Season 1: Episode 10 – Telemedicine: How Health Insurance Providers Block Innovation

Dear Healthcare It’s You: Episode 10

Elisha Yaghmai

To get places to pilot it where it works. It works beautifully. It does exactly what you would want. Right. We are helping people. We're saving lives. We're making diagnoses that were previously being missed. Yeah, we even got a place to partner with us on the inpatient side. Remember I said we were kind of blocked by Medicare? We figured out a way to work around that problem.

Elisha Yaghmai

Right. Okay. Got somebody to partner with us to pilot that. So we're doing virtual hospital care.

Jo O’Hanlon

Right?

Elisha Yaghmai

Even rural hospital.

Jo O’Hanlon

Not all the.

Elisha Yaghmai

Restrictions. Yes. With all of those restrictions in place, we figured out all of it. Right. Okay. And we're doing it. And it is working. It's working exactly as we wanted to work. And yet we're thoroughly blocked by the guardians of the system, which is the insurance companies for various reasons that they had. And not only just not just blocked, but can't even get to the table to have a discussion about what is the problem and how do we reach an accommodation.

Jo O’Hanlon

Welcome back to your health care. It's you. Welcome back to our podcast, Dear Health Care. It's you. This is Dr. Elijah York, my and my co-host. And I'm Joe O'Hanlon. Thanks for being here, Elijah, we left off talking about you thought you'd solve the accessibility issue of health care until insurance wouldn't pay. So let's pick up there with you had all the technology that you needed at a price point that was totally accessible for rural hospitals and what happened?

Elisha Yaghmai

So then we made the mistake of trying to deal with it in a straightforward, straightforward manner. So we had, like we talked about last time, we had a technology package. Yeah, we had tested it out. We knew that it worked. We knew that it would give us the information that we needed for a medical professional standpoint to do our job properly.

Elisha Yaghmai

So then we went and we looked. We were thinking about starting at that point in the state of Kansas, because that was a state that I knew well.

Jo O’Hanlon

And were you still living in Seattle? I was still.

Elisha Yaghmai

Living in Seattle at that point, yeah. And so basically then I actually went and polled the stated published policies for all of these different insurance companies that were that had market share in Kansas. So of course there was Medicare and there was Medicaid called Care in Kansas. And then there were multiple other private insurance companies. Right. That were here as well.

Elisha Yaghmai

All the usual ones that people know for the most part, right? So I went and researched and pulled all of their payment policies. Right. And then I set up a pro forma for how all of that would work. I went through that multiple times, right? So it was all based on published stated policies. Okay. So we then.

Jo O’Hanlon

Can I asked, do they already have explicit policy? They actually terminology.

Elisha Yaghmai

Well, some, some had none. So Medicare didn't have much like when I first called the Mac that kind of manages payment for the region. For example, they didn't know what telemedicine was and there were no there were there was not a medicare fee schedule for telemedicine at the point that I contacted them that actually was published within less than 12 months, might have been less than six months later they published one, but so there were no published fees for Medicare, which is a big deal because they're a large insurer.

Elisha Yaghmai

And then the others, you know, again, kind of like I mentioned, telemedicine was such a limited application, right? They had a few policies. They were very restrictive in terms of what they would allow. But we researched them and we read all the policies and knew the ins and outs and then decided to go forward based on the understanding that we had.

Jo O’Hanlon

Yeah. So this was in 2014.

Elisha Yaghmai

This was in 2014 and.

Jo O’Hanlon

15.

Elisha Yaghmai

Yeah, around that time. We also of course went out and talked to rural hospitals, rural communities to see is there any interest on that side. Right. And there was.

Jo O’Hanlon

Right.

Elisha Yaghmai

There. Again, a lot of folks at that point didn't really know what telemedicine was. Right. Understand how it could work. So there's a lot of explaining going on just in terms of what even what is this and how do you even do it. Right. Right. Well, once we got past that, people got those concepts, then it became the process of trying to implement.

Elisha Yaghmai

So we went to the insurance companies initially and said, well, you have to change the policy. So we're here and we'd like to do telemedicine work in these underserved communities in Kansas.

Jo O’Hanlon

And at the time you were already offering them basically the technology package for free.

Elisha Yaghmai

For free, Yeah, yeah. We had said this. This cost is so low that we're just going to give you the tech. We're not charging for it. We just want to give it to you because we just want to see this thing happen. You just want to see what will happen when we roll all this additional medical service and expertise into these rural areas.

Elisha Yaghmai

So I'd done I'd done the research on that, on the payment structures, right? So I had these performers that I'd set up. I did multiple of these. Right. That calculated, okay, what's what's the typical payment we can expect? How many people are there in rural Kansas? You know, based on that, what are the estimates of how many of different types of specialties they would need?

Elisha Yaghmai

Right. Yeah. So I had all of this and figured, okay, we're going to have this many patients approximately to start really low numbers and we'll have really conservative growth over X amount of time. Yeah, all this was was laid out and the way that it worked was if we had just been able to implement it, it would have paid for the technology by itself because the price of the technology was so low.

Elisha Yaghmai

Right? So we were like, this is just common consumer electronics, right? So let's just give.

Jo O’Hanlon

It to small investment. And at the beginning for you guys.

