforce dependencies.

[00:26:37] Like our clinician leaves, right? What service closes? What privilege expires? What call coverage breaks? And how far must the patient travel? Now, guys, this is really a thing. I've had nurse practitioners, particularly like, you know, APPs or whatever. Locums or something. Or locums or whatever. They move and guess what? Nobody's ever notified the payer that this clinician has left. I mean, that's something that you have to be monitoring at all times.

[00:27:04] Well, the beautiful thing about it is, and, you know, throwing in another sponsor, but credentialing, credential network, they do that. They have a whole term process. You know? And then you move them over to the term and they're able to alert payers and stuff. I mean, it is because it's true. It's like if the provider leaves your system, and I understand the point of wanting to keep it open or active for 30, 45 days to let everything clear out. But after that, like, the provider's still open in your system 100 days after they left. I know. Why? I know.

[00:27:32] Well, I will tell you, if they come back, it's really helpful that they didn't do anything because that may or may not have happened with somebody that I know. It is helpful to come back a year later. Months ago, but they come back. I mean, but that's not always the case, right? Yeah, it's not always the case because if they're a dental provider, utilization, they're being kicked off after three, four months. Yeah, that's true. Yeah, so dental is not a joke, you know? Okay, so fourth, you want to verify provider identity at enrollment and during maintenance, okay?

[00:27:59] And I know that's kind of crazy, but, you know, you just want to make sure that authorized official, ownership, address, phone number, email, bank account, NPI changes need independent confirmation. Not just an uploaded form. And so, like, last night, one of my staff was working on a contracting application and it's in North Carolina and the provider's home address is in Brooklyn, New York. And they're like... New Hampshire, though. No, no, no. Oh, I know. But anyway, it's just to talk about the difference. But yeah, and I'm like, and they're like, well, what should I do?

[00:28:28] I'm like, text the doctor and say, have you moved on down to North Carolina? Because if we put Brooklyn, New York, the payer is going to say, how is the provider living in New York and providing services in North Carolina? Well, that's a legit question. And I believe it is, too. And so that's what we did, you know, is ask the provider. Right. And so that's why you have to monitor for impossible claims, right? States where the provider never worked. True. Equipment the provider never ordered if you're working in cardiology.

[00:28:57] Well, if you're working in cardiology, why are you ordering a knee brace, right? True. Patients never seen volume beyond capacity and payments routed to unfamiliar entities. Mm-hmm. Let's just be honest. Our scorecard, our scorecard, mental health credentialing reform, green, with an enforcement asterisk. Right.

[00:29:16] Medicaid work rolls yellow until outcomes prove eligible people are not lost to paperwork because we don't want them to be lost. Right. So you want to build an enforcement path, right, for your own, like, deadline, right? So New Hampshire is showing us that access can be lost through delay, closure, eligibility churn, identity theft. Yeah.

[00:29:45] Um, you know, things not being done appropriately, different headlines. And then, of course, it's the patient hurting. And then we're hurting our doctors, Shannon. It is hurting the patient, yeah. Yes, we're hurting the patient, but I don't want good doctors to be hurt inadvertently. That's not fair. Mm-hmm. Let's just talk about something really quick, okay? Okay. So let's test this law with a fictional story, okay? Okay.

[00:30:14] So this is not a real provider. This is not a real patient. Okay. So meet Elena. Okay. She's a licensed clinical mental health counselor, and she's joining a small practice in northern New Hampshire. Okay. So the practice has a list of, like, 60 people. Mm-hmm. This Elena is licensed, insured, trained, and ready. Okay. The owner submits a credentialing package to the carrier on, let's just say, January 5th, and gets an automatic email saying received. Okay.

[00:30:43] So question one. Is received the same as complete? Absolutely not. The 30-day clock is tied to a complete application. Interesting. Remember that, guys. Mm-hmm. Complete application. Yeah. So the practice needs written confirmation of completeness or a prompt specific list of deficiencies. Wow. So, okay. So then we go back to January 12th. The carrier asks for a refreshed malpractice face sheet, even though the policy information was already in the application.

[00:31:13] Mm-hmm. So now Elena goes ahead and sends it that afternoon. What is the complete date? Is it the 5th or the 12th, seven days later? Well, mommy, that's exactly where the dispute starts, right? Because the policy should define completeness and prevent serial deficiency requests from becoming like a true hidden way to restart that clock. Okay. So the practice begins seeing patients after submission. Yeah.

[00:31:40] Because the law supports retroactive in-network coverage from the application date. Okay. But the front desk has to decide what to tell patients about co-pays and network status while the carrier has not finished. Mm-hmm. So see how this 30-day rule gets a little complicated? Yeah. Yeah, yeah. It needs a lot of clarification because that communication must be precise, right? Right. You cannot promise payment. And you can't promise reimbursement. No. No. Explain that credentialing is pending coverage. You know, I'm sorry, is pending.

[00:32:10] Coverage is expected to be retroactive if legal and contractual conditions are met. And the claim may require reprocessing. Document what the patient was told. Document, document, document. We always say that. Yeah. So now day 30 arrives. No decision. The portal still says under review. The practice calls. Gets a ticket number. Because Lord knows we all know about those reference numbers. Is that enforcement? No. That's just proof that somebody answered the phone.

[00:32:38] And looked at it, I guess. I don't know. Oh. Hi, Nyleen. So, so true. Oh, excuse me, mommy. Now we have escalation. Okay. You know, the written notice citing the statute, complete application date, provider details, affected patients, and requested remedy. Copy the contracted contact and use the regulator. Yeah. Compliant path when appropriate. So then now we're on day 42.

