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MEDICAL BILLING SERVICES
FOR URGENT CARE CENTERS
ELIGIBILITY & AUTHORIZATION VERIFICATION
BILLING & CODING | ACCOUNTS RECE...
COMPANY OVERVIEW
Key Facts Awards, Affiliations & Certifications
2Sun Knowledge © 2015-16 Private & Confidential
 ‘Onshor...
SERVICE PORTFOLIO
 Provider Support
 Member Support
 Member Retention Program
 Clinical Help Desk
Contact Center
 Uti...
SUMMARY OF SERVICES
4Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA...
HIPAA COMPLIANCE SUMMARY
5Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010...
6Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REVENUE CYCLE
MANAG...
REVENUE CYCLE MANAGEMENT – KEY PROCESSES
7Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, Ne...
SERVICE HIGHLIGHTS
8Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
...
SERVICE AREAS
9Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
We pr...
10Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ELIGIBILITY &
AUTH...
ELIGIBILITY VERIFICATION – HIGHLIGHTS
11Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New ...
ELIGIBILITY VERIFICATION – SERVICE FEATURES
12Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor...
AUTHORIZATION VERIFICATION – HIGHLIGHTS
13Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, Ne...
SAMPLE REPORTS
14Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
0
2...
BENEFITS OVERVIEW
15Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
...
16Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
BILLING & CODING
MEDICAL CODING OVERVIEW
17Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010...
MEDICAL CODING – PROCESS
18Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 1001...
TYPICAL MEDICAL BILLING CYCLE
19Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY...
MEDICAL BILLING SYSTEM
20Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010,...
21Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
OTHER SERVICES
PAYMENT/DENIAL POSTING PROCESS
22Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, N...
PRODUCTIVITY EFFICIENCY TRACKING
23Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York,...
24Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTS RECEIVABL...
STEPS IN A/R FOLLOW-UP
25Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010,...
SAMPLE SOW FOR A/R FOLLOW-UP
26Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY ...
SAMPLE OF AGENT-WISE A/R REPORT
27Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, ...
SAMPLE OF A/R AGING REPORT
28Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10...
BENEFIT HIGHLIGHTS
29Sun Knowledge © 2015-16 Private & Confidential
Reduction in
accounts receivable
by up to 30%
within 1...
30Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
DENIAL MANAGEMENT
REASONS FOR DENIAL
31Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA...
STEPS IN DENIAL MANAGEMENT
32Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10...
DISTRIBUTION OF DENIED CLAIMS
33Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY...
34Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TECHNOLOGY, OPERAT...
IT INFRASTRUCTURE
35Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
...
OPERATIONAL FRAMEWORK
36Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, ...
GOVERNANCE MODEL
37Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
S...
QUALITY ASSURANCE & CONTROL
38Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 1...
COMPLIANCE KEY FACTS
39Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, U...
COMPLIANCE ESCALATION STRUCTURE
40Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, ...
41Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & RESPO...
CHALLENGES & OUR APPROACH
42Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 100...
CHALLENGES & OUR APPROACH
43Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 100...
CHALLENGES & OUR APPROACH
44Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 100...
SUMMARY OF BENEFITS
45Sun Knowledge © 2015-16 Private & Confidential
 Very Little Risk
• Proven track record in providing...
46Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
CLIENTSPEAK
47Sun Knowledge © 2015-16 Private & Confidential
“We have had the pleasure of working with the Sun Knowledge t...
CLIENTSPEAK
48Sun Knowledge © 2015-16 Private & Confidential
“My firm has evaluated an outsourcing transaction with Sun Kn...
CLIENTSPEAK
49Sun Knowledge © 2015-16 Private & Confidential
“I was always against the idea of outsourcing our back end cl...