Elisha Yaghmai

Exactly. Yeah, I was like, Let's just stand this up and you'll pay for it on us, right? Mail it out to you. You set it up and we will bring you all of these different specialties, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And in the part of Here's the thing. So then I went to all my doctor connections, right? And started just recruiting in people that I'd met over the course of my medical life. Up to that point, we had lots of insurance or lots of people that wanted to help in these rural communities, right? So when we started me at 25 specialties, so we went through the expense and time of getting people licensed and training accordingly.

Elisha Yaghmai

So then we go as part of this process, as we're doing all of that, on one side, we go to the insurance companies and say, okay, we're here and we'd like to do telemedicine service. And we either got absolute silence or our applications in some cases were literally thrown away. So application for credentialing, credentialing for those that don't know means you can't just well, you can send an insurance company a bill, right?

Elisha Yaghmai

If you're not on their pay on their provider panel.

Jo O’Hanlon

Right.

Elisha Yaghmai

But they're not necessarily obligated to pay it. Right. So in other words, if I am so called out-of-network, where the out-of-network thing has gotten more infamous recently. Right. Have network charges, If I am out of network, I can send the insurance company a bill, but they may or may not choose to pay that bill. If I'm on their provider panel and I've met their criteria to be paid, in theory, they're supposed to pay me for this, right?

Elisha Yaghmai

So that's the safest course. If you want to be reimbursed for your service from an insurance company is to apply for credentialing to be on their provider panel.

Jo O’Hanlon

Gotcha. That's the same as being like a preferred provider.

Elisha Yaghmai

Exactly. Yeah. It's exactly. You're in their network now. They recognize your existence, right? And they're willing to pay you. There's a contract that's been signed between you, right? So this is what we were trying to do, which if we had been in-person providers, generally speaking, at least in our state, wouldn't have been a problem. Right? You just show.

Jo O’Hanlon

Up and show.

Elisha Yaghmai

Them your certifications and your qualifications and you typically you're going to get on the panel, right? because our state already has a relatively small number of doctors. Right. Relative to the population. So that was how that that was how that was. We show up and say we want to do virtual work and we got completely iced out.

Elisha Yaghmai

So like I said, applications in various places were in some cases thrown away. And I got my this was actually an insurance company rep. So I contacted them six months later, say, hey, you know what? Yeah, it's going on. They're like, we tossed that. We didn't we didn't think it was anything we needed to deal with, right?

Elisha Yaghmai

Or we were told, Sorry, Yeah, that's not a thing we want to do. So just.

Jo O’Hanlon

Because it was too new or they like no bleeding edge, we got.

Elisha Yaghmai

We had a lot of trouble getting anyone to talk to us, frankly, in honest terms. Right. But what we glean from those representatives that would speak to us from very this is from multiple different companies. Right. Over the years trying to get conversations going was that they were worried about they were worried about what they called excess utilization.

Jo O’Hanlon

Okay.

Elisha Yaghmai

So here again, you think about the irony of this, right? So the reality for many people living in rural areas is that for years you're paying a full insurance premium, but you can't get all the services.

Jo O’Hanlon

Because there's nobody in town to do them.

Elisha Yaghmai

There's no one to do them, Right. Yeah. So so in other words, you're paying a premium. And so in other words, if you let's say you live in a small town and you want to see the neurologist, right? Okay. Well, you have two choices. You can drive. You can wait nine months and drive 4 hours. One way, just go just right.

Elisha Yaghmai

Or you can just not go right. Well.

Jo O’Hanlon

Is that what you feel like? the data shows most people are frequently. Yeah.

Elisha Yaghmai

I mean, people would just not go right. Because again, imagine you have all kinds of people, right? So some people, you know, living out there are going to be pretty wealthy and they're like, yeah, you know what? I can take the day off work. I need to go see my doctor or whatever the case is. But other people are working an hourly job, right?

Elisha Yaghmai

Yeah. I don't have this going to take me all day and a tank of gas on top of that or two. Right, Right. And then I.

Jo O’Hanlon

Need a car.

Elisha Yaghmai

Or all this other stuff. I get it. I could arrange all these things. Right? So just imagine if you don't have a lot of discretionary income and you're living in a rural area, you're effectively not going to get that care. Right. And there are tons of people that we encountered in the early days of this. This is exactly what's going on right there, either never been never been diagnosed with something they should have been diagnosed with or they had been diagnosed with it, but they weren't being properly managed because they couldn't access the people with the expertise to do this.

Jo O’Hanlon

Yeah, right.

Elisha Yaghmai

And this was at every level. This wasn't just at the specialty care level. This was at every level in the hospital. General care, you name it, all these kinds of things were going on, right? So, these folks were paying full premiums, but they were not really able to utilize the full service as they would have been if they were living in the city.

Elisha Yaghmai

Yeah. Which had everything.

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

So the insurance companies initial concern was increased utilization. If you make it easy to access, then all of these folks are going to then start to access it and then they're going to we're going to start to see more bills. That was one concern. A second concern, which I think you know, has some legitimacy. And it was concerned about fraud.

Elisha Yaghmai

Right. Okay. If we open up this concept of virtual care, okay, then how do we validate there's already fraud in the existing system, Right? There are doctors there, Doctor. There's insurance fraud, right? There are doctors that will bill for services they never performed. Right. We know this is a thing that happens right there, Doctor. The bill for services.