[00:33:08] Because now it's been 42 days, right? The carrier approves Elena. Effective. Now check this out. February 16th instead of January 5th. Claims for January deny as out of network. The credentialing team celebrates approval while the billing team is left being told that they are completely horrible or just holding the bag. Not horrible. So do y'all hear this?

[00:33:35] The credentialing decision is only half of the law's promise. The provider and the patient need correct, effective dating and network load and claim reprocessing. Right. And that's why documentation and tracking is so important. Every time. You need the software to be able to support all of this, guys. But the practice should reconcile every service from submission through activation. Patient, date, charge, claim status, member. I mean, all of these things are important. Yes. Pay your adjustment and final payment.

[00:34:04] Nobody should be left with an out of network bill because the carrier loaded the date wrong. And that's just, that's, you need to say it again for the people in the bag, girl. I mean, it's serious. It is serious because the patients are the ones being hard. I'm going to go back to New Hampshire law. Yes. And then I got to tell them, Hey, New Hampshire said you got 30 days. I submitted this application. Okay. On the first, on the 12th. On the February. You're telling me I missed the UI, but then on the 12th. So I should have been done on the 12th. Exactly. And now we're on the 16th of February. But that's not good.

[00:34:33] It's not good. And so now when we're looking at it direct, when we're looking, the payment, the payer should have an automatic retroactive process built into the system. So do not want to not pay. Of course. So do not make every small practice manually apply this 40 claims to receive the benefit that the law had already created. Right. So you're talking about an appeal. So they have to appeal. Yep. Yep. Yep. Yep. Yep.

[00:34:58] So now Ms. Elena's profile appears in the directory, but the address is, of course, the address is the old office. No. 20 miles away. So it's on top of the last day move. So Lord knows. Patients call the wrong location, conclude the practice is not accepting any more appointments. Like all of this mess up is happening. This is crazy. Yeah. And that's the thing. I'm just going to say it. Like people want to hire the companies in India. You know, I have a physical therapy group. They hired a company in India. Honey, everything is messed up.

[00:35:26] They're a physical therapy group, but they're not physical therapists. They're EMG. They're board certified EMG. So what did the people do? They set them all up as physical therapy. Oh no. So now they can't get any EMG claims billed. And I'm telling them it is not our fault. When you came to us, this is how you were set up. You know, it's going to take work and time to fix this, you know? Right. And they don't understand that. So even if New Hampshire law says 30 days, there's so many factors. There's so many factors.

[00:35:54] Can go into trying to submit a provider and getting the claim. I mean, what about directory access? Nailene. That's true. That's the biggest thing. You're talking about your patient, not your doctor 90 miles away. An approved provider with bad public data is functionality, is functionality hidden. Okay. So now give Elena a hospital consultation role. Her health plan credentialing is done, but hospital privileges are still pending, Nailene.

[00:36:21] Because we know that billing and hospital privileges are completely separate things. So how does this New Hampshire rule apply to hospital privileges? Do hospitals have to be done in 30 days from your understanding? Yeah. I mean, and that's the question, right? Because, you know, she may, you know, the hospital privileges are pending and she may see the office patients network, but still may not provide the hospital service required by the privileges. Exactly. So what is she actually approved for, approved for?

[00:36:51] And that question never gets old. It's never gets old. Because license, payer, credentialing, contract, enrollment, privilege and billing activation, you can definitely answer something completely different. The organization really needs one readiness metric. Every approval, authority, effective date, owner, evidence link and limitation. No cell should simply say approved. Never. No.

[00:37:19] So this fake Elena story, I don't think just resonates with New Hampshire. I think I found the perfect way to do my microphone now. That sounds amazing. This story is not just a New Hampshire story. It just highlights that New Hampshire is saying 30 days for payer enrollment, whatever, insurance, Medicaid, whatever. The point is that it highlights our everyday problem as an MSP is negotiating the payer side, the enrollment side, the credentialing side, all of the things. Right.

[00:37:48] The carrier corrects an effective date may reprocess the claim. If you have a good payer, you may want to argue with them. If you're good with the rep, yeah, you might. If you're good with the rep, you may be able to do this. Refunds, you know, we're refunding patients for, you know, excess of charges or whatever. We're talking about updates and directory. But that happy ending requires people who knew what to track, knew what to say, follow up with the things. I mean, I just came from.

[00:38:17] Not a happy ending. You called it. Well, you know, the thing is, you come from a place and you say, sometimes the contracts may take, you can say you're a network, but then they may say, oh, it takes six months to load the contract. Oh, yeah. That's, that's, I, you know, I swear the loading thing probably came into effect about six, seven years ago. And I'm like, it was never that way for six months. Even though I'm in network for six months. Yeah. I mean, it's the loading.

[00:38:44] Let us know, let us know what all of this information says, or if you are experiencing all of this. And if you're in New Hampshire, are you experiencing any payer? We really want to know, like really want to know people are listening in New Hampshire. So we need you to comment. That maybe it doesn't work that great, but yeah. Okay. But we need to comment. Let us know if you're experiencing any credentialing delays, meaning payer enrollment with your Medicaid plans or any other commercial plan.

[00:39:14] You can comment on Spotify. You can comment on Apple. You can comment on YouTube. We're on LinkedIn. Or you can even comment on the reels that you see on Facebook. That would make our socials happy. Like whatever. Yes. Okay. We're literally on everything. Everywhere. Everywhere. Yes. And no approval is safe if you have one verify, if you have not verified who is really behind it. No, of course not. So from credentialing chronicles to your ears, stay credentialed.

[00:39:44] Not canceled. Woo, Shannon. That was a lot of tea. Honey. But have they subscribed yet to hear it next week? On all of these platforms, please subscribe, like, and follow us. Go! scale, de-