revenue cycle management by sun knowledge (labs)
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REVENUE CYCLEMANAGEMENT SERVICES
FOR LABORATORIESPrepared for Prepared by
SUN KNOWLEDGE OVERVIEW
Key Facts Awards, Affiliations & Certifications
2Sun Knowledge © 2015-16 Private & Confidential
‘Onshore /Offshore’ KPO & BPO Services Serving US healthcare industry since 2007 Robust & scalable infrastructure State-of-the-art technology and systems Highly skilled and trained staff with good
communication skills and in-depth knowledge of process
Structured training, feedback and coaching HIPAA-HITECH compliant State-of-the-art office inbuilt with all redundancies –
power, infrastructure and others
ISO 27001:2013 and ISO 9001:2008 certified CMMi-SVC implementation in progress under KPMG
guidance Member of NASSCOM, the Governing Industry body for
IT/ITES in India Awarded ‘Best Emerging BPO Company of the year 2010’
by The Economic Times, India Recognized as one of the foremost 'Emerging companies in
Eastern India' by NASSCOM in 2011 Awarded Asia-wide “Healthcare BPO Provider of the Year”
at the Asia BPO Excellence Awards ceremony hosted by Asia BPO Summit on 14th February 2013 in Mumbai, India
Awarded the prestigious “Outsourcing Service Provider of the Year” award in the Asian Outsourcing Excellence Awards ceremony hosted by CMO Asia on 1st August 2013 in Singapore
Awarded “Highest New Job Creator (IT/ITES)” by STPI (Software Technology Parks of India) on 3rd December 2015
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Office at 41 Madison Avenue, 25th Floor, New York, NY 10010
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SUN KNOWLEDGE SERVICE PORTFOLIO
Provider SupportMember SupportMember Retention ProgramClinical Help Desk
Contact Center
Utilization ManagementMedication Therapy ManagementHospital Re-admission
ManagementTherapeutic InterchangeFormulary Management
Clinical Services
Medical Coding & BillingClaims AdministrationEnrollment Processing &
MemberFulfillmentCredentialing Premium Billing and Collections
Administrative Services
Analytics
Telemedicine ServicesRemote Patient MonitoringApplication Development & SupportTechnical SupportTechnical Documentation
IT Services
Claims /Drug Utilization AnalysisPDE AnalysisRAF AnalysisPayment Reconciliation
We provide services to
Providers – Physicians, Hospitals, DME, P&O, Laboratories, Home Health Care and Pharmacies
Payors – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
3Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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SERVICE PORTFOLIO SUMMARY
4Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRACTICE MANAGEMENT
Scheduling
Eligibility & Authorization Verification
Prior Authorization
Customer Care
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SERVICE AREAS
5Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
We provide revenue cycle management services in the following areas:
Durable Medical Equipment Prosthetics & Orthotics Urgent Care
Pathology Critical Care Skilled Nursing Facilities
Wound Care EKG Pharmacies
Cardiology Specialty Clinics Orthopedic Surgery
Anesthesia Family Practice Radiology
Rehab Centers Dermatology Physicians
Healthcare Facilities and more…
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SERVICE HIGHLIGHTS
6Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Up to 97% collection rate in accounts receivable
FREE medical billing software, EMR & setup
Real-time eligibility checks & fast authorization
100% HIPAA-HITECH compliance
Claim status analysis using Rapid Automation Technology®
Turnaround time less than 48 hours max.