Elisha Yaghmai

So their worry was if we open it up to virtual care, what are some doctor comes to us and says, you know, I saw 100 people a day. I did it all virtually right. You can't prove I didn't. So therefore you need to pay me for all this work that I did. Right. And their problem was, well, we don't have an easy way to vet whether that happened.

Elisha Yaghmai

So therefore, we don't necessarily want to be on the hook to pay for it when someone could fraudulently exploit it. Right.

Jo O’Hanlon

Gotcha.

Elisha Yaghmai

Now, from our perspective, we're looking at this and saying, number one, that's not the way we were planning to operate. Obviously, we're trying to actually help patients. But beyond that, we looked at and said, look, this is such a tiny percentage of all the care that goes on. We don't think this, like most people in medicine, weren't even thinking about this, much less doing it right.

Elisha Yaghmai

So we don't think this is going to be a huge issue, at least not at this stage of it. But even if it was bear in mind, you know, folks, there's a video call, right? So there's any data off that there might be the call itself. Right? There is data to validate this.

Jo O’Hanlon

Plus, you would have whatever records and.

Elisha Yaghmai

Exactly you'd have to have things like it would be no different than at the bare minimum. Right. In other words, let's take a fraudulent counter. A doctor, if a patient walks into an office. Right. How does the insurance decide whether an encounter took place? Generally, they look at the note right? Right.

Jo O’Hanlon

They're taking the doctor's life. There's more proof with and.

Elisha Yaghmai

Ironically.

Jo O’Hanlon

Than person.

Elisha Yaghmai

Because you're not necessarily having to rely on just my word that this person saw me. Right. You actually have some sort of digital data, right? Or at least you call it, or the digital data that says, yeah, some exchange went on and it took place for this amount of time. Right? But we couldn't get we couldn't even get as far as discussing this.

Elisha Yaghmai

It was just we don't do telemedicine. Right. And, and therefore we're not going to allow you we're not gonna let you on our payer panel, right? So then we said, All right, because some of us already.

Jo O’Hanlon

Even state was that true even of the ones that have since a prescriptive text about telemedicine in their policy?

Elisha Yaghmai

yeah. Yeah. We went and checked off all the boxes. Yeah. And we said, okay, we've met every criteria you have, every have listed, please credential us so we can start the service. No, we're not doing it. So we're here having met all this stuff, have all these doctors ready to go, Right? Everything else is kind of ready.

Elisha Yaghmai

We're out there trying to see patients and we are trying to get paid and we can't get paid for our work. So.

Jo O’Hanlon

So the hospitals weren't even able to just because it sounded like they were going to be spending so much less on that service versus what they would have had to do otherwise, where they were going to lose money from bringing in an outside doctor.

Elisha Yaghmai

Well, so that they're two different two different pieces. This so we the initial concept that we had had about bringing in doctors to kind of spell the generalists, meaning the people doing the hospital e.R. Care the people that that plan got stymied by medicare.

Jo O’Hanlon

Elisha Yaghmai

The reason it got stymied is because medicare had written into their rules at that time that the telemedicine physician could not be the admitting or attending physician. so what that meant was just take, for example, let's remember the original goal was you got a doctor out in rural Kansas, right? And they're getting call 24 seven 365. Right.

Elisha Yaghmai

So, they burnout. This is what is a known thing. They burn out. They get tired after so many years, many of them move away and the community has to start over again. Right. So our thought was we're going to come in and we're going to do your nights, weekends and holidays so you can get rest. Yeah, right. You can sign out, turn off your pager, you go home.

Elisha Yaghmai

Right. And your patients are going to be taken care of. And then you come back in the morning, we'll hand it back off to you, right? Yeah. And we'll do all this for dirt cheap as compared to what you would normally have to pay to get this right. So Medicare said no, no, no, sorry. Ten Telemedicine. The telemedicine physician can't be the attending or admin.

Elisha Yaghmai

So, this was stymied at the Medicare level.

Jo O’Hanlon

So it was more like specialists that you were exactly.

Elisha Yaghmai

This is suffering. So, we went in and said, All right, we can't do this the way we thought. Yeah. So, let's try to do specialists because at least everybody knows what that is. You're consulting, right? So, we'll do outpatient specialist and we'll do some inpatient stuff, but mostly outpatient to start. This is what we'll do. So that wouldn't have necessarily cost the hospitals a lot right outside of the technology because we'd cut that down to zero.

Elisha Yaghmai

The issue was they could bring this in and potentially actually increase the revenue, right. Because now they're able to offer specialty services locally and that small town. Yeah. And use that to build revenue. Right. Because the specialists order meds and they were imaging and labs and all these other things that hospitals do and now rather than that being safe and out of the community and sent to the larger med center it could be done there.

Elisha Yaghmai

Right. Okay so we were like this can be a revenue booster for your hospital, which is having financial trouble right now in many of these communities. That was the idea. The problem was if the specialists cannot be paid for their work because they cannot build the insurance right, then how do you run it? Well, you go back to, you know, you need grant money, right?

Elisha Yaghmai

And all the things that had been going on before that had been unsustainable long term. You're back in that basket. So our thought was, this is all ridiculous, right? We why are we doing this? We have a perfectly sustainable means to do this now. We don't need to wait for grant money and look at all these hundreds of thousands of people that need this help.

Elisha Yaghmai

We can do this tomorrow.

Jo O’Hanlon

Right?

