Coding & Billing Services for DME (Durable Medical Equipment), Prosthetics & Orthotics

Medical Billing Service Offerings Durable Medical Equipment and Orthotics & Prosthetics

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

2© GoTelecare 2014-15| All Rights Reserved Private & Confidential

Sun Knowledge is our closely affiliated company under the same ownership.

‘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 process knowledge Structured training, feedback and coaching HIPAA-HITECH compliant Offices located in USA& India

• New York City, USA – Situated in Manhattan (facility inbuilt with all redundancies – power, infrastructure and others)

• Kolkata, India – Situated in the IT Hub(facility inbuilt with all redundancies – power, infrastructure and others)

ISO 27001:2005 and ISO 9001:2008 certified company 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

Overview

Key Facts Awards, Affiliations & Certifications

GOTELECARE SERVICE PORTFOLIO

Provider Support

Member Support

Member Retention Program

Clinical Help Desk

Contact Center

Utilization ManagementMedication Therapy ManagementHospital Re-admission

ManagementTherapeutic InterchangeFormulary Management

Clinical Services

Enrollment Processing & Member

FulfillmentClaims AdministrationCoding & Medical BillingCredentialing Premium billing and collections

Administrative Services

Analytics

Telemedicine Services

Application Development

Data Modeling & Data Warehousing

Technical Support

Technical Documentation

IT Services

Claims /Drug Utilization Analysis

PDE Analysis

RAF Analysis

Payment Reconciliation

We provide services to

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

Private & Confidential© GoTelecare 2014-15| All Rights Reserved 3


ADVANTAGES & BENEFITS

• Significant decrease in operational expenses

• With over 5 years of successful DME and O&P experience, Sun Knowledge/GoTelecare provides professional consulting to best allocate resources to increase profit margins.

• We guarantee > 50% operational savings effective immediately.

• For Example: New York Home Health Care Equipment reported to Sun Knowledge a $2.1 million operational savings in Y1*

• Heightened collection and increased Account Receivables

• 30% of DME and O&P Rx are incomplete when first received. We excel in completing the Rx claim quickly.

• Cyclical Data Reporting

• Data reporting interval can be customized to meet the needs of the customer.

• Demonstrated experience handling DME and O&P claims

• Medicare, Medicaid, and Commercial Plans Fee for Service and Capitated Plans

* New York Home Health Care Equipment is the largest DME company in New York City servicing residents in 13 counties in 3 states since 1982.


Durable medical equipment (DME) is any equipment that provides therapeutic benefits to a member because of certain medical conditions and/or illnesses that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and is appropriate for use in the home.Example:

Ambulatory equipment: rollator, cane, crutch Chairs: Geriatric chair, wedge cushions, Wheel chairs etc. Breast pump CPAP & BiPAP machines & supplies Continuous Passive Motion machine Perenteral & enteral feeding equipment & products Hospital bed: Semi electric, fully electric, Side rails, gel overlay mattress etc. Blood pressure, Glucose monitoring devices Orthotics: Splint, brace , inserts etc. Oxygen devices: Concentrator & supplies Respiratory equipment: Nebulizer compressor, Suction machines etc.

BILLING FOR DURABLE MEDICAL EQUIPMENT


DME coverage may be subject to a copay or coinsurance. Authorization is required for various DME and this varies from payer to payer. This is considered a part of the member’s DME benefits provisions. For DME to be covered the general billing requirements are:

A prescription from the ordering physician dated prior to delivery date Certain items must be rented prior to being converted to purchase and therefore must be billed as rentals Consideration of limitations based on time period within which the item can be covered if supplied earlier.