Low service fees with no hidden cost
Zero lockup service contract that can be cancelled anytime
Excellent references from reputed clients across the US
Real-time audits and custom reporting
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OUR HIPAA COMPLIANCE SUMMARY
7Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SL. COMPLIANCE ASPECT HIGHLIGHTS
1 Physical Access Authorized access only | Bio-metric access | Proximity card system | Photo ID cards | Access log review
2 General Security 24 hour security personnel | Logging of visitor details | Physical register retained for 10 years
3 Monitoring CCTV monitoring (with recording) of production area | Daily review of recording
4 Vendor Access Signing confidentiality agreement before accessing sensitive areas | Accompanied by security personnel/employee during all times
5 Mobile Phones All employees (except managers) are required to deposit mobile phones in the locker box before entering facility
6 Personal Baggage No backpacks or other bags allowed | All baggage to be deposited in locker box before entering facility
7 Network & Application Usage
Unique user IDs created using Microsoft Active Directory | Access to storage devices, shared drives, USB/mass storage devices, printers – controlled by Domain Group Policy | No wireless access points
8 Firewall Unified Threat Management System | Internet traffic regulation using multiple filters | Network Address Translation (NAT) | Intrusion Prevention Systems (IPS) | Port-mapping for traffic between Virtual LANs | Default setting to deny all traffic
9 VPN (Virtual Private Network)
Site-to-site IPSec VPN tunnels | Authorized access via client-to-site VPN connections | Access authorization controlled by Active Directory's authentication service
10 Redundancy Management
Fully redundant network stack | Two ISP links configured in active-active mode | Power backup supplied by 130 KVA UPS and 750 KVA generator | 22 KVA UPS backup for server and network systems
11 Virus & Malware Protection
Central anti-malware system | Automatic updates | Extra protection by gateway firewall | Centralized OS patch management system (using Microsoft's WSUS server)
12 Other Measures Fire extinguishers at key areas | Half-yearly fire drills
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8Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REVENUE CYCLE MANAGEMENT
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REVENUE CYCLE MANAGEMENT – KEY PROCESSES
9Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
360° Revenue Cycle Management
Services
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IMPORTANT TASKS
10Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Inpatient/Outpatient Hospital Coding Physician Coding
Patient entry demographics & insurance information Fee Schedule / Charge Entry Scrubbing all entries for correctness and completeness with appropriate billing edits;
correction of identified errors Submission of claims to payers, e.g. EDI or paper Creation and mailing of patient statements Posting of payments received from patient and payer Reconciliation of charges, payments received and adjustments made
Denial Management, e.g. understanding denials and making corrections Resubmission of claims AR calls as follow-up on outstanding issues Closure of a claim once the balance is zero
CODING
BILLING
A/R FOLLOW-UP
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MEDICAL BILLING CYCLE
11Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Rx Order Entry
Patient Demographics and Insurance Entry
Product Code /Rx & Dx Entry
Eligibility Verification/ Authorization
Collection of complete Rx
Collection of documents for Auth
Approval
Submission
Rejection/Denial Management
A/R Follow-up
BILLING
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MEDICAL BILLING CYCLE
12Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Order entry based on the Rx received from the Physician• Patient demographics & insurance entry• Provider information entry• Product code entry• Rx & Dx entry (with appropriate timeframe)• If necessary, a telemedicine consultation can be completed to obtain a Rx to expedite the order entry process
Eligibility verification and authorization requirement enquiry Collection of documents required by payer for auth approval, e.g. face-to-face consultation notes, and obtaining
authorization from Payer Determination that Payer criteria is met before delivery of equipment, e.g. some products have time/frequency/
annual cost limitations f (if criteria is not met, the Patient is contacted and informed of the financial responsibility)
Generation of delivery ticket (based on which delivery is made to the patient) Creation of claim after receipt of confirmation of delivery Submission of EDI / paper claim to payers Cash posting Rejection & Denial Management A/R follow-up
BILLING
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MEDICAL BILLING SYSTEM
13Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
We use Kareo for coding and billing services that covers the complete billing cycle:
SOAP notes review
Superbill generation and coding
Claims edit checking and correction
Claims submission through EDI clearing house at a scheduled time
Rejection management
ERA/EOB posting and reconciliation
Automatic secondary payor billing
Denial Management
Patient statement generation and mailing
Sun Knowledge handles medical billing - promptly, perfectly and professionally – using Kareo® or any other billing system as preferred by the client.
BILLING
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MEDICAL CODING OVERVIEW
14Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Service Offerings
• Place of Service Based Coding – Inpatient, Outpatient Coding
• Provider Specialty Based Coding– E/M, Cardiology, Orthopedics, Physical Medicine etc.
• Review medical notes and clinical documents
• Assign ICD-10 codes for the diagnosis identified by the physician and Procedure codes (CPT/ ICD 10 PCS)
• Assign modifiers as applicable
• Code review and quality assurance
• Communication with Physician’s office for additional medical documentation and clarification
Key Tasks
CODING
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MEDICAL CODING – PROCESS
15Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Downloading Allocation
CodingQuality Check
Uploading Feedbacks & Updates
Encrypted reports are downloaded from SFTP site
Reports are allocated to coders according to specialty
Quality checked for LCDs, updates and client specs.