Elisha Yaghmai

So, we kept banging on the door with these insurance companies and saying, look, we please talk to us, listen to our arguments. Right. And mostly we got just silence. But occasionally we'd hear back from somebody that was basically, you know, thanks, but no thanks. We're not interested in what you have, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Over time that evolved, too. So then a couple of these companies went out and made deals with private firms like large private firms with lots of capital behind them. So we were at that point based in the state, right? They went out with other firms and so they decided to start to offer some direct to consumer.

Jo O’Hanlon

Firms are.

Elisha Yaghmai

Like just companies that had big time money behind them, like so big venture capital, one of the things like.

Jo O’Hanlon

That.

Elisha Yaghmai

So, they would contract with them to provide so-called direct to consumer services. So this was what you're talking about, right, With that, your phone, with your sore throat, somebody on the phone, they give you something for it that you may not need, but they'll give it to you. Right. That was the idea. So we went back to them and said, hey, we see that you've you wouldn't let us treat grandma with heart failure, right.

Elisha Yaghmai

But you're allowing this other company that's not from the state to come in here and treat people for their minor complaints over the phone. This doesn't seem right to us, right? Yeah.

Jo O’Hanlon

And they were covering those.

Elisha Yaghmai

Well, initially they were coming. Nothing. Yeah. Then they went to this. Well, we're going to partner, but only with our specific select entities. Right? That's all we're going to do. And that, you know, that to us seemed hypocritical, right? Because we're like, you still won't let us do regular medicine, right? Even though we're not asking you to do anything other than just pay your normal fee.

Elisha Yaghmai

That's all right. So, then we started having these roundabout discussions where they would tell us things like, Well, you see, the difference is that they do telehealth and you do telemedicine.

Jo O’Hanlon

okay, So what's the difference there?

Jo O’Hanlon

So, so this was.

Jo O’Hanlon

Their actual like.

Elisha Yaghmai

Well, so that conversation went approximately like this, I would say. Okay, so when you partner with this other service, they have a provider, your patient calls the provider over video call, they call them. They cannot really do much of an exam on them at that point because they don't usually have diagnostic equipment in the home or wherever that.

Elisha Yaghmai

Yeah, right. They can't do much of exam. They can't really order any diagnostic tests. It's just them talking to the patient. Right. And you will pay for this. The, the whole exchange takes place over the internet. You will pay for this. We can then we can do a full physical exam on the patient. We have assistance of medical professionals at the bedside.

Elisha Yaghmai

We can order any tests we want to tell in order that that takes place in a hospital. Yeah. You won't pay for us because we're on the internet, but you will pay for them who are also having a doctor see the patient. Yeah, that's right. That's because what they do is telehealth. And what you do is telemedicine. And we don't cover telemedicine.

Jo O’Hanlon

That's.

Elisha Yaghmai

That's a real conversation, right?

Jo O’Hanlon

So, they were only wanting to cover if it was literally just someone with their phone or computer and, and, and, and testing ability and.

Elisha Yaghmai

A specific firm. It wasn't like any doctor could do this, right. So, it was a it was like whatever the deal was right between these two companies from the insurance company in their preferred provider of the service. Right. Whatever that deal was. And I can't comment on what it was, but whatever that was, they were willing to do that.

Elisha Yaghmai

But they were not willing to allow doctors from within the actual state that they served. Right to do the exact same thing, except if you met these very restrictive criteria, which we did right, which they then wouldn't allow because they said, you're not credentialed with us because they would not allow us to credential with them. Basically, the the insurance companies could say we cover telemedicine.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Unfortunately, no one wants to offer telemedicine. That's why there's not more telemedicine available, which wasn't true. We very much did not. But by not credentialing anyone that wanted to offer telemedicine, you therefore don't have any telemedicine offered. So, you see the contradiction here, right? So, this was the issue. And so I will add to that a few states prior to this had passed legislation called payor parity legislation.

Jo O’Hanlon

Okay.

Elisha Yaghmai

Pay parity legislation was basically meant to say because the people that were doing this were most concerned that if they tried to offer virtual service, the insurance companies would would would cut down the reimbursement amount because they would say it's costing you less to provide virtual service, but you don't have to maintain a big building.

Jo O’Hanlon

Staff, right?

Elisha Yaghmai

So, we're going to pay you less.

Jo O’Hanlon

So as far as the doctors fees work.

Elisha Yaghmai

Exactly right. So let's say let's say the doctor normally can do this service and code bill a certain code and get it right. They were worried that insurance was going to come through and say, well, sorry, your cost to provide the service is lower, so we're only going to pay you $80. Right. Rather than 70 zip rather than $100.

Jo O’Hanlon

Right. Even though the doctor is not the one that would be often like paying for that cost of service, be in a hospital anyway, What.

Elisha Yaghmai

Would be the insurance? Well, I'm oversimplifying it to some degree, but the idea the idea was the insurance company theoretically could say that since the cost to provide virtual service is lower than the cost to provide in-person service for a variety of reasons, we're going to pay you less per encounter than.

Jo O’Hanlon

We would, right? Yeah.

Elisha Yaghmai

So? So, a few states, Very few. And New Mexico is one of them. Actually. It's one of the reasons why we went to New Mexico in the early stages have enacted pay or parity.

Jo O’Hanlon

Right. Okay.

