Paper Trails and Patient Safety w/ Credentialing Chronicles

Erik Sunset: [00:00:00] All right. Hello and welcome back. I’m Erik, your host of the DocBuddy Journal here at DocBuddy. Of course, we deliver healthcare solutions that take the pain and costs outta broken workflows like with op notes, which gives ASCs and their affiliated clinics the power of instantly generated operative reports approved from the point of care.

Erik Sunset: You can find out more about that and all of our solutions at docbuddy.com. And today we’ve got a couple of really cool guests. We’re joined by the host of the newly launched Credentialing Chronicles podcast. We’ve got Shannen Aguayo and Nyleen Flores. hitting milestones before recording too. I, I won’t, uh, steal any of your thunder, but a lot of listens happening, uh, with just four episodes. I know the next one will be publishing soon, but Lene so good to have you back. And Shannen, so nice to have you for the first time.

Nyleen Flores: Thank you. Thank you, Erik. Yes. We’re so excited. We’ve officially hit our 1500 downloads, [00:01:00] uh,

Nyleen Flores: in less than three weeks, so we’re

Nyleen Flores: so excited and you can tell, you know, this really was a necessary, uh, outlet that was needed to talk about things that we generally have to keep confidential when we talk about our docs.

Shannen Aguayo: Exactly. Yeah. And the funny thing is, is that we still try to respect the privacy. And so we, you know, always put our disclaimer because medical staff professionals do not play about confidentiality. Um, and so, and, and you know, we’re really good at spilling the T without spilling the name. So, um, I think that’s what we’re becoming known for.

Erik Sunset: Well, I, I can, uh, attest to that firsthand. I have had a riot listening to your shows with just listening to episode four before we, uh, before we got together today. So obviously we need to, uh, be sure people can subscribe and like, and follow Credentialing Chronicles on your podcast player of Choice.

Erik Sunset: Before we talk a little bit more about the show, uh, Shannen, let’s start with you. Can you give [00:02:00] our listeners a little bit of background on yourself? What led you to this point?

Shannen Aguayo: Yes, yes, definitely. I’ve been in corporate credentialing for over 25 years. Um, about 11 years ago, 12 years ago, I went into consulting with a, an. Amazing company down in Austin, Texas. Um, and just really learned a lot from her and decided, Hey, let me open my own company and do it my way. Um, and so yeah, we have a, uh, NCQA certified, uh, credentialing verification organization.

Shannen Aguayo: It’s about to be a woman, uh, certified credentialing verification organization any day now. And, um, we just provide credentialing, compliance, payer enrollment, all of that monitoring with a white. Gloved concierge touch. And so, you know, we’re, my people are available 24 7. They’re mostly NAM certified. Um, and we just really take care of the providers.

Shannen Aguayo: If they call us at 11 o’clock at night, we’re, we’re helping them out.[00:03:00]

Erik Sunset: That’s fantastic, and Nyleen, let’s give the listeners a quick refresh on your background and then we’ll get into

Nyleen Flores: Yeah, so I’ve been in healthcare for about 16 years and I started at the hospital and then got into private practice, ran a nephrology practice for a long time, then got into medical staff, and so right now I am. With and finally rebranded my company. It’s called Med Elevate Solutions. And so we’re providing streamlining, uh, uh, services for surgery centers for private practices, basically looking at their overall practices and assisting them with streamlining and optimizing all kinds of solutions.

Nyleen Flores: So DocBuddy is a great help with that. Um, all kinds of solutions so that they can get paid on time. Document accordingly, report accordingly, and then also comply with all federal and state regulatory bodies. So lots going on with with me. And then [00:04:00] obviously our newest venture, joint venture with Shannen, with Credentialing Chronicles.

Nyleen Flores: So lots of fun.

Erik Sunset: So there’s two, there’s probably no better people on the face of the earth that I could ask this question to. Then, you know, from my vantage point, credentialing and enrollment are really the first steps of the revenue cycle, right? Like nobody’s paying you unless you’re on a panel. So, with that in mind, what are, what are some of your very best practices for listeners, uh, in a credentialing or enrollment sense?

Nyleen Flores: So for the doctors, obviously when they get out of medical school, the first thing they have to do is educate themselves. Educate themselves. In saying that there’s two processes that have to go through. They have to go through, they have to go through credentialing, which is an affiliation process. To a surgery center, a hospital of wherever.

Nyleen Flores: They’re going to seek this thing called privileges, so, which is basically they’re doing what they say they [00:05:00] can do and they’re gonna be verified for that. Then there’s another process which uses the same terminology, and that’s called credentialing as well, but that is credentialing and enrolling with payers or insurance companies.

Nyleen Flores: And unfortunately that class is not taught in med school, so, and

Shannen Aguayo: I, I would say one of the best practices that doctors could do though, is as they’re leaving medical school, as they start to leave their residency, start to actually start practicing, maybe keep a, um, you know, one of those three ring binder notebooks. And they could keep all of their certificates in there.

Shannen Aguayo: They keep, uh, their drivers a picture of their driver’s license, any peer references, intern, fellowship, um, hospitals, they’re with publications. They might have done different versions of their cv. So that way that we could see, like them updating it, um, because really the processes [00:06:00] that Nyleen talks about.

Shannen Aguayo: Every one of those documents are gonna be needed, um, including some CAQH stuff. And, and it just is, it, it becomes like a document torture. If we’re like, okay, now we need all of these. And he, he or she was just living their life getting the certificate, you know, and sums at my mother’s sums in my storage unit, you know, and then we’re like, well, we kind of need those, especially when they’re starting to get on panels, credential with hospitals, things, different things of that nature.

Nyleen Flores: Right.