Analysis of reports, allocation of ICD and Service codes
Analysis of reports, allocation of ICD and CPT codes
Client reports back with feedbacks and updates
Medical Coding Process Flow
CODING
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MEDICAL CODING – HIGHLIGHTS
16Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
• Our coders deliver error-free charge sheets within agreed TAT provided by the client
• We monitor, analyze and improve coding documentation to avoid denials and guarantee reimbursements
• We carefully determine the codes according to the clinical information provided by the Healthcare Provider/Professionals and report back accordingly
• Our coders have undergone extensive medical coding training and are well aware of updated coding guidelines
• All our coders are ICD-10 certified (CPC)
CODING
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ELIGIBILITY & AUTHORIZATION VERIFICATION
17Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
• Full range of verification services
• Fast 24-hour turnaround time
• 96 – 99.9% accuracy
• Detailed documentation
• 100% HIPAA compliance
• Experience with national and private carriers
VERIFICATION
• Diligent follow-up till resolution and closure
• Uniform importance given to every account irrespective of size, age or claim value
• Fast completion of authorization process
• Periodic follow-ups to maintain authorization validity
ELIGIBILITY VERIFICATION
AUTHORIZATION VERIFICATION
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SAMPLE REPORTS
18Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/20150
20
40
60
80
100
120
140
96
83
94
98 96
29
11
6
31 32
125
94
100
129
128
41
32
26
30 28
ELIGIBILITY VERIFICATION
Number of New Patient Patient Brought ForwardPrimary Checked Secondary Checked (if applicable)
4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/20150
5
10
15
20
25
30
35
40
45
5045
25
38
4446
20
15
26
22 21
25
1012
2225
AUTHORIZATION VERIFICATION
Auth Required Auth Obtained Auth Pending
VERIFICATION
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PRIOR AUTHORIZATION
19Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
• Full Range Service Authorization Request Follow-up Approval
• 100% HIPAA-HITECH Compliance
• Low prices with no hidden cost
• Highly streamlined, fast and accurate service
• DME• Hospitalization• Outpatient Surgery requiring general anesthesia• Skilled Nursing • Organ, Bone Marrow, Stem Cell Transplants and other similar procedures• Inpatient rehabilitation – Treatment for alcohol or drug abuse• Other conditions
We cater to
PRIORAUTHORIZATION
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ACCOUNTS RECEIVABLE
20Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTSRECEIVABLE
Our A/R follow-up service is designed to increase the Revenue Collection for our clients.
The process begins after the Provider creates and sends Health Insurance Claims (Electronic/Paper claims or Manual HCFA forms) to various Insurance Companies.
Depending on the transmission type and length of time since submission, we begin our follow-ups.
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STEPS IN AR FOLLOW-UP
21Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTSRECEIVABLE
A/R Analysis 14% of all claims submitted to the payers are denied and have to be resubmitted, appealed
or written off by providers
50% of denied claims are never re-filed
50-70% of denied claims have higher chance of being recovered
Follow-up with payer Aggressive follow up with the insurance company's on all accounts at any
stage of the aging bucket plays an important part in A/R follow up activities. Closure of claim
Reducing days in A/R, claims submission and improving collection ratio with an increase in the probability of payment through timely follow-up is the responsibility of the A/R team
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DENIAL MANAGEMENT
22Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTSRECEIVABLE
Claim Correction and ResubmissionThese are the claims which are corrected, modified, and resubmitted as a corrected claim to Insurance companies.
For such claims, every effort is made to resolve the denial to avoid billing the patient.
Patients' Responsibility These are claims which cannot be further worked upon and the final bill is sent to the patient for payment collection.
The reasons for sending the patient a bill generally include In-Network deductibles and non-covered benefits as per the insurance plan. Patients receive a statement with a clear explanation for the balance due.
1
2
2 Categories of Denial Management
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DISTRIBUTION OF DENIED CLAIMS
23Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTSRECEIVABLE
24%
11%
3%35%
17%
10%
Distribution of Denied Claims
Auth RelatedCoding Correction RequiredOON IssueOthersPatient info missingTimely Filing
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AR AGING REPORT SAMPLE
24Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTSRECEIVABLE
SUN KNOWLEDGE WEEKLY AR AGING REPORT FOR Client X Inc. - 07/06/2015 through 07/12/2015
PAYER
>120 Days 91 – 120 Days 61 – 90 Days 31 – 60 Days
Claims Completed Remaining Claims Completed Remaining Claims Completed Remaining Claims Completed Remaining
AARP HEALTH CARE OPTIONS 26 23 3 17 16 1 44 41 3 37 32 5
AMERICAN TRANSIT INSURANCE COMPANY 12 11 1 6 5 1 15 15 0 10 10 0
BCBS 28 24 4 16 13 3 41 37 4 32 30 2
MAGNACARE 13 12 1 9 9 0 23 22 1 11 10 1
HIP_PALLADIAN HEALTH 6 6 0 12 9 3 12 10 2 15 15 0
MANAGED PHYSICAL NETWORK 12 10 2 8 7 1 10 10 0 10 8 2
STATE FARM INSURANCE 7 6 1 4 4 0 5 5 0 4 4 0
TOUCHSTONE HEALTH 5 5 0 8 6 2 6 4 2 16 12 4
UNITED HEALTHCARE 31 28 3 23 20 3 49 43 6 41 39 2
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THE SUN KNOWLEDGE ADVANTAGE
25Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Increased revenue – reduced collection time (95% + collection rate)
Reduction in accounts receivable by 30% within 1 month
Expert handling of accounts receivable by highly experienced staff with demonstrated expertise
Claim submission within 48 hours of receipt of billing input
Provider can focus more on core services
Adherence to CMS billing requirements
Proper records maintenance and visibility through reporting