Elisha Yaghmai

So, the insurance companies there got around it by simply not credentialing anyone that wanted to do telemedicine. Right. So, they would go. So, sure, we have we have payor parity, right? look, you know, no one's billing us for telemedicine. Go figure. Right. Well, no one was billing because they wouldn't allow me. I wanted their panel that wanted to do telemedicine.

Elisha Yaghmai

Right. Because again, the majority of doctors were still firmly entrenched in doing regular in-person medicine. Right. So they weren't thinking about virtual every day. Right.

Jo O’Hanlon

So that's something that changed in the laws in these couple of states. Or was that I didn't.

Elisha Yaghmai

Know that they had passed they had passed laws in their states to say there's this payor parity.

Jo O’Hanlon

Right. Okay.

Elisha Yaghmai

So, so we went on we we saw that and we learned from that, Right? Yeah. Okay. So, they can say there's payor parity, but basically they just play the game of not credentialing. Yeah. Right. And then you can't get in and then therefore no service can be offered. Right. So, so we tried a few things. We first went and said there was, there's a tradition of where one one party can bill for another party.

Jo O’Hanlon

Okay.

Elisha Yaghmai

And insurance. So in other words, let's say let's say I'm a hospital and you're a doctor, you could come and say, I'm going to assign my billing to you.

Jo O’Hanlon

Okay.

Elisha Yaghmai

So, that you hospital can bill on my behalf. So, when I see five patients, I don't submit the bill to the insurance for the five patients. You submit the bill on my behalf, right? You call it. You go through the work of collecting that money, and then you give me a piece of it. Right. Okay. This is a longstanding tradition in American health care, right?

Elisha Yaghmai

Yeah. So, we went to the hospitals and said, can we assign our billing to you? Right. You're an established, impersonal entity. They already know you. You're already on the panel. If we came to work for you in an in-person locum tenens basis. Right, you would do this.

Jo O’Hanlon

Look.

Elisha Yaghmai

Locum tenens. Is that that temporary doctor? yes, that is right. So, temperature to productivity. So, if we had come to do this or even if we'd come to work for you full time traditionally, right, we would assign our billing to you. Right. You would fill it out and then you would pay us our salary or whatever rate is, right?

Elisha Yaghmai

So, we were like, perfect. We do virtual service. It's the same basic idea, right? You just pay us an hourly rate or whatever and we'll assign or billing to you.

Jo O’Hanlon

Right? Okay.

Elisha Yaghmai

The insurance companies went to them and said, Sorry, you can do that. You can do that. Reassigned to billing for everything except for telemedicine. That's the one thing we will not allow you to do that.

Jo O’Hanlon

So, they were already a preferred like service on there already there are there are any in on that.

Elisha Yaghmai

Already in Right. So, we thought we could end around it by having the people that are already in Bill for us. They blocked it by saying if it's virtual that you're trying to vote for, nope, sorry, can't do it. Right.

Jo O’Hanlon

So.

Jo O’Hanlon

So, how did that not go against the payer party law?

Elisha Yaghmai

Well, because Kansas didn't have one. That's Kansas didn't have one. Right. And in New Mexico, where they did have that right, they just wouldn't process your credentialing application.

Jo O’Hanlon

You were already like your did you try that to have a good idea?

Elisha Yaghmai

We tried. So we tried in Kansas to tried in Mexico and in both places, effectively again, except for the one insurer. Yeah, we just got blocked every time you just either no response or a rejection of our application. This is how this went, right. So and then to add so to further the irony, right in this era when everyone's worried about spiraling health care costs, Yeah, one of the very first things we did was go to them and say our carrying costs to provide this service is lower.

Elisha Yaghmai

We don't need to maintain a big hospital or a big clinic.

Jo O’Hanlon

Yeah, we're.

Elisha Yaghmai

Working out of our home office or whatever it is. We're working out of a much, much more cost effective structure. We don't need all the staff, Right?

Jo O’Hanlon

Right.

Elisha Yaghmai

So, we are happy to take a lower payment. You can pay us less per visit. We will take a lower payment. We offered them discounts, right? We were like, we'll be we'll do this in perpetuity. Well, we're not worried about how much you pay us. Just let us do it. Just let us do this because there are people that need this help.

Elisha Yaghmai

Well, so give us a pay cut. We're happy with that. Let us do it.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Nonstarter. Nothing. Nothing would go couldn't. Couldn't get any movement on any of this stuff. Right. So so so I mean, you have to you have to appreciate this was three and a half years of this So so multiple things are happening at the same time. We from our perspective, we fix the tech problem right? We fix tech problem.

Elisha Yaghmai

We got places to pilot it with us before when we thought the insurance credential would be coming through. Right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

We get places to pilot it where it works. It works beautifully. It does exactly what you would want. Right? We are helping people. We're saving lives. We're making diagnoses that were previously being missed. Yeah, we even got a place to partner with us on the inpatient side. Remember I said we were kind of blocked by Medicare? We figured out a way to work around that problem.

Elisha Yaghmai

Right? Got somebody to partner with us to pilot that. So we're doing virtual hospital care, right? Even for a hospital.

Jo O’Hanlon

With all the.

Elisha Yaghmai

Restrictions? Yes. With all of those restrictions in place, we figured out all of it. Right. Okay. And we're doing it. And it is working. It's working exactly as we would want it to work. And yet we're thoroughly blocked by the guardians of the system, which is the insurance companies. Right. For various reasons that they had. And not only just not just blocked, but can't even get to the table to have a discussion about what is the problem and how do we reach an accommodation right around this.

