View
113
Download
1
Category
Preview:
Citation preview
ACCOUNTS RECEIVABLE
MANAGEMENT SERVICESFOR HOSPITALS
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
SUN KNOWLEDGE 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, 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
SERVICE PORTFOLIO
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
PAYER SERVICES
Claims Adjudication
Credentialing
Utilization Management
Customer Care
TELEMEDICINE
Telemedicine
Remote Patient Monitoring
OUR 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 AccessSigning 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
7Network &
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 FirewallUnified 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
9VPN (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
10Redundancy
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
11Virus & 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
ACCOUNTS RECEIVABLE MANAGEMENT
6Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTS RECEIVABLE IN THE REVENUE CYCLE
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
ACCOUNTS RECEIVABLE MGMT. PROCESS OVERVIEW
8Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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.
FOLLOW-UP
9Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
No Remark Claims:
Any claim in which absolutely no status is known for the claim.
Last Remark Claims:
Claims which remain unpaid for various reasons. These claims are routinely followed up on a monthly basis.
2 types of Claims Follow-ups
1
2
STEPS IN ACCOUNTS RECEIVABLE FOLLOW-UP
10Sun Knowledge © 2015-16 Private & Confidential
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 Payor
• 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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
STEPS IN ACCOUNTS RECEIVABLE FOLLOW-UP
11Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Online Claims Follow-UpUsing various insurance company websites and Internet payer portals, we check on the status of outstanding claims.
Automated Claims Follow-Up (IVR)By calling insurance companies directly, an Interactive Voice Response (IVR) system will provide the status of unpaid claims.
Insurance Company RepresentativeIf necessary, calling a ‘live’ insurance company representative will give us a more detailed reason for claim denials when such information is not available by the first 2 methods.
1
2
3
DENIALMANAGEMENT
12Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REASONS FOR DENIAL
13Sun 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
STEPS IN DENIAL MANAGEMENT
14Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
DISTRIBUTION OF DENIED CLAIMS
15Sun 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
BENEFIT HIGHLIGHTS
16Sun Knowledge © 2015-16 Private & Confidential
Reduction in accounts receivable
by 30%within 1 month
Accounts Receivable recovery cost starts from
2.5%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
SAMPLEREPORTS
17Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE OF AGENT-WISE A/R REPORT
18Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
User IDTouched Accounts
Note Count
Days WorkedHours
WorkedNotes Per
HourMax Note Time
AverageNote 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
SAMPLE OF A/R AGING REPORT
19Sun 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
SAMPLE SOW OF A/R FOLLOW-UP
20Sun 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.
…
SUMMARY OF BENEFITS
21Sun 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 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
TESTIMONIALS
22Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
23Sun 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
CLIENTSPEAK
24Sun 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
CLIENTSPEAK
25Sun 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: ronnie.hastings@sunknowledge.com
Sun Knowledge41 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
Recommended