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26Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & RESPONSES
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CHALLENGES & OUR APPROACH
27Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Assignment of adequate staff Completion of secondary verification Rigorous audit
Time consuming with limited staff Documentation collection requires
continuous follow-up Increased TAT
Time consuming with limited staff Secondary verification not carried out
Checking Authorization Requirement and Obtaining Authorization
Eligibility Verification
Patient Demographics / Insurance / Charge Entry
Transaction audit to minimize errors; reduces denial due to missing patient information
TASK DESCRIPTION CHALLENGES APPROACH
Missing information / Key-in errors Increased denial rate Increased TAT
Assignment of adequate staff Systematic and regular follow-up with
physicians’ offices & payors to collect documentation and obtain authorization
Proper tracking mechanism
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CHALLENGES & OUR APPROACH
28Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Defining KPI for rejection management process and assigning responsibility
Claims reconciliation and exception report generation
Unapplied balance Accumulation of backlog Manual posting Denials not posted
Delayed correction and resubmission Possible loss of payment
Payment Posting
Rejection Management
Paper Claim Submission
Proper tracking of every submission of paper claims
Moving to EDI based submission whenever possible will reduce cost of manual work and faster payment cycle
TASK DESCRIPTION CHALLENGES APPROACH
Additional work for printing and faxing/mailing
Delayed filing leading to denials Lack of information about the actual
status
Defining guidelines
Review of patient payments
Define KPI – TAT & Accuracy
Denial posting and review
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CHALLENGES & OUR APPROACH
29Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Proper documentation – process manual, guidelines & checklists
Defining proper tracking mechanism through various reports -Ageing, Status, Daily, Exception
Generate exception reports and regular audit of every process tasks
Defining KPIs and assigning responsibility
Lack of clarity of claims volume and current status affects management decision making process
Impact on overall billing process performance and improvement
Decreased productive efficiencyProcess Administration and Reporting
AR Follow-up & Denial Management
Regular analysis, follow-up and review
Transaction audit
TASK DESCRIPTION CHALLENGES APPROACH
Accumulation of backlog Denials not posted Claims reconciliation issue
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SUMMARY OF BENEFITS
30Sun Knowledge © 2015-16 Private & Confidential
Very Little Risk• Proven track record in providing healthcare BPO/KPO services• Experienced in providing services to both payers and providers• Experienced working with various software platforms• Quick and efficient resource for special projects requiring technical and process expertise
Significant Upside Potential• Great understanding of the Healthcare Industry. Operation scale-up with a short notice• Extremely competitive rates, greater productivity, improved quality, increased member and provider
satisfaction Proven Process Performance
• Low denial rate reduced collection time increase in revenue collection• High billing & coding accuracy; TAT: 24 – 48 hours • Adherence to CMS billing requirements
Clear Communication and Quick Response Time at All Times ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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TESTIMONIALS
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CLIENTSPEAK
32Sun Knowledge © 2015-16 Private & Confidential
“We have had the pleasure of working with the Sun Knowledge team throughout the few months utilizing their services for patient data entry and eligibility verification. They are a devoted and responsible team that is highly experience in what they do. They are always concerned about the client’s needs and are always there to help. I highly recommend the services offered by Sun Knowledge.”
COO of a leading medical billing and credentialing company in New York
“Your team amazed me with the manual and the amount of info you provided with that short training session.”
Practice Manager of a major Dermatology group in New York and New Jersey
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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CLIENTSPEAK
33Sun Knowledge © 2015-16 Private & Confidential
“My firm has evaluated an outsourcing transaction with Sun Knowledge. They provide superior service at a very attractive rate and have demonstrated to us their commitment to this partnership. Their expertise across various process areas in the PDP/MAPD domain and unique cost structure puts them in an incredible position to work with plans throughout the healthcare industry.”
Chairman, President and CEO of a major New York based Health Plan
“Our company is very pleased with the administrative, and business analytical solutions which Sun Knowledge delivers to our company from a quality & cost perspective. They have been a true partner in bringing industry expertise, and innovative solutions to the table. Their ability to grow with our evolving needs for higher end services such as clinical services is a significant differentiator among healthcare business process outsourcing firms.”
Executive Vice President of Operations of a leading MSO
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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CLIENTSPEAK
34Sun Knowledge © 2015-16 Private & Confidential
“I was always against the idea of outsourcing our back end claims processing work but I was wrong. Sun Knowledge provided extraordinary deliverables on a timely basis which led to cost cutting considerably for us.”
CEO of a leading MA-PD Plan
Ronnie Hastings(646) 661-7853Email: [email protected]
Sun Knowledge41 Madison Ave., Suite 2511, 25th Floor
New York, NY 11001, USA
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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