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MEDICAL BILLING SERVICES FOR URGENT CARE 41 Madison Avenue, 25 th Floor, New York, NY 10010, USA Phone: (646) 661-7853 | E-mail: [email protected]

Medical Billing Services for Urgent Care Centers by Sun Knowledge

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MEDICAL BILLING SERVICESFOR URGENT CARE

41 Madison Avenue, 25th Floor, New York, NY 10010, USAPhone: (646) 661-7853 | E-mail: [email protected]

Private & Confidential 2Phone: (646) 661-7853 | E-mail: [email protected]

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

SUN KNOWLEDGE OVERVIEW

Key Facts Awards, Affiliations & Certifications

‘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

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

SUN KNOWLEDGE SERVICE PORTFOLIO

Provider SupportMember SupportMember Retention ProgramClinical Help Desk

Contact Center

Utilization ManagementMedication Therapy ManagementHospital Re-admission

ManagementTherapeutic InterchangeFormulary Management

Clinical Services

Medical Coding & BillingClaims AdministrationEnrollment Processing &

MemberFulfillmentCredentialing Premium billing and collections

Administrative Services

Analytics

Telemedicine ServicesRemote Patient MonitoringApplication Development & SupportTechnical SupportTechnical Documentation

IT Services

Claims /Drug Utilization AnalysisPDE AnalysisRAF AnalysisPayment Reconciliation

We provide services to

Providers – Physicians, Hospitals, DME, P&O, Home Health Care and Pharmacies

Payers – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs

Private & Confidential 3Phone: (646) 661-7853 | E-mail: [email protected]

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

SUMMARY OF SERVICES

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

Private & Confidential 4Phone: (646) 661-7853 | E-mail: [email protected]

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

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 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

Private & Confidential 5Phone: (646) 661-7853 | E-mail: [email protected]

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

REVENUE CYCLEMANAGEMENT

Private & Confidential 6Phone: (646) 661-7853 | E-mail: [email protected]

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

ACCOUNTS RECEIVABLE IN THE REVENUE CYCLE

360° Revenue Cycle Management

Services

Eligibility & Authorization

VerificationPatient

Information Entry

Coding

Charge Entry

Claim Submission

Payment Posting

Accounts Receivable

Denial Management

Reporting

Private & Confidential 7Phone: (646) 661-7853 | E-mail: [email protected]

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

SERVICE HIGHLIGHTS

Cutting-edge rapid automation technology

Up to 97% collection rate

Real-time eligibility checks & fast authorization

100% HIPAA-HITECH compliance

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

Extensive payer-side experience (in claim adjudication)

Private & Confidential 8Phone: (646) 661-7853 | E-mail: [email protected]

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

SERVICE AREAS

We provide turnkey revenue cycle management services in the following areas:

Prosthetics & Orthotics Durable Medical Equipment Urgent Care

Pathology Emergency Rooms Skilled Nursing Facilities

Wound Care EKG Pharmacies

Cardiology Specialty Clinics Orthopedic Surgery

Anesthesia Family Practice Radiology

Rehab Centers Dermatology Physicians

Healthcare Facilities and more…

Private & Confidential 9Phone: (646) 661-7853 | E-mail: [email protected]

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

ELIGIBILITY & AUTHORIZATION

VERIFICATION

Private & Confidential 10Phone: (646) 661-7853 | E-mail: [email protected]

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

ELIGIBILITY VERIFICATION – HIGHLIGHTS

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 rapid database accessthrough appropriate lookup software applications)

Private & Confidential 11Phone: (646) 661-7853 | E-mail: [email protected]

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

AUTHORIZATION VERIFICATION – HIGHLIGHTS

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 have given us a unique understanding of the authorization process, allowing us to complete the process faster than others!

Private & Confidential 12Phone: (646) 661-7853 | E-mail: [email protected]

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

SAMPLE REPORTS

4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/20150

20

40

60

80

100

120

140

96

83

94

98 96

29

11

6

31 32

125

94

100

129

128

41

32

26

30 28

ELIGIBILITY VERIFICATION

Number of New Patient Patient Brought ForwardPrimary Checked Secondary Checked (if applicable)

4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/20150

5

10

15

20

25

30

35

40

45

5045

25

38

4446

20

15

26

22 21

25

1012

2225

AUTHORIZATION VERIFICATION

Auth Required Auth Obtained Auth Pending

Private & Confidential 13Phone: (646) 661-7853 | E-mail: [email protected]

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

BILLING & CODING

Private & Confidential 14Phone: (646) 661-7853 | E-mail: [email protected]

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

MEDICAL CODING OVERVIEW

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

Private & Confidential 15Phone: (646) 661-7853 | E-mail: [email protected]

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

MEDICAL CODING – PROCESS

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

Private & Confidential 16Phone: (646) 661-7853 | E-mail: [email protected]

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

MEDICAL BILLING SYSTEM

We use some of the premium medical billing software systems for coding and billing services that cover the complete billing cycle, including: 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 any billing system as preferred by the client.

Private & Confidential 17Phone: (646) 661-7853 | E-mail: [email protected]

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

OTHER SERVICES

Private & Confidential 18Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 19Phone: (646) 661-7853 | E-mail: [email protected]

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

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.