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Medical Billing Services for Urgent Care Centers & Emergency Dept. by Sun Knowledge

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Medical Billing Services for Urgent Care Centers & Emergency Dept. by Sun Knowledge

  1. 1. MEDICAL BILLING SERVICES FOR URGENT CARE CENTERS ELIGIBILITY & AUTHORIZATION VERIFICATION BILLING & CODING | ACCOUNTS RECEIVABLE
  2. 2. COMPANY 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
  3. 3. SERVICE PORTFOLIO  Provider Support  Member Support  Member Retention Program  Clinical Help Desk Contact Center  Utilization Management  Medication Therapy Management  Hospital Re-admission Management  Therapeutic Interchange  Formulary Management Clinical Services  Medical Coding & Billing  Claims Administration  Enrollment Processing & Member Fulfillment  Credentialing  Premium billing and collections Administrative Services Analytics  Telemedicine Services  Remote Patient Monitoring  Application Development & Support  Technical Support  Technical Documentation IT Services  Claims /Drug Utilization Analysis  PDE Analysis  RAF Analysis  Payment Reconciliation We provide services to Providers – Physicians, Hospitals, DME, P&O, Urgent Care, Home Health Care and Pharmacies Payers – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs 3Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA
  4. 4. SUMMARY OF SERVICES 4Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA PRACTICE MANAGEMENT Scheduling Eligibility & Authorization Verification Prior Authorization Customer Care BILLING & COLLECTIONS Coding Charge Posting Claims Submission Payment Posting Denial Management Accounts Receivable PAYOR SERVICES Claims Adjudication Credentialing Utilization Management Customer Care TELEMEDICINE Telemedicine Remote Patient Monitoring
  5. 5. HIPAA COMPLIANCE SUMMARY 5Sun Knowledge © 2015-16 Private & Confidential 41 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
  6. 6. 6Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA REVENUE CYCLE MANAGEMENT
  7. 7. REVENUE CYCLE MANAGEMENT – KEY PROCESSES 7Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA 360° Revenue Cycle Management Services Eligibility & Authorization Verification Patient Information Entry Coding Charge Entry Claim Submission Payment Posting Accounts Receivable Denial Management Reporting
  8. 8. SERVICE HIGHLIGHTS 8Sun Knowledge © 2015-16 Private & Confidential 41 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  Rapid claim status analysis in denial management  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
  9. 9. SERVICE AREAS 9Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA We provide turnkey 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…
  10. 10. 10Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA ELIGIBILITY & AUTHORIZATION VERIFICATION
  11. 11. ELIGIBILITY VERIFICATION – HIGHLIGHTS 11Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  Full range of verification services  Fast 24-hour turnaround time  Above 99.9% accuracy  Detailed documentation  100% HIPAA compliance  Experience with national and private carriers We have the experience, training and resources to complete quick verification checks, a feature that Urgent Care Centers love us for. In some cases, such services can even be rendered in real-time (with the help of fast, software-assisted database enquiries)
  12. 12. ELIGIBILITY VERIFICATION – SERVICE FEATURES 12Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Our eligibility check covers the following:  Policy active for date of service  Co-pay / Coinsurance / OOP  Rx & Dx entry (with appropriate timeframe)  Provider status (INN / OON)  CSI check  Authorization requirement  Obtaining authorization  Patient responsibility Our comprehensive verification process helps eliminate unpleasant surprises at the time of submitting claims, and removes most uncertainties about insurance coverage and reimbursement.
  13. 13. AUTHORIZATION VERIFICATION – HIGHLIGHTS 13Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  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 Years of experience in working at claims adjudication for major insurance companies in the US has given us a unique understanding of the authorization process, allowing us to complete the process faster than others!
  14. 14. SAMPLE REPORTS 14Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA 0 20 40 60 80 100 120 140 4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015 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 Forward Primary Checked Secondary Checked (if applicable) 0 5 10 15 20 25 30 35 40 45 50 4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015 45 25 38 44 46 20 15 26 22 21 25 10 12 22 25 AUTHORIZATION VERIFICATION Auth Required Auth Obtained Auth Pending
  15. 15. BENEFITS OVERVIEW 15Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  360o operations support in medical benefit coverage  Quick authorization process  Detailed documentation  100% HIPAA-HITECH compliance  Experience in working with both Payers and Providers  Highly accurate eligibility data maintenance (in sync with CMS)  Excellent references from more than 7 years of successful operation!