Erik Sunset: Well, what I, I wanted to ask there too, I know it’s very, uh, paperwork intensive process. A lot of effort can go into compiling that binder. How often does somebody hand you their binder and go, uh, help me out with this carrier, this carrier, and this carrier? Please. It’s gotta, that’s

Shannen Aguayo: That, that, that would be never, never have I been handed a binder. Um, I, I say this advice all the time, right Nyleen? I mean, I know you do too, right? Um, but never have we been handled, you know, a, a binder. [00:07:00] Um, at a QC we have a process called like a self credentialing, where some of the providers that are just tired of looking for everything, we kind of compress it all into one and then we kind of re credential them every two or three years.

Shannen Aguayo: And give them their, all their documents and then they could just hand that binder to their hospitals, to their people. And that makes those providers very, very, um, happy because everything is verified and complete. And the medical staff professionals love that as well. ’cause they don’t have to always go back.

Shannen Aguayo: And so that’s type of like a self credentialing that they do.

Nyleen Flores: Yes. And there’s also platforms on there. And so there’s platforms obviously, like in the state of Florida there’s CE Broker. I’m not even sure if that’s a Florida thing or a national thing to be honest with you, full disclosure, but like that’s where they keep all their CMEs in one

Nyleen Flores: area. So there’s a platform that came out, um, and it’s called Mockingbird.

Nyleen Flores: And so what they do is they basically keep everything including CMEs in like a

Nyleen Flores: file.

Shannen Aguayo: them. Yeah.

Nyleen Flores: So the [00:08:00] doctors can upload all that information because on top of that, they’re gonna need to put all that information in. This thing called CAQH,

Nyleen Flores: which is like, um. Online repository that the insurance companies go to to collect the data, to get like the copies of their certificates, the copies of their licenses. So they do have to keep an online version as well. Um, what happens with the binder, which is why we as medical staff professionals always say. Keep a binder is because the paper is always better,

Nyleen Flores: um, because you can always lose a digital file or have your, you know, hard drive, crash like-minded and then you lose everything.

Nyleen Flores: So the paper is always best. Um, and then you would have to hand that either to each facility you go to for that privileging process or. To the insurance companies or a CVO, which is what Shannen has. It’s a centralized verification organization that kind of does all that different types of credentialing for you.

Erik Sunset: Sure. So it sounds like one of the ways people can really make it hard [00:09:00] on themselves is not knowing where all these documents exist, or not having access to the.

Nyleen Flores: Yes, and it starts with them graduating with like their college degree and then

Shannen Aguayo: Yeah, their med degree. Yeah. Yeah, yeah. And, and I mean, when you talk about pitfalls, Erik, right? That’s the number one. You know, um, the, the, another big one is, you know, not being available for signatures. I mean, nowadays, thank you know. After Covid, thank God a lot of the electronic signatures are accepted by everybody.

Shannen Aguayo: Um, but back in the day, you actually had to get those live signatures in black or blue ink, and that was so hard. Um, but even now, you know, some of the do. Oh, I didn’t get it. I don’t know how to do it. And so you’re like, oh, let me walk you through, sir. Let me, or, or ma’am, let me get you through this signing of a document.

Erik Sunset: Yeah, here’s, here’s how you do the.

Shannen Aguayo: Yeah. Yeah. You press start right there at the DocuSign. Yeah. Yeah.

Erik Sunset: So then with, with, um, the last, uh, presidential election, and this [00:10:00] isn’t a political show, which is discourse on the industry. Ha, has there been anything that changed with the new administration and a different looking Congress in terms of credentialing in 2025? Or is there anything new for this year unrelated to the elections last year that people need to look out for?

Shannen Aguayo: Well, I think that, uh, I’m sorry, Nyleen, do you want me to take it or you wanna

Nyleen Flores: Yeah, go ahead. Go.

Shannen Aguayo: Okay. Um, I think really credentialing doesn’t, um, become affected by the political change in office. I think sometimes the plans do. Um, so, you know, some of the Medicaid Medicare Advantage plans, the plans under it, the carved out plans?

Shannen Aguayo: Yeah, those do because they change. Um, you know, when Obamacare came in, a lot of. Plans changed, and then the doctors have to get re credentialed and it’s this huge thing and the, and the patients have to be, you know, moved to that plan. Um, but I think as far as what we’re talking about as far as credentialing with an affiliation or credentialing with a, a health plan, those things really don’t change.

Shannen Aguayo: But what does change is our, um, standards, accreditation, [00:11:00] standards change. So a big one of that is the NCQA. Um, in your system, in your field, the triple A, HC, um, and they are the ones that put out the standards. And so they’re the ones that say, we want a CV in month, year to month, year format. And when we’re auditing you, that’s how we wanna see that cv.

Shannen Aguayo: And so when Susie is in the office saying, Dr. Smith, I, I, I know this is your CV for 19,000 years. But I have to have it changed in the format. You know, we really can’t be mad at Susie because it’s being asked for on an accreditation level, you know? Um, and so I think that’s something to just kind of understand that timelines change.

Shannen Aguayo: Right now. NCQA has huge timeline changes coming out, and so where things used to be able, you used, a doctor, used to be able to sign an application. And that application would be able to sit for a year and or be processed out for 365 days. Well, now they’re shortening it so it, it then shorted to 180. Now [00:12:00] organizations are one 20 and CVOs like myself are now 90 days.

Shannen Aguayo: And so from the time that the provider signs the release to say Yes, credential me to the time that the actual client gets back the file. We only have 90 days to do that. Um, a QC tries to get it done in 30 to 40 days, so we’re way above that. But I mean, it, it, things like that do change, you know, we’re, so we’re having to put more pressure on providers to say, get these things done.

Erik Sunset: Yeah. And you, you really, it sounds like you really have to navigate a bureaucracy, uh, to get it right or know how to

Shannen Aguayo: Yes, sir. Mm-hmm. Yes, sir.

