Complete Accounts Receivable Management guide for Hospitals by Sun Knowledge

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



SERVICE PORTFOLIO



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



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



ACCOUNTS RECEIVABLE IN THE REVENUE CYCLE



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



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



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


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


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



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



REASONS FOR DENIAL



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



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



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


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


SAMPLEREPORTS



SAMPLE OF AGENT-WISE A/R REPORT



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



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



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


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


TESTIMONIALS



CLIENTSPEAK


“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


CLIENTSPEAK


“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


CLIENTSPEAK


“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

For Additional Information, Please Contact…


mailto:[email protected]