  16. 16. 16Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA BILLING & CODING
  17. 17. MEDICAL CODING OVERVIEW 17Sun Knowledge © 2015-16 Private & Confidential 41 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
  18. 18. MEDICAL CODING – PROCESS 18Sun Knowledge © 2015-16 Private & Confidential 41 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
  19. 19. TYPICAL MEDICAL BILLING CYCLE 19Sun Knowledge © 2015-16 Private & Confidential 41 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
  20. 20. MEDICAL BILLING SYSTEM 20Sun Knowledge © 2015-16 Private & Confidential 41 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 payer billing  Denial Management  Patient statement generation and mailing Sun Knowledge handles medical billing - promptly, perfectly and professionally – using Kareo® or other billing systems as preferred by the client.
  21. 21. 21Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA OTHER SERVICES
  22. 22. PAYMENT/DENIAL POSTING PROCESS 22Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Payment posting is crucial to the billing process. Due to the sensitivity of this process, accurate and efficient payment posting process is indispensable. Our billers are known to be highly efficient and analytical in the payment posting process. Payment Entry Process Select Patient Account Select EncounterSelect Encounter If not found Refer Client SpecifiesDenial Denial Code Hold Transfer BalanceTransfer BalanceWrite-off Post Payment Payment
  23. 23. PRODUCTIVITY EFFICIENCY TRACKING 23Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Employee Name Note Count Days Worked Hours Worked Notes Per Hour Max Note Time Avg. Note Time John Smith 977 23 203.55 4.8 1:29:52 0:07:15 Jane Doe 1025 23 214.97 4.77 0:55:14 0:04:56 Rick Williams 913 21 207.07 4.06 1:27:08 0:07:14 Robert Frost 870 21 187.35 4.64 0:42:54 0:04:05 Dan Chesser 910 23 216.47 4.2 3:50:55 0:06:18 Derek Malia 823 23 210.37 3.91 7:01:30 0:04:37 Our clients depend on transparency. We provide our clients with the ability to maintain detailed tracking for increased productivity and efficiency. Sample Report
  24. 24. 24Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA ACCOUNTS RECEIVABLE MANAGEMENT
  25. 25. STEPS IN A/R FOLLOW-UP 25Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  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 our A/R team
  26. 26. SAMPLE SOW FOR A/R FOLLOW-UP 26Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Sun Knowledge will make outbound calls to reach out to the Payers to gather information about the status of claims as per the list provided by Customer. Key tasks involved in carrying out this work are detailed below.  Planning to start calling Payers as per the list of claims based on the downloaded AR Reports  Research details of the claims in the AR list in the Clients system  Making outbound calls to the respective Payers for claims aged 31 days and more  Document finding of the calls  Preparation of claims reports with status information gathered during the call Modifications, removal or adding tasks to this are agreed upon between client and Sun Knowledge. …
  27. 27. SAMPLE OF AGENT-WISE A/R REPORT 27Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA User ID Touched Accounts Note Count Days Worked Hours Worked Notes Per Hour Max Note Time Average Note Time XX12_GT 37 37 1 8.22 4.5 0:20:06 0:02:00 XX13_GT 50 51 1 8.83 5.77 0:35:44 0:05:45 XX14_GT 37 37 1 8.9 4.16 0:15:26 0:02:19 XX15_GT 41 41 1 8.65 4.74 0:38:47 0:09:48 XX16_GT 34 48 1 9.32 5.15 0:23:57 0:03:45 XX17_GT 83 83 1 9.63 8.62 0:42:35 0:02:37 XX18_GT 50 50 1 9.3 5.38 0:35:14 0:05:18 XX19_GT 45 46 1 9.65 4.77 0:24:11 0:05:05 XX20_GT 53 53 1 8.87 5.98 0:33:47 0:04:01 XX21_GT 14 14 1 9.93 1.41 0:37:20 0:08:23 Total Touched 444 460 Total time 91.30 5.04 Average Touched 44 46 Average time 9.13
  28. 28. SAMPLE OF A/R AGING REPORT 28Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA SUN KNOWLEDGE WEEKLY AR AGEING 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 MAGNACARE 7 7 0 11 9 2 5 5 0 8 3 5 OXFORD 12 9 3 17 12 5 23 22 1 22 16 6 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
  29. 29. BENEFIT HIGHLIGHTS 29Sun Knowledge © 2015-16 Private & Confidential Reduction in accounts receivable by up to 30% within 1 month Accounts Receivable recovery cost starts from 1% of collections Expert handling of accounts receivable by highly experienced staff Same attention to every cash amount regardless of its size or source Demonstrated expertise in working on difficult-to- recover aging A/R Over 7 years’ experience in claim adjudication for major US insurance plans 41 Madison Avenue, 25th Floor, New York, NY 10010, USA