Erik Sunset: Well, I appreciate the, uh, the display of expertise there. Ladies, I wanna get you kind of into your natural elements, uh, what people can get more of on credentialing Chronicles.

Erik Sunset: So I, I know, I know there will be a couple of these that come to mind and certainly don’t steal any of your own thunder, but I gotta ask, what are, what are some of the, the wilder, either the funniest or the scariest sort of credentialing stories that you’ve been a part of and heard of? There’s gotta be some good ones [00:13:00]

Nyleen Flores: Well, our disclaimer says we don’t talk about the people that we’ve credentialed, but since we’re not on credentialing

Shannen Aguayo: Yeah, I.

Nyleen Flores: I was a little, I do wanna ask though, with your experience, and, and this can just launch into like the t that we need to talk about. In your experience with DocBuddy and having doctors quote unquote complete op notes, have you ever questioned, is this really a doctor? Because the op note is like so bad.

Erik Sunset: Um, I’ll, I need to give you, there’s two versions to this answer. Here that DocBuddy obviously takes access and controls very seriously, and we have policies and procedures in place to prevent the completion of operative reports by those that are not authorized to do so. However, we’re not in control of everything that happens in the world and kind of on this, in this same vein for maybe the [00:14:00] less sophisticated facility that isn’t as concerned with adhering to compliance or the law.

Shannen Aguayo: Say that again,

Erik Sunset: Do you have a function that would allow my providers, that would allow my surgeons to batch complete all their op reports for a week or two? And the answer is no, we don’t.

Shannen Aguayo: And you shouldn’t.

Erik Sunset: we’re gonna pretend that you didn’t ask us that. But the answer is no. They will need to review them one by one.

Shannen Aguayo: Mm-hmm.

Erik Sunset: So, Natalie, I, I’ll have to come on your show, your guys show to, uh, spill my own tea.

Erik Sunset: But that is, that is my answer. We take.

Shannen Aguayo: He said he ain’t No, that’s.

Nyleen Flores: So, yeah, exactly. So, okay. So crazy stories. Um, we’ve, I have had everything from I. A, a neurosurgeon committing suicide in a bathtub in his parents’ house.

Nyleen Flores: Two, one jumping off of a ledge. [00:15:00] Two, one being found in a closet with a needle in his arm. Two, a, uh, electrophysiologist asking for privileges in a procedure.

Nyleen Flores: She’s never done it. Well, she hasn’t done it in over seven years and had to tell her no. I have had, um. Uh, a doctor who, um, was actively sexually harassing and the nurses refused to say anything for many years until finally action was taken. I’ve had, um, somebody impersonating a surgical assistant in the operating room that we had to physically remove from the operating room after somebody googled them and found out that they weren’t an actual surgical assistant.

Shannen Aguayo: Poor Erik’s face. Erik, do you really wanna know the team? Are you being burned over there?

Erik Sunset: No, no, I don’t.

Erik Sunset: You know, call this out that we recently had, uh, Dr. Steph Simmons, who’s the CMO of the [00:16:00] Dr. Lorna Breen Kiros Foundation on our show in the last couple of episodes, de-stigmatizing providers seeking mental health, kind of right up your alley. ’cause they do a LOLer

Nyleen Flores: Yes. Which that is a beautiful story, the whole Lorna ring, because it’s really sad, you know? She, she, I. Was really, really needing help. And unfortunately she fell to the problem of covid. But burnout is real. And the thing is, is doctors are held to an above normal standard. And then at the same time it’s the, the. They’re just, it, it’s just diff, it’s just so hard. It’s so different. Um, doctors, uh, DUIs, uh, is your pediatrician arrested with a DUI Do. You continue having your child see that pediatrician, like this is real stuff that dealt with on a day to day basis. Lying. They had a $5 million lawsuit they never disclosed. Um, I mean, I could just keep going on [00:17:00] and on.

Shannen Aguayo: Yeah, and, and, and I think that the system that is now. Place perpetuates these type of bad actors to continue because there are levels of protections by facilities, by the state board. Um, you know, all of the due diligence that could be done is not done sometimes. Um, and it’s because. People don’t, at the very high level, do not want full transparency on their providers because I think, like me and Nyleen have discovered, um, it provides a shortage of then providers

Erik Sunset: Oh yeah.

Shannen Aguayo: do, you know, if you don’t have the providers to do the job because your bylaws says that if you have sexually assaulted somebody in the last five years, that you cannot work at their facility, and then your provider comes back and they are sexually assaulting somebody.

Shannen Aguayo: What do, what do we do? You know? And, and that’s, that’s really what the problem is, to be honest with you, is that [00:18:00] I think that there is so much going on that people just do not want transparency.

Nyleen Flores: And the financial impacts. So we

Nyleen Flores: all know, especially in surgery centers, uh, money is an issue, right? And we all know when you’re trying to sell your product, it’s, it’s, it’s the money it comes to down to the bottom line because surgery centers are making half of what a hospital is making. So this is why it’s a push through.

Nyleen Flores: So. I may or may not know somewhere that is a surgery center who is may or may not allowing someone who may or may not be sanctioned in over five states and has. You know, hurt multiple people, um, because they’re just like, we just need the revenue, we need the cases. We don’t have a choice. I have to let ’em on staff. And I’m like, screaming at the top of my lungs. But at the end of the day, what are you gonna do?

Nyleen Flores: You know?

Shannen Aguayo: gets hurt. Mm-hmm.

Nyleen Flores: And [00:19:00] then, but you’re gonna pay for it now. Are you gonna pay for it later? I mean, that’s just my perspective,

Nyleen Flores: but.

Shannen Aguayo: I, I think there, there, there just needs to be a, a new, um, I think a new fresh air in the thought process, to be honest, Erik, because, you know, doctors are graduating every day, you know, and they say that there’s a huge shortage here and there’s a huge shortage there. And so it’s, if, you know, we allow these type of practices to continue, then the new doctors that are coming out fall into being, you know, vulnerable to these situations as well.