Sample Report

Private & Confidential 20Phone: (646) 661-7853 | E-mail: [email protected]

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

TELEMEDICINE

Our customizable telemedicine platform (offered through our telemedicine partner GoTelecare Inc.) connects patients, healthcare providers and ancillary staff members to complete face-to-face consultationso Reduces healthcare costso Decreases patient wait times for patient appointmentso Increases patient satisfactiono Simple, easy to use user interface

Diabetic Verification Formo Expedites the process to receive the returned, signed Diabetic Verification Form from the

primary care physician

Prescription Refillso For rental devices; decreases the time associated with

obtaining a prescription refill

Private & Confidential 21Phone: (646) 661-7853 | E-mail: [email protected]

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

ACCOUNTS RECEIVABLEMANAGEMENT

Private & Confidential 22Phone: (646) 661-7853 | E-mail: [email protected]

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

ACCOUNTS RECEIVABLE FOLLOW-UP

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.

Private & Confidential 23Phone: (646) 661-7853 | E-mail: [email protected]

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

THE SUN KNOWLEDGE EDGE

Sun Knowledge’s trained and highly-skilled billing and AR follow up personnel can help Providers submit claims to the correct Payer(s) and follow up with them to realize the maximum payment fast!

When claims need to be chased,

we know whom to ask,when to ask

andhow to ask!

Private & Confidential 24Phone: (646) 661-7853 | E-mail: [email protected]

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

STEPS IN A/R 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 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 what we excel in!

Private & Confidential 25Phone: (646) 661-7853 | E-mail: [email protected]

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

SAMPLE OF AGENT-WISE A/R REPORT

User ID Touched Accounts

Note Count Days Worked Hours

WorkedNotes Per

Hour Max 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

Private & Confidential 26Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 27Phone: (646) 661-7853 | E-mail: [email protected]

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

BENEFIT HIGHLIGHTS

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

Private & Confidential 28Phone: (646) 661-7853 | E-mail: [email protected]

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

DENIAL MANAGEMENT

Private & Confidential 29Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 30Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 31Phone: (646) 661-7853 | E-mail: [email protected]

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

DISTRIBUTION OF DENIED CLAIMS

24%

11%3%

35%

17%

10%

Distribution of Denied Claims

Auth Related Coding Correction Required

OON Issue OthersPatient 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

Private & Confidential 32Phone: (646) 661-7853 | E-mail: [email protected]

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

TECHNOLOGY, OPERATIONAL & COMPLIANCE FRAMEWORK

Private & Confidential 33Phone: (646) 661-7853 | E-mail: [email protected]

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

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 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

Private & Confidential 34Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 35Phone: (646) 661-7853 | E-mail: [email protected]

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

GOVERNANCE MODEL

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

Private & Confidential 36Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 37Phone: (646) 661-7853 | E-mail: [email protected]

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

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

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.

Private & Confidential 38Phone: (646) 661-7853 | E-mail: [email protected]

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

COMPLIANCE ESCALATION STRUCTURE

Service DeliveryService Delivery Mgr

(Service Delivery POC)

Head of Operations

(1st Level Escalation POC)

Operations

CEO & MD

(Final Escalation POC)

Executive Board

Board of Directors

ComplianceCompliance Mgr

(Compliance Escalation POC)

Head of ComplianceCompliance

Team LeadProcess Team Lead

(Service Delivery POC)

TechnologyTechnology Mgr

QualityQuality Mgr

HR/TrainingHR/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

Private & Confidential 39Phone: (646) 661-7853 | E-mail: [email protected]

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

CHALLENGES & RESPONSES

Private & Confidential 40Phone: (646) 661-7853 | E-mail: [email protected]

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

CHALLENGES & 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

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

Private & Confidential 41Phone: (646) 661-7853 | E-mail: [email protected]

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

CHALLENGES & OUR APPROACH

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

Private & Confidential 42Phone: (646) 661-7853 | E-mail: [email protected]

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

CHALLENGES & OUR APPROACH

Proper documentation – process manual, guidelines & checklists

Defining proper tracking mechanism through various reports -Ageing, Status, Daily, Exception

Generate exception reports and regular audit of every process tasks

Defining KPIs and assigning responsibility

Lack of clarity of claims volume and current status affects management decision making process

Impact on overall billing process performance and improvement

Decreased productive efficiencyProcess Administration and Reporting

AR Follow-up & Denial Management

Regular analysis, follow-up and review

Transaction audit

TASK DESCRIPTION CHALLENGES APPROACH

Accumulation of backlog Denials not posted Claims reconciliation issue

Private & Confidential 43Phone: (646) 661-7853 | E-mail: [email protected]

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

SOCIAL MEDIA MARKETING

Private & Confidential 44Phone: (646) 661-7853 | E-mail: [email protected]

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

EVEN MORE BENEFITS

Private & Confidential 45Phone: (646) 661-7853 | E-mail: [email protected]

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

ACTIVE BRANDING & VIGOROUS LEAD GENERATION THROUGH SOCIAL MEDIA MARKETING

3.4Million

HealthcareProviders

Tap into our massive, and ever-growing, database of over 3 million healthcare providers from every corner of the US, and discover your next client!

Active Multi-

ChannelMarketing

Targeted, high quality lead generation through various digital channels for B2B marketing such as Email marketing, SEO (Search Engine Optimization), LinkedIn® marketing, PPC (Pay Per Click) advertising, and more!

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 at All Times

ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection

Private & Confidential 46Phone: (646) 661-7853 | E-mail: [email protected]

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

TESTIMONIALS

Private & Confidential 47Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 48Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 49Phone: (646) 661-7853 | E-mail: [email protected]

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

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

Private & Confidential 50Phone: (646) 661-7853 | E-mail: [email protected]

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

Ronnie Hastings(646) 661-7853Email: [email protected]

Sun Knowledge41 Madison Avenue, 25th Floor,

New York, NY 10010

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