Practice Management & Claims Administration

PRACTICE MANAGEMENT & CLAIMS ADMINISTRATION

CONTACT: RONNIE HASTINGS (646) 661-7853

GoTelecare 41 Madison Avenue, 25th Floor, New York, NY 10010

2© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010

Company Overview

‘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 facility inbuilt with all redundancies –

power, infrastructure and others

Sun Knowledge, our contracted company, is ISO 27001:2013 and ISO 9001:2008 certified

CMMi-SVC implementation in progress under KPMG guidance

Member of NASSCOM Awarded ‘Best Emerging BPO Company of the year 2010’

by The Economic Times Recognized as one of the foremost ‘emerging companies'

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 on 3rd December 2015

Key Facts Awards, Affiliations & Certifications


Our Service Offerings

Provider Support

Member Support

Member Retention Program

Clinical Help Desk

Contact Center

Utilization ManagementMedication Therapy ManagementHospital Re-admission ManagementTherapeutic InterchangeFormulary Management

Clinical Services

Enrollment Processing & MemberFulfillment

Claims Administration Coding & Medical Billing Credentialing Premium O&P Billing and Collections

Administrative Services

Analytics

Telemedicine Services

Application Development

Data Modeling & Data Warehousing

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


REVENUE CYCLE MANAGEMENT


Revenue Cycle Management Services

360° Revenue

Cycle Management

Services

Eligibility & Authorization

Verification

Prior Authorization

Billing

CodingScheduling

Payment Posting

Accounts Receivable


Revenue Cycle Management – Service Snippets

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 (understanding denials and making corrections) Resubmission of claims A/R calls as follow-up on outstanding issues Closure of a claim once the balance is zero

CODING

BILLING

A/R FOLLOW-UP


Revenue Cycle Management Experience

HOSPITAL

Accounts Receivable Follow - Up

Denial Management

Claims Resubmission

DME

Order Entry Eligibility

Verification/ Authorization

Follow up on Auth Approval

Delivery Scheduling

Submission of claim

Rejection Management

Payment Posting A/R Follow-Up Denial

Management CPAP Compliance

Tracking

O&P

Rx Order Entry Patient

Demographics and Insurance Entry

Product Code entry/Rx & Dx Entry

Eligibility Verification/ Authorization

Collection of complete Rx

Collection of Documents for Auth Approval

Submission Rejection/Denial

Management A/R Follow-Up

URGENT CARE

Order Entry – Patient Information, Ordering Physician, Rx & Diagnosis

Eligibility Verification

Medical Document Collection

Authorization Approval

Order Audit Confirmation

Submission of Claims


Payment Posting A/R Follow-Up

Patient Entry: Demographics & Insurance


Authorization Follow-Up

Charge Entry Submission of

Claims (EDI/Paper)



Management

PHYSICIAN

Patient Entry: Demographics & Insurance

Charge Entry Submission of

Claims (EDI/Paper)



Management

HOME HEALTH


Areas of Operation

We provide turnkey billing & coding services in the following areas:

DME / HME Prosthetics & Orthotics Urgent Care

Pathology Critical Care Radiology

Internal Medicine EKG Compounding Pharmacies

Cardiology ENT Orthopedic Surgery

Anesthesia Family Practice Specialty Clinics

Rehab Centers Pharmacy Physicians, and more…


ELIGIBILITY & AUTHORIZATION

VERIFICATION


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

Insurance Claim Eligibility Verification – Highlights


Insurance Claim Eligibility Verification

Eligibility check covers the following:

Policy active for date of service

DME coverage

Copay / Coinsurance / OOP

Rx & Dx entry (with appropriate timeframe)

Provider status (INN / OON)

CSI check

Authorization requirement

Obtaining authorization

Patient responsibility


Insurance Claim Authorization 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


Highlights

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


PRIOR AUTHORIZATION SERVICES


Prior Authorization – Highlights

• 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


Sample Reports

06/04/2015 07/04/2015 08/04/2015 09/04/2015 10/04/20150

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)

06/04/2015 07/04/2015 08/04/2015 09/04/2015 10/04/20150

5

10

15

20

25

30

35

40

45

5045

25

38

4446

20

15

26

22 21

25

1012

2225

AUTHORIZATION

Auth Required Auth Obtained Auth Pending


MEDICAL CODING SERVICES


Coding Services – Overview

Service Offerings

Medical Coding• Place of Service Based Coding – Inpatient, Outpatient Coding

• Provider Specialty Based Coding– E/M, Cardiology, Orthopedics, Physical Medicine etc.