Shannen Aguayo: And then it just creates a, a, a. You know, an even more non-transparent system. And so we just really advocate that each facility can be as transparent as they, um, want to be in their credentialing bylaws and credentialing manuals, and we advocate that they should be.

Erik Sunset: Well, I think Lene raised an interesting point there. Either Pay Now in the specific hypothetical example, yes, you will not be able to handle those cases, but imagine the [00:20:00] liability you’re undertaking by allowing this provider to continue practicing against your own bylaws. And at some point, somebody’s gonna find out or somebody will be, god forbid, hurt so badly that everybody will

Shannen Aguayo: Mm-hmm.

Nyleen Flores: Mm-hmm.

Shannen Aguayo: Look at Dr. Death’s situation. I mean, that’s exactly what happened.

Erik Sunset: Yeah. Yeah, you’re, you’re totally great. Episode four of Credentialing Chronicles. You hear all about it.

Nyleen Flores: Yeah. Um, yeah, so there’s, there’s, there’s a lot. And then we also don’t want to lose sight of our wonderful physicians, and it gives them a bad name. You know, this

Nyleen Flores: is the whole stereotypes, you know, where people make. Certain races and they make fun of, you know, these people are this and these people are that even in our, in our own country or people from the south are this, or people from the north are this.

Nyleen Flores: And so we make these generalizations and, and that’s not always fair. So same thing is while we are exposing all of these things, we do recognize that there are amazing physicians. And so those amazing physicians should stand up for themselves and if they see something. [00:21:00] You know, and, and it, in Dr. Death’s situation, just to talk about that for a second, it was a physician who finally put his

Nyleen Flores: foot down.

Nyleen Flores: And so those are the doctors we need. We need good doctors to say, Hey guys, this is not right.

Shannen Aguayo: Yeah, and, and I, we have a PSA, you know, segment in every episode, and that’s what we talk about. You know, doctors, if you see something, it’s okay to go to your medical director or your medical staff office and say something in private, in confidential. It will not be talked about, you know, you it, you won’t hear that it’s from you.

Shannen Aguayo: Um, and we’re just trying to really empower people that are in these environments. To be more vocal, um, and just really protect patient lives. And then on the, you know, offensive side, we’re trying to empower patients. Patients are not taught that they can go to the medical boards and verify their doctors for free or set up a Google alert.

Shannen Aguayo: To see if their doctor comes out on the news because he or she has been drunk driving or, you know, just found on a [00:22:00] hundred counts of child pornography. I mean, there are so many things that come out and you just don’t know, um, until it comes out. And then it’s, you know what, we always talk about a pattern of behavior.

Shannen Aguayo: It’s been happening for years. That’s what they always say. It’s 10 years, you know, it’s been going ongoing.

Erik Sunset: Well, physician, uh, mid-level. Anybody in a medical organization, like as you say, if you see something, you should say something, but that’s true for all professions. Medicine’s a little different because you have patient lives in the balance at times or you’re, you’re caring for people. So it is a little bit different and they should.

Erik Sunset: In my view, be held to a slightly higher standard. But right is right and wrong is wrong that it shouldn’t be tolerated.

Shannen Aguayo: they could say, see something, say something on the subway. I mean, why are we not saying that in healthcare or in any other professional, like you’re saying, Erik?

Nyleen Flores: Mm-hmm.

Erik Sunset: Yeah. I’m gonna, I don’t, I’m gonna butcher the phrase if I try to give it to you off the top of my head, but it’s, you know, evil doesn’t triumph because, uh, good isn’t strong enough. It’s ’cause [00:23:00] nobody does

Shannen Aguayo: Mm-hmm. Mm-hmm. Yep. Exactly.

Nyleen Flores: Mm-hmm.

Erik Sunset: Well for how about a little levity? ’cause that got, that got a little heavy. And I do want to take a quick aside here that if, uh, you are in medicine, whether you’re a provider or otherwise, and you are not feeling well, go get the help that you need. And Dr. Lauren Breen Heroes Foundation is, uh, there to provide resources to you.

Erik Sunset: I mean, that, that is a really serious topic and unfortunately. Uh, we’ve seen the loss of some of our, uh, surgeon clients over the last, uh, two years to their own hand, and it’s just, it’s a tragedy. You don’t wanna say it’s preventable, you know, people will make their own choices, but heavy stuff.

Shannen Aguayo: Yeah, I think, but the good thing is, is that in, in transparency, you know, helps good be identified, excellence be identified, and it also helps things that shouldn’t be happening be identified. And so, you know, I think transparency is just something that has been lacking from credentialing, you know, since it came into [00:24:00] existence and was part of legislation.

Shannen Aguayo: Um, and I think now just. Our podcast is just kind of shining a light on it and people are saying, oh, you know, I’ve been asked to falsify audits or this, I’ve had to quit. I, I went into a new profession. I mean, you really don’t understand the types of messages we have been getting since we started this podcast.

Shannen Aguayo: And it just goes to, you know, like, we have needed to do this. Like this is something that needs to be talked about. I think there’s a lot of confusion around credentialing.

Erik Sunset: Yeah, I’m, I’m glad you’re doing it. I’m glad that platform exists. And for that, a little bit of levity that I, that I owe our listeners and owe you to. Uh, many years ago I worked at a, a pure revenue cycle vendor here in Miami, and credentialing was a part of the services offered. So this is just shortly after Covid and, and down here in Miami, we had a pandemic for all of about 90 days.

Erik Sunset: And then

Nyleen Flores: Pretty much, pretty much.

Shannen Aguayo: Yeah. Yeah.