  30. 30. 30Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA DENIAL MANAGEMENT
  31. 31. REASONS FOR DENIAL 31Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  Authorization Issues  Referral Issues  Medical Necessity and Medical Records requests  Non-Participation with Insurance Network  Terminated Insurance  Coordination of benefits  Wrong Diagnosis  Inclusive Procedures  Partial Payments  Out-of-network claim status and deductibles  EDI Rejections  No status and No claim on File  PIP cases
  32. 32. STEPS IN DENIAL MANAGEMENT 32Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Claim Correction and Resubmission These 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
  33. 33. DISTRIBUTION OF DENIED CLAIMS 33Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA 24% 11% 3% 35% 17% 10% Distribution of Denied Claims Auth Related Coding Correction Required OON Issue Others Patient info missing Timely Filing Claims denied as Others are due to the following reasons:  Claim denied as duplicate  Claim previously paid  Patient not eligible on DOS  Payer didn’t receive EOB from primary payer  Provider needs to verify if item billed is rental or purchase  Bill Primary  Patient not covered due to pre-existing condition  Plan doesn’t cover medical services such as DME  Not covered by member’s plan  Claim exceed maximum number times it can be billed
  34. 34. 34Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA TECHNOLOGY, OPERATIONAL & COMPLIANCE FRAMEWORK
  35. 35. IT INFRASTRUCTURE 35Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  Service continuity supported by BCP and disaster management mechanisms  100% redundancy in all IT assets, providing high-availability and reliability  12 Mbps leased line internet connectivity provided by two ISPs in load sharing and automatic failover configuration  Data protection and security provided by a leading firewall system combined with other physical and logical access controls  Voice telephony infrastructure built using E1 lines provided by two IPLC providers  Avaya PBX with IVR, ACD and CTI functionalities and 100% call recording & reporting features  Data center with 13 IBM x3650 rack servers with rack mounted UPS  Polycom VSX 7000A video conference system for remote training and client communication  24/7/365 IT-Infrastructure support personnel for user support, using ticket management system  120 KVA on-line UPS power backup systems and additional backup provided by 180 KVA power generator
  36. 36. OPERATIONAL FRAMEWORK 36Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA TRANSITION  Project scoping & planning  Knowledge transfer – Process training and assessment  Process documentation  Solution customization  Infrastructure set up  Pilot/Transition period TRAINING  Training Need Identification  Customized training program as per client’s requirement  Pre-process & process training  Voice & accent and cultural training  Refresher training PRODUCTION  Project management approach  Exception handling and reporting  Effective coaching & monitoring practices  Periodic review and evaluation  Service level management and reporting QUALITY  Regular audit for process and deliverables  Identify and analyze errors to take corrective measures  Flowcharting and root cause analysis for process improvement measures  Management reporting of quality assurance activities  Capacity planning  Forecasting, staffing & scheduling  Real time reporting  Billing and revenue management MIS / WFM  Ensure 100% adherence to federal / data protection laws  Governance & compliance audits  Organization preparedness for client & third party audits  HIPAA compliance CONTROL & COMPLIANCE PROJECT MANAGEMENT & OVERSIGHT IT INFRASTRUCTURE– TOOLS & TECHNOLOGY
  37. 37. GOVERNANCE MODEL 37Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Sun Knowledge Governance Structure Steering Committee Program Management Office Project Delivery Team  Executive sponsorship  Management oversight  Ensure business goals and engagement goals alignment  Ensure tangible results and demonstrable value  Continuously educate & report executive leadership on the critical success factors of engagement  Plan and implement change; define, establish performance, metrics aligned to goal  Review project scope, timeline and budget and monitor project progress  Communication, status reporting & escalation to steering committee  Manage cross team dependencies  Identify, initiate & institutionalize process improvements  Oversee knowledge repository building  Project Management  Scope Management  Knowledge Management  Change Management  Ensure successful engagement startup  Quality Management  Resource Management  Communication & Status Reporting  Issue Management  Monitor & measure knowledge transfer process  Incorporate industry best practices
