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MEDICAL BILLING SERVICESFOR URGENT CARE CENTERS
ELIGIBILITY & AUTHORIZATION VERIFICATIONBILLING & CODING | ACCOUNTS RECEIVABLE
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
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, 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 & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SUMMARY OF SERVICES
4Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRACTICE MANAGEMENT
Scheduling
Eligibility & Authorization Verification
Prior Authorization
Customer Care
HIPAA COMPLIANCE SUMMARY
5Sun Knowledge © 2015-16 Private & Confidential41 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
6Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REVENUE CYCLEMANAGEMENT
REVENUE CYCLE MANAGEMENT – KEY PROCESSES
7Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
360° Revenue Cycle Management
Services
SERVICE HIGHLIGHTS
8Sun Knowledge © 2015-16 Private & Confidential41 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
SERVICE AREAS
9Sun Knowledge © 2015-16 Private & Confidential41 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…
10Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ELIGIBILITY & AUTHORIZATION
VERIFICATION
ELIGIBILITY VERIFICATION – HIGHLIGHTS
11Sun Knowledge © 2015-16 Private & Confidential41 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)
ELIGIBILITY VERIFICATION – SERVICE FEATURES
12Sun Knowledge © 2015-16 Private & Confidential41 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.
AUTHORIZATION VERIFICATION – HIGHLIGHTS
13Sun Knowledge © 2015-16 Private & Confidential41 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!
SAMPLE REPORTS
14Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
BENEFITS OVERVIEW
15Sun Knowledge © 2015-16 Private & Confidential41 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!
16Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
BILLING & CODING
MEDICAL CODING OVERVIEW
17Sun Knowledge © 2015-16 Private & Confidential41 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
MEDICAL CODING – PROCESS
18Sun Knowledge © 2015-16 Private & Confidential41 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
TYPICAL MEDICAL BILLING CYCLE
19Sun Knowledge © 2015-16 Private & Confidential41 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
MEDICAL BILLING SYSTEM
20Sun Knowledge © 2015-16 Private & Confidential41 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.
21Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
OTHER SERVICES
PAYMENT/DENIAL POSTING PROCESS
22Sun Knowledge © 2015-16 Private & Confidential41 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
PRODUCTIVITY EFFICIENCY TRACKING
23Sun Knowledge © 2015-16 Private & Confidential41 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
24Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTS RECEIVABLEMANAGEMENT
ACCOUNTS RECEIVABLE ANALYSIS
25Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
We are offering our Accounts Receivable Analysis Service for FREE for a limited time. Contact us today for a no-obligation AR health checkup.
Try our Accounts Receivable Analysis Service to quickly find out how much extra reimbursement you are entitled to from Medicare and other insurance companies.
The Sun Knowledge AR Analysis Team uses our proprietary Rapid Automation Technology to scrutinize your financial records and find out problems such as,
• Number of bills remaining unpaid
• Cases where services have been under-billed
• Claim corrections that are pending
• Claims about to cross the Timely Filing Limit, and more!
STEPS IN A/R FOLLOW-UP
26Sun Knowledge © 2015-16 Private & Confidential41 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
SAMPLE SOW FOR A/R FOLLOW-UP
27Sun Knowledge © 2015-16 Private & Confidential41 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.
…
SAMPLE OF AGENT-WISE A/R REPORT
28Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
SAMPLE OF A/R AGING REPORT
29Sun Knowledge © 2015-16 Private & Confidential41 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
BENEFIT HIGHLIGHTS
30Sun 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
31Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
DENIAL MANAGEMENT
REASONS FOR DENIAL
32Sun Knowledge © 2015-16 Private & Confidential41 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
33Sun Knowledge © 2015-16 Private & Confidential41 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
34Sun Knowledge © 2015-16 Private & Confidential41 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 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
35Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TECHNOLOGY, OPERATIONAL & COMPLIANCE FRAMEWORK
IT INFRASTRUCTURE
36Sun Knowledge © 2015-16 Private & Confidential41 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
OPERATIONAL FRAMEWORK
37Sun Knowledge © 2015-16 Private & Confidential41 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
GOVERNANCE MODEL
38Sun Knowledge © 2015-16 Private & Confidential41 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
QUALITY ASSURANCE & CONTROL
39Sun Knowledge © 2015-16 Private & Confidential41 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
COMPLIANCE KEY FACTS
40Sun Knowledge © 2015-16 Private & Confidential41 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.
COMPLIANCE ESCALATION STRUCTURE
41Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
42Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & RESPONSES
CHALLENGES & OUR APPROACH
43Sun Knowledge © 2015-16 Private & Confidential41 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
CHALLENGES & OUR APPROACH
44Sun Knowledge © 2015-16 Private & Confidential41 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
CHALLENGES & OUR APPROACH
45Sun Knowledge © 2015-16 Private & Confidential41 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 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
SUMMARY OF BENEFITS
46Sun 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
47Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
CLIENTSPEAK
48Sun 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
49Sun 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
50Sun 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
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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