Erik Sunset: uh, but you know, Miami’s kind of a different [00:25:00] place compared to a lot of the us So coming back to the office that June and, uh, overseeing the sales organization, I ended up fielding a lot of calls from our corporate office, from providers that I wanna open a covid lab. Can you do my credentialing?

Erik Sunset: I’m like, okay. Is this like part of your practice or is this a new tax ID that we’re talking about here? Oh yeah, it’s a new one. It’s not part of my practice at all. The, the letdown of so many individuals hoping to open their Covid lab put me at the end of the, the wrong end of the screaming match. What are you being United said?

Erik Sunset: They have enough Covid labs. Like, this is outrageous. I’ve been in practice for so long. Call ’em again. Call ’em again. Call ’em again. No, we don’t need 25 Covid Labs on every block, you know, in, in June of 2020 or whatever it was.

Shannen Aguayo: Mm-hmm.

Erik Sunset: So what are, what are some screaming matches maybe you’ve got to have at the expense of a payer to get somebody credentialed and enrolled?

Erik Sunset: Or, or, or what’s maybe some heightened interactions that you can share with [00:26:00] our listeners?

Shannen Aguayo: YII, I mean, I could tell you just to, I could tell you a good positive story. I love positivity, Erik. Um, we are big advocates of sending, you know, en enrollment people, um, you know, managers, you know, we’ll send you a pizza. We’ll send some DoorDash lunch orders over if we can get an effective date a little sooner.

Shannen Aguayo: Um, I’ll send you, do you need an edible arrangement? Do you feel like a little cantaloupe? I will send that over to you. And so, you know, I mean, thank you, thank you for making sure that this clinic, this organization, I work with a lot of FQHCs and we do that a lot for the FQHCs. Um, ’cause it’s so important for them to, you know, be in the panels.

Shannen Aguayo: Um, and so, yeah, you know, we will just, um, you know, I try not to get. Into screaming matches because you know, you get way more accomplished with honey than vinegar and so you know that. But that is something a little trick of the trade I’ll disclose to y’all.

Nyleen Flores: So [00:27:00] Shannen. Shannen is the sweet one. I’m the, I’m the Florida girl. So let’s talk about Florida. I don’t, I have no patience.

Nyleen Flores: I’m so sorry. That is my absolute downfall. So the problem with a place like Florida, um, Erik, is that it’s oversaturated that is different from A-F-Q-H-C, uh, or a rural facility. When I moved to Georgia, I got on the panels within 30 days, but that’s because there’s no, there was no other hand surgeon in 60 mile radius.

Nyleen Flores: So the panel said, oh great, you’re a new

Nyleen Flores: doctor. Lemme look at your zip code. We need you, no problem. Here’s your contract. Not the case in Florida, had a primary care clinic I opened and it’s years. And they’re like, panel is closed, panel is closed, panel is closed. So at that point you just get into an endless cycle because they’re saying there’s, like you said, too [00:28:00] much in this. Zip code. So if there’s 25, 27, a hundred primary care providers in this particular zip code, they’re gonna close the panel. And so at that point, it’s you having to prove why your service line is different.

Nyleen Flores: It is why you’re special. So that is, and it’s not, it, it, it’s not winnable. I mean, it’s just standing in a queue and just keep trying, keep track.

Nyleen Flores: Huge problem is anesthesia. Anesthesia to get in network is. Near impossible. It is extremely difficult in a high density area like Miami, like Naples, like Tampa. They’re it. They’re just so overly saturated and they don’t, I really don’t think they take into consideration the, a population of people. They just take into consideration the number of providers in that particular zip code.

Shannen Aguayo: And how, how often do they even update that, right?

Nyleen Flores: Right, and then you can keep asking. So they’ll just tell you reapply in X number of [00:29:00] months. And so then you

Nyleen Flores: have to reapply and resubmit and request and redo and repay. And then that’s not even getting into the contracting issue. Why is healthcare the only business where somebody else, a third party tells you what you’re allowed to make? That is so not fair. So not only that, right now, I just, I’m in a screaming match right now with, with a payer in Georgia, and I’m telling them, they’re like, no, we’re gonna pay you. Check this out. She started at 80% of Medicare. I’m like.

Nyleen Flores: Why would I expect, why would I accept that? I’m like, no, I, I need, I need more. She comes back, she counters 88% of Medicare, so it’s like, it’s a, so when that, that is the screaming match of like, we’re not going to accept this. My doctor is worth more. And

Nyleen Flores: so all of that is time. You can’t treat the patients, and in the meantime, patients don’t know. You know, they

Nyleen Flores: don’t know that I can make $5,000 for the surgery versus with this insurance, but [00:30:00] yet UnitedHealthcare is only willing to pay me $300.

Shannen Aguayo: Mm-hmm.

Erik Sunset: Right.

Shannen Aguayo: Exactly.

Nyleen Flores: that’s where the screening match. It’s the only business where somebody else decides what you are entitled to get paid or what you are worth. You don’t get to choose that even though you’re the one selling the product, which is the healthcare.

Shannen Aguayo: Yeah, I, I am having an issue with that exact happening too with some physical therapists up in Pennsylvania. Um, they do the electrical. You know, um, procedure, and they’re all board certified. They do this and they wanna pay ’em $78 and I think the, the payment is actually like 3 24. But they’re saying because they’re physical therapists and they’re saying, well, no, we’re board certified.

Shannen Aguayo: You know, no, we just wanna pay neurologists. This, I mean, it’s just crazy. And so, yeah, I am actually going through that right now. If. I just try not to get to a point of screaming. I’m like, are you hungry? Are you not happy? What, what do, what can we do, you know, to make you happy and then make you do the right thing? I [00:31:00] just wanna make this work, ma’am. Okay? We’re all in this together. That’s where I come from.