  38. 38. QUALITY ASSURANCE & CONTROL 38Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Our Quality Control & Assurance processes help us meet our client’s expectations and SLA target. We use Quality Assurance program to set production and quality goals. Our daily quality audit activities ensure that we evaluate our agents’ work on all relevant criteria. The highest quality is ensured by carrying out rigorous quality assurance and control activities such as,  Periodic process review  Process audit  Testing deliverables and root cause analysis  Process improvement / re-engineering  Incorporating customer feedback  Internal quality audit of client deliverables & review reporting  Weekly/monthly monitoring of productivity reports
  39. 39. COMPLIANCE KEY FACTS 39Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  Well defined policies to cover compliance aspects  Written procedures covering compliance aspects  Proactive compliance reporting and issue escalation  Action list for changes in rules and regulations by regulatory authorities  Compliance evaluation framework  Periodical training on compliance issues and update  Periodic audit and review mechanism to address potential compliance risks  Implementation of data privacy and security standards like HIPAA-HITECH and ISO 27001  Incident reporting for data security violation  Compliance awareness among the employees and reward on compliance reporting  Compliance violation by employees leads to employee retraining and reassessment Sun Knowledge has defined and established a process and system to avoid compliance risks while carrying out operations and encourages employees to proactively report compliance issues to the higher management.
  40. 40. COMPLIANCE ESCALATION STRUCTURE 40Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Service Delivery Service Delivery Mgr (Service Delivery POC) Head of Operations (1st Level Escalation POC) Operations CEO & MD (Final Escalation POC) Executive Board Board of Directors Compliance Compliance Mgr (Compliance Escalation POC) Head of Compliance Compliance Team Lead Process Team Lead (Service Delivery POC) Technology Technology Mgr Quality Quality Mgr HR/Training HR/Training Mgr Compliance Issue Trigger Point  Process Team Leader will inform Service Delivery Manager and Compliance Manager immediately after occurrence of the event  Compliance Manager/ Service Delivery Manager will assign the severity of the compliance issue Compliance Escalation Path Severe Compliance Escalation Path
  41. 41. 41Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA CHALLENGES & RESPONSES
  42. 42. CHALLENGES & OUR APPROACH 42Sun Knowledge © 2015-16 Private & Confidential 41 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
  43. 43. CHALLENGES & OUR APPROACH 43Sun Knowledge © 2015-16 Private & Confidential 41 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
  44. 44. CHALLENGES & OUR APPROACH 44Sun Knowledge © 2015-16 Private & Confidential 41 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 efficiency Process 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
  45. 45. SUMMARY OF BENEFITS 45Sun 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 • Billing & Coding Accuracy > 99.9%; TAT: 24 – 48 hours • Adherence to CMS billing requirements  Clear Communication and Quick Response 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
  46. 46. 46Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA TESTIMONIALS
  47. 47. CLIENTSPEAK 47Sun 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
  48. 48. CLIENTSPEAK 48Sun 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
  49. 49. CLIENTSPEAK 49Sun 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) 661-7853 Email: ronnie.hastings@sunknowledge.com Sun Knowledge 41 Madison Ave., Suite 2511, 25th Floor New York, NY 11001, USA For additional information, please contact… 41 Madison Avenue, 25th Floor, New York, NY 10010, USA

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