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ACCOUNTS RECEIVABLEMANAGEMENT SERVICES
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 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
3Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SERVICE PORTFOLIO
4Sun Knowledge © 2015-16 Private & Confidential
PRACTICE MANAGEMENT
Order Entry
Eligibility & Authorization Verification
Prior Authorization
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
OUR 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
ACCOUNTS RECEIVABLE MANAGEMENT
6Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTS RECEIVABLE IN THE REVENUE CYCLE
7Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
360° Revenue Cycle Management
Services
ACCOUNTS RECEIVABLE MGMT. PROCESS OVERVIEW
8Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Our A/R follow-up service is designed to increase the Revenue Collection for our clients.
The process begins after the Provider creates and sends Health Insurance Claims (Electronic/Paper claims or Manual HCFA forms) to various Insurance Companies.
Depending on the transmission type and length of time since submission, we begin our follow-ups.
FOLLOW-UP
9Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
No Remark Claims:
Any claim in which absolutely no status is known for the claim.
Last Remark Claims:
Claims which remain unpaid for various reasons. These claims are routinely followed up on a monthly basis.
2 types of Claims Follow-ups
1
2
STEPS IN ACCOUNTS RECEIVABLE FOLLOW-UP
10Sun Knowledge © 2015-16 Private & Confidential
A/R Analysis
• 14% of all claims submitted to the payers are denied and have to be resubmitted, appealed or written off by providers
• 50% of denied claims are never re-filed
• 50-70% of denied claims have higher chance of being recovered
Follow-up with Payor
• Aggressive follow up with the insurance company's on all accounts at any stage of the aging bucket plays an important part in A/R follow up activities
Closure of claim
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Reducing days in A/R, claims submission and improving collection ratio with an increase in the probability of payment through timely follow-up is
the responsibility of the A/R team
STEPS IN ACCOUNTS RECEIVABLE FOLLOW-UP
11Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Online Claims Follow-UpUsing various insurance company websites and Internet payer portals, we check on the status of outstanding claims.
Automated Claims Follow-Up (IVR)By calling insurance companies directly, an Interactive Voice Response (IVR) system will provide the status of unpaid claims.
Insurance Company RepresentativeIf necessary, calling a ‘live’ insurance company representative will give us a more detailed reason for claim denials when such information is not available by the first 2 methods.
1
2
3
DENIALMANAGEMENT
12Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REASONS FOR DENIAL
13Sun 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
14Sun 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
15Sun 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
BENEFIT HIGHLIGHTS
16Sun Knowledge © 2015-16 Private & Confidential
Reduction in accounts receivable
by 30% within 1 month
Accounts Receivable recovery cost starts from
2.5% of collections
Expert handling of accounts receivable by highly experienced staff
Same attention to every cash amount regardless of
its size or source
Demonstrated expertise in working on difficult-to-recover aging A/R
Over 7 years’ experience in claim adjudication for
major US insurance plans
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLEREPORTS
17Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE OF AGENT-WISE A/R REPORT
18Sun 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
19Sun 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
SAMPLE SOW OF A/R FOLLOW-UP
20Sun 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.
…
SUMMARY OF BENEFITS
21Sun Knowledge © 2015-16 Private & Confidential
Very Little Risk• Proven track record in providing healthcare BPO/KPO services• Experienced in providing services to both payers and providers• Experienced working with various software platforms• Quick and efficient resource for special projects requiring technical and process expertise
Significant Upside Potential• Great understanding of the Healthcare Industry. Operation scale-up with a short notice• Extremely competitive rates, greater productivity, improved quality, increased member and provider
satisfaction Proven Process Performance
• Low denial rate reduced collection time increase in revenue collection• Billing & Coding Accuracy > 99.9%; TAT: 24 – 48 hours • Adherence to CMS billing requirements
Clear Communication and Quick Response Time at All Times
ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
22Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
23Sun Knowledge © 2015-16 Private & Confidential
“We have had the pleasure of working with the Sun Knowledge team throughout the few months utilizing their services for patient data entry and eligibility verification. They are a devoted and responsible team that is highly experience in what they do. They are always concerned about the client’s needs and are always there to help. I highly recommend the services offered by Sun Knowledge.”
COO of a leading medical billing and credentialing company in New York
“Your team amazed me with the manual and the amount of info you provided with that short training session.”
Practice Manager of a major Dermatology group in New York and New Jersey
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
24Sun Knowledge © 2015-16 Private & Confidential
“My firm has evaluated an outsourcing transaction with Sun Knowledge. They provide superior service at a very attractive rate and have demonstrated to us their commitment to this partnership. Their expertise across various process areas in the PDP/MAPD domain and unique cost structure puts them in an incredible position to work with plans throughout the healthcare industry.”
Chairman, President and CEO of a major New York based Health Plan
“Our company is very pleased with the administrative, and business analytical solutions which Sun Knowledge delivers to our company from a quality & cost perspective. They have been a true partner in bringing industry expertise, and innovative solutions to the table. Their ability to grow with our evolving needs for higher end services such as clinical services is a significant differentiator among healthcare business process outsourcing firms.”
Executive Vice President of Operations of a leading MSO
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
25Sun Knowledge © 2015-16 Private & Confidential
“I was always against the idea of outsourcing our back end claims processing work but I was wrong. Sun Knowledge provided extraordinary deliverables on a timely basis which led to cost cutting considerably for us.”
CEO of a leading MA-PD Plan
Ronnie Hastings(646) 661-7853Email: [email protected]
Sun Knowledge41 Madison Ave., Suite 2511, 25th Floor
New York, NY 11001, USA
For Additional Information, Please Contact…
41 Madison Avenue, 25th Floor, New York, NY 10010, USA