Erik Sunset: nobody, nobody really wins with the screaming match, but unfortunately, sometimes you can sometimes be the right thing, even if it’s still the

Shannen Aguayo: you’re right. You know, you’re right.

Erik Sunset: Well, let’s, let’s talk about the payers a little bit more. Let’s, uh, sharpen our spears a little bit because at some point there will be a reckoning.

Erik Sunset: I don’t know what that will be. And certainly not advocating for any, you know, sort of physical reckoning, uh, but more regulatory, um, as Ani point out, we’ll, we’ll pay you some, uh, percentage less than 100 of Medicare. Like what Medicare rates just dropped. You know, I’m, I’m ex specialty. They’re already paying me 9% less this year.

Erik Sunset: Like, I’m gonna get. A proportion of that, uh, from a private carrier, like, I don’t think so. How do we fix, how do we fix this three-legged stool where there’s really only one leg on the patient, provider, and payer stool that seems to matter.

Shannen Aguayo: [00:32:00] Well, I think the first thing is, you know, a paper trail, um, and, you know, talking to the, you know, um, provider reps in the area in charge of the contracting process. Um, and then, you know, once you get, I. Their initial offer submitting, you know, some negotiation paperwork, um, and you’re really, you know, trying to keep a paper trail and saying, look, this is like, you know, Nyleen said this is what makes me special.

Shannen Aguayo: This is, which is kind of sad, right? It’s like you have to, you went through all this schooling, you should be able to see insurances. It’s like, now you have to play this game of I’m special. Pick me. You know? And that’s very hard to do for providers, and I think sometimes they get very upset because they don’t understand that that is the game that they’re asking us to play right now.

Shannen Aguayo: What do you think? Love.

Nyleen Flores: Yeah. I, and I just don’t, I don’t know, because it’s, uh, controlled by people with a lot of money with,

Nyleen Flores: uh, every other ulterior motive other than helping the patient.[00:33:00]

Nyleen Flores: How is it possible that you tell me I. My person who has a meniscal tear that’s been diagnosed by an MRI, the entire thing is completely frayed.

Nyleen Flores: The person cannot walk, and you mean to tell me I have to send them to six weeks of therapy to make the injury worse? Put the patient in pain. Have them spend more money before you approve an MRI. Like I, I have eight patients that were just denied last week. Eight,

Shannen Aguayo: And then, and then, you know, you have some of the doctors that are employed by the insurance companies and they’re employed to look at these cases and deny them. And so, you know, I mean, that, that is, that is who’s looking at it, right? And so you have to think, you know, maybe the doctors should say, no, I don’t wanna work for your insurance company, because ultimately I wanna help people.

Shannen Aguayo: You know? ’cause

Erik Sunset: Well to that, to that point in this orthopedic, um, example that Nile painted for us, the odds are it’s not an orthopedist reviewing that case.

Shannen Aguayo: exactly.[00:34:00]

Erik Sunset: Could be an

Shannen Aguayo: It’s not because it would be too much money to pay one.

Erik Sunset: Well, and we, we love our, we love our retina docs, but you know, last time they were reviewed, an orthopedic case was in medical school.

Shannen Aguayo: and I, I think some, unfortunately, some people will say anything, you know, for if the dollar is great enough. I’m sorry, but I do feel like that.

Erik Sunset: That’s true that, that, that seems like a pretty easy fix. You know, I’m not here to advocate for a stroke of a pen, you know, law fixing things when the market maybe should do a better job of fixing it itself. But this seems like a really easy one just to go, you know what, if it’s this type of a case, then I need this type of doctor reviewing it,

Shannen Aguayo: it exactly.

Nyleen Flores: And in TikTok and in Instagram, there’s these great doctors that I absolutely love to follow because they’re bringing it out to light and they are

Nyleen Flores: physicians who are absolutely trying to help patients.

Nyleen Flores: And the, the one particular breast surgeon, she breaks my heart because she is literally crying on

Nyleen Flores: there.

Nyleen Flores: She’s like, my patient has cancer,

Nyleen Flores: my patient [00:35:00] needs a

Shannen Aguayo: And we were just denied and taken outta

Nyleen Flores: We were just denied. She’s like, I’m, I’m literally have the knife in my hand. And they

Nyleen Flores: pulled me out because United decided to, to not approve the surgery

Shannen Aguayo: Or the surgery ran too long.

Nyleen Flores: or the surgery ran too long.

Nyleen Flores: I mean, that is, the doctors are not allowed to practice medicine

Shannen Aguayo: Yeah, at that. At that point. At that point, it is not medicine that is being practiced. Yeah. There’s no love. There’s no compassion, and they’re taking all of those things out of it, you know, and it’s all becoming about money, and unfortunately, that’s why the medical staff professionals are so important.

Shannen Aguayo: Because they keep the human side of it in and they are the ones that are the gatekeepers of patient safety, and they’re the ones that say, look, this doctor just came out. They haven’t done, but one case, I have the case logs right here. I cannot grant privileges because the bylaws don’t allow me to. And holding that firm and not saying, yeah, let’s just do it, you know?

Nyleen Flores: Yeah, I.

Erik Sunset: Well, Shana, [00:36:00] the, the example you just brought up that the procedure was gonna be too long. I, I think that’s, if we’re matching up on the headlines here, it wasn’t, it was that the anesthesia portion, they wouldn’t approve the anesthesia for the full duration of the surgery. So it’s like you can anesthesia for a third of your procedure, like, no, I need it for 110% of my procedure.

Shannen Aguayo: exactly. Does that even make sense? Yeah.

Nyleen Flores: It actually passed into state senate after the uproar. It was taken back, but the fact that it even got through some states was abominable.

Shannen Aguayo: But again, that’s the transparency now, right? Where a doctor didn’t have that available to step on TikTok and say, look what is happening in real life, in real time. And I think, again, you know, that’s what Credentialing Chronicles is doing is like we wanna keep the line live about what is happening and allowing people to see.