GoTelecare handles medical coding - promptly, perfectly and professionally – using Kareo® or other billing systems as preferred by the client.

• 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 – Key Facts

• 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 – Sample Production Report

Weekly Chart Review Summary Mon Tue Wed Thu Fri

No. of charts to be reviewed/pending brought forward 42 124 110 91 62

No. of charts received 142 48 52 40 51

No. of charts reviewed 65 68 74 70 67

No. of charts with insufficient information to code 34 14 23 20 17

No. of calls made to physicians office to get information 25 18 22 16 12

No. of charts succesfully coded 60 62 71 69 62

No. of charts coding pending/ carried forward 124 110 91 62 51


Sample Coding Report

CPT Codes Billed Report

CPT codes Code description Units Billed Charges Payments Collection %

99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT 158 $$$$ $$$$ 68.18%

99218 INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT 162 $$$$ $$$$ 76.00%

99225 SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT 192 $$$$ $$$$ 70.00%

99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT 161 $$$$ $$$$ 88.57%

99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES OR LESS 254 $$$$ $$$$ 60.00%

99252INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED

HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING

168 $$$$ $$$$ 60.00%

99281 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT 126 $$$$ $$$$ 93.75%


MEDICAL BILLING SERVICES


Medical Billing Cycle Services

Encounter (SOAP) notes review

Superbill generation and code review

Claims edit checking and correction

EDI claims submission through clearing house

Rejection managementERA/EOB posting and reconciliation

Automatic secondary payer billing

Denial Management

A/R Follow-up


Practice Management & Billing System

GoTelecare billing executives have experience in working on several industry standard practice management and billing software systems such as:

We can provide medical billing & coding services using customer’s billing system or can set up customer’s practice in a billing system managed by us.

Kareo SOS

Emdeon / Capario One Meditech

Brightree Alpha Collector

Fastrack OPIE

CPR+ HME Futura

DME Works PrimeRx

Team DME


Billing & Coding Services - Highlights

FREE Billing Software FREE EMR FREE Implementation No Hidden Cost Up to 95% Collection Rate 99.9% Coding Accuracy Claims Submission within 24 – 48 hours max. 100% HIPAA-HITECH Compliance Custom Reporting Excellent References Real Time Audits


OTHER PRACTICE MANAGEMENT SERVICES


Payment/Denial Posting Process

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


Productivity Efficiency Tracking

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.

A Sample Report


Denial Management

Auth Related14%

Coding Error5%

OON Issue8%

COB Issues10%Patient info missing

6%

Exceeds Timely Filing8%

Duplicate Claim5%

Service Not Covered6%

Primary Paid Max7%

Pre-Existing Con-dition

5%

Others26%

Distribution of Denied Claims


Challenges and Our Approach

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


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 & payers to collect documentation and obtain authorization

Proper tracking mechanism



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


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


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



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


Accumulation of backlog Denials not posted Claims reconciliation issue


Client Benefits

Significant decrease in operational expenses We charge as low as $10 per hour per employee! Our clients save on other associated costs for employees including Health Insurance Premiums, Payroll Costs,

Medicare Tax, Human Resources, Employee Attrition, additional Real Estate and Infrastructure Costs We guarantee > 50% operational savings effective immediately; e.g. one of our clients reported a $2.1 million

operational savings in Y1 alone!

Heightened collection and increased Accounts Receivables 30% of DME Rx are incomplete when first received. We excel in completing the Rx claim quickly.