Elisha Yaghmai

So this is.

Jo O’Hanlon

At this point, like how many hospitals have you piloted with?

Elisha Yaghmai

We had 35 hospitals, I think at our initial peak.

Jo O’Hanlon

Where they're billing departments like kind of on your behalf as well. You know, we floated this.

Elisha Yaghmai

We floated this ourselves. Yeah, it was it was it was from a business perspective, it was a miserable experience because we were paying people with the expectation that at some point you.

Jo O’Hanlon

Pay.

Elisha Yaghmai

And just keep getting blocked and blocked and blocked and blocked a block so we can't actually get much payment back.

Jo O’Hanlon

Wow.

Elisha Yaghmai

So here again, we start out and we said, all right, well, at least we have Medicare, right? There's lots of folks on Medicare in rural areas, Right? So we'll at least start doing what we can do and we'll build that up. So we hired a third party billing entity, which a lot of medical practices do. We didn't know anything about billing it that.

Elisha Yaghmai

Yeah, right. We hired a third party billing and we made almost nothing because they couldn't figure out how to bill properly. They couldn't figure out how to build Medicare properly. Right.

Jo O’Hanlon

Because it was a whole different.

Elisha Yaghmai

System because it was a completely reverse system had to do with where the provider was located. It was some technicalities of it, but the point is that Medicare system for that was the complete opposite of everything else that they did. So these folks come in doing things the normal way. Yeah, all the claims are being rejected because they're being filed the wrong way from Medicare's perspective.

Jo O’Hanlon

Okay.

Elisha Yaghmai

Well, this was early days, right? This entity didn't know that. We obviously didn't. Yeah, right. And so they just kept sending us back claims saying, sorry, you're being denied. Sorry, being denied, sorry, being denied. Right. So we're making no money from anyone that we're billing here. Meanwhile, we're still trying to pay the docs, right? Yeah, but they're doing so.

Elisha Yaghmai

This was this.

Jo O’Hanlon

Was how many doctors, all those doctors that you had already collected, they were all working.

Elisha Yaghmai

Now, many of them were. Or at least they were offering time, right? Yeah. The problem. So then the problem was as as patients began to realize, well, this is not we weren't billing the patients, actually, we were just eating it because we did. We didn't. We thought we still could get paid from insurance by following the rules, right?

Elisha Yaghmai

Yeah. So, we're following the rules and just keep getting rejection, rejection, rejection, rejection, rejection. So, as it became more clear that insurance was not going to cooperate, and then everything was really quite difficult to do right then a lot of primary primary care doctors, rural patients were like, Well, we don't want to do this because we don't wanna take the risk, right?

Elisha Yaghmai

That insurance won't pay this. And then we'll be on the hook for the bill.

Jo O’Hanlon

Right? Right.

Elisha Yaghmai

That was their perspective on it. Yeah. So the utilization was relatively low because of these fears.

Jo O’Hanlon

Right?

Elisha Yaghmai

So, we did this for three and a half years worth of time.

Jo O’Hanlon

Wow. Yeah.

Elisha Yaghmai

Pushing and pushing and pushing. I've often use the analogy it would be akin to developing a cure for a specific type of cancer and then having insurance tell you, I'm not paying for that.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And you try the cure and you're like, well, this works. But insurance like sorry, you know, I'm not I'm not going to reimburse you for it, Do you? What do you do? Right. Because this was our this was our conundrum, right? From a business perspective. Right. It helps you again, remember, like we talked about before in general in American health care, if insurance won't pay for it, nobody does it right.

Elisha Yaghmai

It doesn't matter whether it's the right thing to do. It doesn't matter whether it's helpful. Yeah, no one will do it if the reimbursement isn't there. Yeah. So we had done things the exact opposite way. We went and found a solution to a problem and then tried to get payment for it. And then we suddenly found out we can't get paid.

Elisha Yaghmai

So, our problem was that while we were also doing all those piloting activities and everything else right. That's going on, we're realizing this works like this works, this does solve access problems. This improves the quality of the care that can be offered, right? This reduced costs, this increases revenue for the real hospitals. This does all kinds of positive things.

Elisha Yaghmai

Now you're telling us that you want to pay for it, right? What do we do? Because our choice was we all shelve this thing that we've discovered, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And go home and just be so frustrating.

Jo O’Hanlon

And unfortunately.

Elisha Yaghmai

It would be right. But that's the that's the business way to do that, Right? This was our, you know, our conundrum. So it was do we shelve all this and say, sorry, it's just not the right time, We're just too early to market it right in the in the use entrepreneurs speak. We're just too early to the market.

Elisha Yaghmai

Right.

Jo O’Hanlon

Right.

Elisha Yaghmai

Or do we keep going? Our decision at that point whether it was smart or stupid is up for debate. Right? But our decision at that point was to keep going, right? So it was so we just kept pushing you.

Jo O’Hanlon

Can I ask where you go into debt in this? yeah.

Elisha Yaghmai

my goodness. Yeah, yeah, yeah, yeah. We were we were heavily on red. Yeah. Every single year. Just losing money, losing money, losing money.

Jo O’Hanlon

Living on the dream. Yeah.