Shannen Aguayo: They are on alert. They need to stay on alert. Patients need to be on alert. Doctors need to be on alert. MSPs need to be on alert because there are people out there trying to do bad things.[00:37:00]

Nyleen Flores: Yeah,

Shannen Aguayo: Thank you, Nelly.

Erik Sunset: just wanted to let that breathe a little bit because there, there are certainly folks out not for the, the best interest of the patient, but for, in my experience, for the most part, providers are doctors are out and certain there’s, there’s some bad apples, some bad apples

Shannen Aguayo: It, it, it’s, it’s 230 files. Good, great. Amazing doctors. And the 231st file is, is somebody with 99 sanctions.

Erik Sunset: Right.

Shannen Aguayo: So, no, it, it’s not. We’re, we’re not, you know, we, Nyleen always says this, we always say we love doctors, APRNs, PAs, you know, we need them. You know, they are amazing healers, heroes. But on the other hand, we need to protect the good ones because if we allow bad people in there to just run amuck and not be identified and say, look for these signs and not learn from our mistakes, then we’re not [00:38:00] protecting the good doctors either.

Erik Sunset: Sure this, this is, get flashing back to our, our last topic just a little bit. Um, two years ago, uh, around January timeframe, there is this really long Twitter thread posted around the, that this is healthcare’s top deck of the sinking Titanic moment. This is when things like chat GPT were fairly new or becoming more prominent, and the thesis was.

Erik Sunset: That the traditional pay for insurance, whether you get it from your employer, whether you get it yourself, that this model was going to go away because there is this parallel world starting where it’s all cash for service regardless of what it is, you know, simple primary care visit that already kind of happens, right?

Erik Sunset: With, uh, MinuteClinics and your walk-in type places. I, I see you going, gimme just a

Shannen Aguayo: The online.

Erik Sunset: But the, the, the issue with, in this thesis that I saw was that you cannot have an LLM like chat, GPT [00:39:00] or clot or pick whichever one you like. You know, intaking a bunch of patient information, spitting out a diagnosis and having a physician sitting at his desk stamping prescriptions or approving orders to do the next, uh, piece of care or whatever.

Erik Sunset: But with how little the average healthcare consumer gets from their insurance. I think it’s be gonna become more of a reality, at least in parts, uh, in the near term than, uh, than maybe I initially thought seeing this thesis. So do you have any thoughts on that?

Nyleen Flores: Well, I am. Providing healthcare setting, um, in that providing healthcare setting every day. And AI is enormously assisting physicians to the point that you allow it to, it can take over. Uh, I get reached out to by a lot of AI companies that are looking to fully [00:40:00] automate. There are EHR systems that use AI robots to quote unquote screen the documentation and automatically provide an ENM, or it’s called an evaluation management level of service that was provided to the patient.

Nyleen Flores: And then in turn, the insurance companies are using their robots to. Screen and they’ll say, this provider submitted this many level four claims. Oh, we’re gonna deny 50% of them because we say it’s not enough. So I have had multiple claims denied by a robot because obviously all the criteria is met. Um, but the robot decided that we did not meet the level of service, and so they asked me to resubmit a claim with a lower level of service. Insurance company robot did that. So AI is already real and it’s already being used in healthcare to adversely [00:41:00] affect the physician, which leads to disgruntled physicians and obviously a continued ongoing loss of revenue. So that being said, we use a AI uh, robot now currently with our current software. And what it does is. It turns on when the physician walks into the room and it listens to the conversation. What I will tell you, it’s really good because it documents what the patient said and it transcribes it. It will put it to where it goes into the system. It’s not flawless. Some words with. Certain accents are not interpreted and typed in correctly, so they do have to be reviewed. But it’s extremely helpful in streamlining the documentation, um, into the EHR. So it’s what you said, just a little bit. The doctor is walking in and actually seeing the patient and it’s documenting it, [00:42:00] the feedback from the physician. Is that it is extremely helpful and it’s a lot cheaper than hiring a scribe because a scribe, you have to pay hourly benefits and you hourly wage and, and benefits and stuff like that. So it replaces the need for a scribe to walk and, you know, shadow a doctor into the room and it allows the physician to, uh, talk to the patient instead of the computer. So it allows them to examine the patient. So the what we can assist it also helps is when the medical assistant goes in there, the robot turns on and the assistant is go, the medical assistant will go and says, okay, can you tell me how many surgeries have you had?

Nyleen Flores: And then they’ll go in and my gallbladder removed. I had my knee surgery, I had my shoulder done, I had my adenoids removed, and then the robot will. Type it into the surgery history and you just have to move it into that. So that is extremely helpful because you do have to meet certain qualifications to meet the level of service, even though,

Nyleen Flores: so I wouldn’t [00:43:00] say it’s all bad.

Nyleen Flores: It it is good, but it does require a human. I’m against automatic coding currently.

Erik Sunset: Uh, I’m with you, and as a quick aside, and Shannen, I’ll turn it over to you here in a second. I know we’re getting close to the end of our time together, but what you just said about the auto denial, like, oh, this guy just, he can’t have this many level four visits, even if the documentation bears it out.

Erik Sunset: Even if in the contract, this is what we define a level four visit as.

Nyleen Flores: They will.

Erik Sunset: And this prior death of the show. Also an orthopedic surgeon, a lot of lot of folks to treat here in Miami for their knees and hips and, and elbows. He turned to an LLM to produce really succinct documentation summaries to go, here’s where your contract says this is a level four.