E.g. CPAP machines cannot be ordered more than once every 5 years while most CPAP supplies are available every 3 months

Appropriate modifiers must be billed with DME Letter of medical necessity and additional documentation may be required for some DME, e.g. orthotics,

beds & mattresses, BiPAP machines etc. Coverage for such equipment is subject to medical review. Coverage of DME is also subject to qualifying diagnosis, E.g. CPAP machines – Obstructive Sleep Apnea Maintenance, repair, or replacement and supplies may be eligible for separate reimbursement under a

contracted maintenance fee with a DME supplier acceptable by the payer.

DME COVERAGE & BILLING


The billing cycle for DME involves the following activities: 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 auth requirement enquiry Collection of documents required by payer for auth approval, E.g. face to face consultation notes,

Polysomnography / Titration report etc. and obtaining of authorization from payer. Determination that payer criteria is met before delivery of DME, E.g. some DME have time / frequency / annual

cost limitations for DME (if criteria is not met the patient needs to be 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

DME BILLING CYCLE


DME AND O&P BILLINGChallenges Vs 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 Auth

Eligibility verification

DME BILLING – CHALLENGES VS. APPROACH

9Sun Knowledge © 2015-16 Private & Confidential

Patient Demographics / Insurance / Initial Rx Entry

Transaction audit to minimize error that will reduce 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 and payers to collect documentation, obtain authorizationProper tracking mechanism

Defining KPI for rejection management process and assigning responsibility Claims reconciliation and exception report generation

Unapplied balance Accumulation of backlog Manual posting Denials not posted Payment reconciliation issue

Delayed correction and resubmissionPossible loss of payment

Payment Posting

Rejection management



Paper claim submission

Proper tracking of every submission of paper claimsMoving to EDI based submission whenever possible will reduce cost of manual work and faster payment cycle


Additional work for printing and faxing/mailing Delayed filing leading to denials Lack of information about the actual status

Defining guidelinesReview of patient payments Define KPI – TAT & Accuracy Denial posting and review

Proper documentation – process manual, guidelines & checklistsDefining proper tracking mechanism through various reports -Ageing, Status, Daily, ExceptionGenerate exception reports and regular audit of every process tasksDefining 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 efficiency

Process administration and reporting



AR Follow-up & Denial Management

Regular analysis, follow-up and review Transaction audit


Accumulation of backlogDenials not postedClaims reconciliation issue


ELIGIBILITY VERIFICATION & AUTHORIZATION – SAMPLE REPORT

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

Auth Required Auth Obtained Auth Pending


DENIAL MANAGEMENT – SAMPLE REPORT

Auth Related14%

Coding Error5%

OON Issue8%

COB Issues10%

Patient info missing6%

Exceeds Timely Fil-ing8%

Duplicate Claim5%

Service Not Covered

6%

Primary Paid Max7%

Pre-Existing Condition

5%

Others26%

Distribution of Denied Claims


TELEMEDICINE DME and Orthotics and Prosthetics


Very Little Risk GoTelecare is experienced in handling complex contracts/claims GoTelecare is experienced working with various claims & billing systems Quick and efficient resource for special projects when needed e.g. member retention program, etc. Quick and efficient temporary resource when needed e.g. inventory back up, annual enrollment period, etc.

Significant Upside Potential GoTelecare has a good understanding of US Health Care industry. We work both for the payers and providers. Extremely competitive rates, greater productivity, improved accuracy of claims, increased provider

satisfaction, reduction in overtime cost Reduced Admin Cost Leverage partial outsourcing to increase and/or create operational expansion opportunities

Proven process performance Claims Processing: Accuracy > 98%; TAT: 5 - 10 days Efficient coding & billing process – special focus on rejection and denial management Contact Center: Abandonment Rate < 2%, ASA within 30 Seconds for 90% of calls, High CSAT

Clear Communication And Quick Response Time At All Times End user data privacy and protection through implementation of industry standard like ISO 27001:2005 & HIPAA

ADVANTAGES OF UTILIZING OUR SERVICES


CUSTOMER TESTIMONIALS & ADDITIONAL INFORMATION

David MusikerRegional Director

[email protected]

For Additional Information, Please Contact