Elisha Yaghmai

Just everything. Savings are.

Jo O’Hanlon

Going.

Elisha Yaghmai

Away, Right? So. So every dollar I made went into it, right? I mean it was just. Yeah. I would go out and make that money, right. And would just all be plowed into just for keeping the thing alive for another month. Right. So all of this is happening and then the change took place in a legislatively, right? So after all, trying to do things the front door way and just let's sit down and talk and yeah.

Elisha Yaghmai

Discuss things and figure out a compromise or accommodation. Couldn't get any of that done. I will add we also we didn't it wasn't just private insurance. We also met with Medicare. We met with Medicare and said, here's a situation.

Jo O’Hanlon

About the bill, about the.

Elisha Yaghmai

Process, but also about their their block on the attending physician. Right. So we got a meeting with them. And to their credit, they did actually give us a meeting. They brought in their real health people. We had a meeting about this. We outlined for them exactly what we were doing. We're like, here's the situation Road, Kansas. There are people dying over these issues like this is real stuff, right?

Elisha Yaghmai

And here's what we're doing and here's how it helps. And they were like, that's great. We love it. We love to hear what you're doing. That's fantastic. And we were like, Great, We love that you love it. How do we change your policy? And that is where the conversation stopped. It was basically, Sorry, nobody here really knows how to do that.

Elisha Yaghmai

We don't have the authority to do that. It might even take an act of Congress to do that. So, you know, we can't change anything about this, but you all just keep right on. You know, you.

Jo O’Hanlon

Keep doing what you're doing.

Elisha Yaghmai

This is our so that's Medicare. And then, of course, private insurance is.

Jo O’Hanlon

Just not it. Yeah. So in a way your stuff.

Jo O’Hanlon

So.

Elisha Yaghmai

You know I want to say what is this now 20 a.m. I have my I think I have my dates right there's 2017 actually the winter 2017 Independence, Kansas lost its hospital. They went bankrupt.

Jo O’Hanlon

well.

Elisha Yaghmai

The rep from who represented independence, the state rep introduced a bill to support telemedicine payment. He did this on his own volition. We had nothing to do with it. Right. Introduced this bill. We went to the hearing and we each got 2 minutes to speak about why we favored this. Right? Yeah, that our thing. And then in the end it just got shelved.

Elisha Yaghmai

Like that was the end of the legislation just got shelved. There was just, you know, the statements made by the representative, the insurance companies were not factually accurate. That's how I would describe it. They were not factually accurate. I think some of it I'm not trying to impugn their ethics or the case. I think they had an understanding of things that was not correct.

Elisha Yaghmai

The representative was out there speaking.

Jo O’Hanlon

Of what telemedicine was or.

Elisha Yaghmai

They had an understanding of what it was and what it could be and what it could do. That was incorrect. They had not updated their knowledge, but part of why they hadn't updated their knowledge was a refusal. And again, I don't know who in the organization refused. Right. So, I can't I'm not speaking to any one person or any.

Elisha Yaghmai

Yeah. Any entity. What I'm saying is that you couldn't get the they couldn't get there was no way for us to communicate the information about what was happening at that moment in that field. You could have a conversation. So they made these statements. It ended up and as American politics often does in this haze of sort of who's right and nobody knows who's right, Right.

Elisha Yaghmai

So let's just shelve the whole thing. So we had a surface.

Jo O’Hanlon

Shelving is the official term.

Elisha Yaghmai

I guess it just got suspended, right? Yeah. Sooner or later, we'll just we don't know.

Jo O’Hanlon

It wasn't dead in the water, but it was like no plan to come back.

Elisha Yaghmai

Maybe next year we'll come back to it. Right. Let's revisit this legislation.

Jo O’Hanlon

Okay.

Elisha Yaghmai

So the interesting part was we get to this, so we decide at that point to hire a lobbyist. Right now, bear in mind, I said we didn't have any money, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

We didn't we didn't have any money hemorrhaging ground. So but we found a couple of lobbyists in Topeka that took our case at less than their market rate. Well, simply because they just believed in the cause. Right. Which I will be forever grateful for. It was remarkable that they did that, right? Yeah. And to their credit, they got us a meeting with one of the main legislators in charge of this stuff.

Elisha Yaghmai

This happened over the summer, right? So we got to sit down for about an hour with this gentleman and talk to him about the real issues that are going on. Right. So this for us was unprecedented. Right. And so he listened to the whole thing and says, well, this is amazing that he can do all the.

Jo O’Hanlon

Stuff.

Elisha Yaghmai

For the rural population. You could do this. And we're like, yeah, we could do this.

Jo O’Hanlon

He's like, Why aren't you doing it everywhere?

Elisha Yaghmai

We're like, Well, funny you should ask me. Yeah.

Jo O’Hanlon

Right. So, so he's like.

Elisha Yaghmai

We're we're going to have we're going to have a hearing later. I'm going to I'm going to put together an interim hearing. Right. And we're going to get some representatives of the House and the Senate together and we're going to have a hearing about this thing. And true to his word, he did it right. So we had a two day hearing about this issue.

Elisha Yaghmai

We went to it. We testified in it. Once again, it was going to health care providers on one side and the insurance companies on the side. And at the end of that hearing, it seemed like the opinion in the legislature had shifted enough that it became likely that the legislation that had been proposed at that time was actually going to pass.