Erik Sunset: Here’s my documentation that matches right up with what you sent me. Here is a source from a medical book and. You’re paying it baby. Or you could talk to my lawyer. Period. So I thought that was pretty, yeah. Oh yeah. That he, he has less [00:44:00] problems with that payer after, you know, the barrage of LLM

Shannen Aguayo: but that’s what I think, right? When you ask me, that’s what I think, I think that AI is as useful as it can be, but you always need a human there to kind of check, because I can’t even use tech talk to text without it telling, you know, I, I just, the most craziest, bizarre story to my daughter. And I’m like, I swear that’s not what I said.

Shannen Aguayo: You know? So, I mean, and, and you know, I percent, I have. Full confidence in that talk to text because I talk very clearly. But the story that they have now transcribed to my daughter is just crazy. And so I’m like, okay. Um, yeah, if, if talks to texts cannot be at at a hundred percent workable, I, I’m not gonna trust it, you know, in credentialing, in compliance, you know.

Shannen Aguayo: But yes, it is a great tool, you know, a medical. Staff person needs to know what exactly is the standard for privileges for orthopedic surgeon. Yes. Use chat TTP and then look it up and see what [00:45:00] they say and verify it with two or three other sources. And yes, you might. Be able to get these privileges approved through your committee.

Shannen Aguayo: Um, ’cause you did a great job and you use that as a resource. But I think actually depending upon that, um, like the web crawlers and things that you see in credentialing, you know, um, I, you know, I, we have clients that trust these big software companies and everything that they say and they leave them and come to us and say.

Shannen Aguayo: They weren’t able to do everything that they said, and I, and I think it’s just better if we have a team like yours that can do it. And so I’m like, yes, let’s do that. You know? And so I just think that it is very useful, but I think that it does not omit humans from the process.

Erik Sunset: No, I mean, it’s a, it’s a very much an in-person practice of medicine. Uh, just a close the loop on that top deck of the Titanic moment. I, I thought a lot of it was, um.

Shannen Aguayo: I.

Erik Sunset: Really hopeful, um, and hopeful in a way that maybe there’d be a lot less lawyers practicing in the medical field as well, [00:46:00] and a

Shannen Aguayo: No, definitely not. There’s more.

Erik Sunset: that isn’t gonna go away.

Erik Sunset: And probably for some good reason too. You know, love, love all

Shannen Aguayo: Yeah. Yeah.

Erik Sunset: Not there. But the other half of that though is that because patients get so little from their private insurance now, maybe there will be a new bloom of more concierge medicine specialties, cash pay surgeries, which you need, would, would need the surgery center to accommodate as opposed to hoping to book your own room at the hospital for your left total knee, which hate to come out of pocket for

Shannen Aguayo: Well, the, the, the people you know now are, are, are really even considering should I get my medical treatment done in the United States, or should I go to Turkey or Dubai, or what do they call it, medical traveling. You know, that, that is like literally a term now. And so that’s kind of scary too. Um, when United States used to produce the best doctors.

Shannen Aguayo: And so, you know, it’s just things like that that, you know. We have to think about like we outsourced everything to China now. Everything’s [00:47:00] made in China now people are mad. You know, now like we’re like, we can’t even make cars anymore. And it’s like, we can’t do that to medicine with these patients’ lives, you know?

Shannen Aguayo: And then just say, oh sorry, there was things that went wrong. Um, because you know, being in credentialing, I will always advocate for patients.

Erik Sunset: Love that. Well ladies, let’s let the listeners know where they can get more of you. How can somebody listen to credentialing Chronicles?

Shannen Aguayo: Do it. Nile. You do. I love listening to you.

Nyleen Flores: Credentialing Chronicles. It’s now available on all your podcasting platforms available on Apple, Spotify, Amazon, um, YouTube or videos are, are the video audio not on video just yet? Working on that? Um. Subscribe and follow, uh, our website. They can also just log onto our website, credentialing chronicles.com episodes are [00:48:00] posted right on there as well. As well as all of our teasers, all of the releases we publish every Tuesday

Nyleen Flores: at midnight and so available for all. We love to hear you. We have so much more to discuss and I we’re having a blast

Shannen Aguayo: Yeah, and I think we started with doctors, you know, we had to start with the, the good gossip. Um, but we’re, you know, we’re going more into giving some accreditation, gossip, some facility gossip. Surgery center gossip. I mean, Nyleen has pages and pages of surgery center gossip. Um, and so, you know, we, we we’re trying to get into, um, more every area of healthcare and not just kind of focusing on doctors because we don’t, you know, we’re.

Shannen Aguayo: I think we’re what, 13 episodes in right now as as far as our recording, and they’re all about either dentists, doctors, nurse practitioners, and so I’m like, I think we need to start talking about some facilities and the things that they do, [00:49:00] so it’s gonna be everybody. We got a lot of gossip.

Erik Sunset: Uh, well, I, I hope I can, uh, get an invite. I’ve got a couple, maybe, maybe a little bit of tea, maybe not as hot as your tea, but being a door-to-door medical software sales guy, once upon a time, had some interactions. I won’t forget anytime soon. I’ll leave it at that.

Shannen Aguayo: Don’t play with

Erik Sunset: invite.

Shannen Aguayo: because if we bring you on, you gotta start spilling.

Nyleen Flores: Yes, yes.

Shannen Aguayo: Okay?

Erik Sunset: so.

Shannen Aguayo: Yes.

Nyleen Flores: Thank you so

Nyleen Flores: much, Erik.

Shannen Aguayo: Thank

Erik Sunset: want to thank you both my and Shannen.

Shannen Aguayo: you guys so much for supporting us.

Erik Sunset: This has been a riot and you’ve got a standing invite to come back obviously, and for our listeners, we want to thank you for listening. On behalf of the entire DocBuddy team, be sure you’re subscribed to both Credentialing Chronicles and the DocBuddy Journal on Apple Pods, Spotify and YouTube.

Erik Sunset: So you always get the newest episodes of the show. Until next time, I’m your host, [00:50:00] Erik. We’ll talk to you soon.