Cyclical Data Reporting Data reporting interval customized to meet the needs of the customer Productivity Efficiency Tracking allows for quantifying the team workload

Demonstrated experience handling DME claims Medicare, Medicaid and Commercial Plans Fee for Service and Capitated Plans


TECHNOLOGY, OPERATIONAL & COMPLIANCE FRAMEWORK


IT Infrastructure

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 Fortigate® 310B firewall 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


Operational Framework

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


Quality Assurance & Control

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


Training Methodology

• Regular process test and appraisals

• Work in-sync with Operations & QA

• Preparation of training Modules

• Preparation of training Plan in ‘Knowledge Net’ training module

• Process training and refreshers

• Availability of training documents in ‘Knowledge Net’ portal

• V&A, Soft skills training

• Post-training assessment• Training feedback• Review of training

program

Training Need Identification

Training Program Planning

Conduct Training

Training Evaluation


Compliance – Key Facts

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

GoTelecare has defined and established a process and system to avoid compliance risks while carrying out operations and encourage employees to proactively report compliance issues to the higher management.


Data Security and End-User Privacy

Information security management system is aligned with ISO 27001:2013 standard Implementation of policies and procedures with respect to PHI comply with HIPAA-HITECH regulations Data replication between Sun Knowledge’s servers in NY and India via site-to-site IPsec VPN tunnels helps strong

business continuity management Daily off-site backup process to mitigate data loss risk in case of disaster Implementation of physical access control system in office premises restricts access to sensitive areas housing

application and database Physical and logical segregation of internal network into VLAN segments to control and protect data storage and

transmission between business/process units Implementation of perimeter security devices, like firewall and segregation of sensitive information systems Access to all information systems through two levels of authorization Implementation of two levels of end point malware protection network and system level anti-malware systems Use of secure e-mail system for e-mails with sensitive PHI information Implementation of access restrictions to prevent unauthorized deletion or movement of data using external

storage devices like optical discs, pen drives, etc. Security incident monitoring, reporting and resolution system Periodic employee awareness training on data privacy & protection and HIPAA regulations


WHY US?


Advantage GoTelecare

1Over 7 Years of Experience in Working as Vendors for

Major Health Insurance

Companies Across US

Deep Knowledge of both the Payer

and the Provider Side

of the US Healthcare Spectrum

2Consistent

Performance in Delivering up

to 95% Collection Rate

to Clients

Already

Recovered over millions in

Account Receivables

and counting…

3The Only

Medical Billing Company with Its Own State-

of-the-Art Telemedicine

Platform

4The Best

References in Every

Segment of US

Healthcare Knowledge &

Business Process

Outsourcing

5The Lowest Prices in

the Market!


Our 4 Pillars of Strength

Highest Quality

Excellent References

Unique Profile

Cheapest Rates

Consistently delivering the best quality, with the highest levels of accuracy, efficiency & expertise

Glowing testimonials from every client and not a single customer

churn in our 7+ years of operation

Huge experience in working for both Payers and Providers and

the only billing company with its own Telemedicine platform

The lowest rates in the market, with custom pricing options to

delight all clients


GoTelecare vs. Other Staffing Agencies


Why Us?

Very Little Risk• Proven track record in providing healthcare BPO/KPO services• Highly experienced in providing services to both payers and providers• Experienced in 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 increase in revenue collection • Verification & authorization accuracy > 99.9%; TAT: 24 hours • High accuracy in Eligibility Data Maintenance (in sync with CMS)

Clear Communication and Quick Response at All Times ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection


What are Our Clients Saying

"The professionalism I have experienced with GoTelecare’s employees has made them very easy to work with and has improved our operation processes. Any time I have a question, they are literally just a phone call or e-mail away. I love the accessibility!”

- CFO of a major US healthcare company

“I am starting to see an upswing with Medicare and United cash flow”

- CEO of a leading US healthcare organization

“Your productivity is very impressive for your first month. Almost everyone has an average of close to 40 accounts per day. We have gone over a few things with you and each time we talk, I am impressed with how quickly changes and improvements are put in place.

I will continue to share feedback as I get it on additional improvements that can be made and appreciate your attentiveness and questions that you bring to our daily meetings.

- Manager (Revenue Cycle) of a reputed US healthcare company


Contact

41 Madison Avenue, 25th Floor, New York, NY 10010

(646) 661-7853 [email protected]

Ronnie Hastings

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