Elisha Yaghmai

And what we had requested was not payment parity, but mandated payment, meaning if you cover the thing at all, in other words, if you cover that activity. Yeah. And the activity can be provided virtually, you must pay something for it. Okay. You don't have to pay the same, but you got to pay something. Okay, That's different than payor parity, which is if you're going to pay me $100 for this here and I'm going to do it virtually, you pay me $100.

Elisha Yaghmai

Right? Okay. We tried to to do away with the end around by saying you you cannot stop us from credentialing.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Right.

Jo O’Hanlon

So that was explicit.

Elisha Yaghmai

Yeah. That was explicit that you can't establish an credentialing just because we want to work virtual and you have to pay for it. If it's an if it is a covered activity that was fundamentally different than, to my knowledge, any of the legislation that had come before it. Yeah, I may be wrong about that, but I don't. They can't be too far off because most everything else was payer parity in the few places that had even been passed.

Jo O’Hanlon

Right.

Elisha Yaghmai

This is a big door. So that represented a whole session. So there was some more politicking that went on and more testifying, but that ultimately those initiatives came through.

Jo O’Hanlon

And when did that all come finally live?

Elisha Yaghmai

The beginning of 2019. Okay. Yeah. So that was when that legislation really actually came through and went through. But what it took.

Jo O’Hanlon

Five years after the start.

Elisha Yaghmai

From 2014 to 2019 is what this took right. This was and there had been to be fair, there had been other proposed telemedicine legislation in previous years that had been killed. Right. Every couple of years they'd bring something in and it would get killed in.

Jo O’Hanlon

Other places, similar to what you were trying to do, not.

Elisha Yaghmai

Just in, you know, not just around the country, even in Kansas, like at least once or twice. I think the rep from Independence, I may be mistaken about was I think he tried to introduce bills a couple of different times. They kept getting killed right before it ever got anywhere. Yeah, this finally got through, got a full hearing, went through all the chambers, all the politics around it went through and this thing came out the other end for the.

Jo O’Hanlon

State.

Elisha Yaghmai

Or the state for the state of Kansas. That was beneficial. So that represented change. I think what we so what we learned from this, we learned a lot about the political process and getting legislation passed. Right. And we had a we were we were very hands on with this whole process of what was on the testifying and legislation and all the specifics of what was going on.

Elisha Yaghmai

But we learned a lot about that process. We learned a lot about how health care policy is actually made and the decisions that are being made by the different parties that are involved, some of why they're doing what they're doing.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And I think that that that whole process of what I've described really opened our eyes to say, okay, there is a bigger problem here. This isn't just about who gets paid and how much they get paid. Right. Right. There's a bigger problem in terms of control. Right. Who's in charge of this?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

What what what is good for people versus what is good for the survival of a company or a corporation?

Jo O’Hanlon

Right.

Elisha Yaghmai

These two things appear to be in conflict, or at least when they appear to be in conflict. Decisions were made to protect the entity, right? Not necessarily the public. Yeah. You can argue about the value of the entity and what role it should have, right? There's all kinds of discussion you can have, but none of that discussion was going on.

Elisha Yaghmai

Right, Right. It was just about, are you paying for it? Are you not paying for it? Yeah, right. There was no questioning of the broader context in which this was going on. This, I think for us and for me specifically raised really serious questions about the entire system. We had to go through this entire slog of misery to get we ultimately had to have legislation passed to change one thing so that we could help some people.

Jo O’Hanlon

In.

Elisha Yaghmai

One state.

Jo O’Hanlon

Right? Yeah.

Elisha Yaghmai

When analyzed objectively, this was a very the whole thing was simple. Almost all the major questions had already been answered from the jump. The thing could have probably been resolved in an hour long conversation.

Jo O’Hanlon

Right.

Elisha Yaghmai

Where we just, you know, here's the safeguards we to put this stuff in place, right? All I could have done. But it wasn't that. Instead, it was a much, much, much, much, much, much, much more prolonged, painful effort that required.

Jo O’Hanlon

Political and.

Elisha Yaghmai

It definitely required all of these resources in an effort to change one tiny thing.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

I think, you know, for people hearing this, that should, I hope, raise questions in your own mind about all the other things that go on or don't go on in health care.

Jo O’Hanlon

Right.

Elisha Yaghmai

What's the machinery behind that And is that the machinery that we should have. Yeah, right.

Jo O’Hanlon

Especially if it doesn't have any room for growth or change or development.

Elisha Yaghmai

When change is perpetually blocked because it is new.

Jo O’Hanlon

Right.

Elisha Yaghmai

Right. That should raise a question. So there are other questions that came out of all of this. Right. But that was the very first thing we learned was, okay, wait a minute. So folks are in charge, aren't necessary, at least from our perspective, always acting in the best interests of those those who they purport to be the stewards for, if that makes sense.

Elisha Yaghmai

So why don't we come up with another way? And so our our clinic came out of that frustration.

Jo O’Hanlon

Okay. Well, thank you for what you've done for our state prior to all this, too. I mean, that's that's a huge thing. That's a testament to who you are in terms of like you're going into debt for all of us. And I mean, just believing in it, keeping hounding in a system that continues to tell, you know, when like for your example of like finding a cure for a problem in the system.

Jo O’Hanlon

So I know that we're going to delve into more of like that next time. Thanks for being with us and we'll see you next time.