Complete Durable Medical Equipment (DME) Billing Guide | Sun Knowledge

MEDICAL BILLING & COLLECTION

FOR DME

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


PRACTICE MANAGEMENT

Scheduling

Eligibility & Authorization Verification

Prior Authorization

Customer Care

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


REVENUE CYCLEMANAGEMENT

REVENUE CYCLE MANAGEMENT – KEY PROCESSES


360° Revenue Cycle Management

Services

SERVICE HIGHLIGHTS


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

REVENUE CYCLE MANAGEMENT


• Physicians / Hospitals

• DMEPOS

• Pharmacy (WC/ PIP)

Work with physicians to enroll them with payers, setup billing systems with fee schedules, review clinical notes, code CPT/ICD, submit claims, payment posting and follow-up with payers and patients

Setup DME companies in DME billing system, receive orders, generate claims, payment posting and follow-up with payers and patients

Setup billing systems for submission of WC/PIP claims, code and apply correct modifiers, check eligibility with adjusters, generate claims, payment posting and follow-up

Sun Knowledge provides medical billing & coding services - prompt, perfect and professional. We are HIPAA compliant.

REVENUE CYCLE MANAGEMENT SERVICES


End-to-End Billing Services:

Hospitals/ Physicians DMEPOS Pharmacy (WC/PIP)

Stand Alone Billing Services:

AR Follow-up & Collection Eligibility & Auth Verification Pre-Auth Service Credentialing Patient Collection Coding

PRACTICE MANAGEMENT & BILLING SYSTEM


Sun Knowledge billing executives have experience in working on several industry standard practice management and billing software:

Sun Knowledge can provide medical billing & coding services using customer’s billing system or can setup customer’s practice in a billing system managed by Sun Knowledge.

Kareo SOS

Emdeon / Capario One Meditech

Brightree Alpha Collector

Fastrack OPIE

CPR+ HME Futura

DME Works PrimeRx

Team DME

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



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


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



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


Accumulation of backlog Denials not posted Claims reconciliation issue

ADDRESSING PROBLEMS WITH EFFECTIVE SOLUTIONS


We address problems like:

Reduced profit margins

Caused by

• Claims denial

• Delayed submission of claims

• Inefficient processes

• Low productivity

Reduced strategic directives

Caused by

• Operation reports lacking focus on orders received/delivered

• Reports on claims submission lacking functional clarity

We produce benefits like:

Process optimization

Achieved through

No backlogs in inventory/open order Significant reduction in payment realization cycle Reduction in average cost by 40% Improved efficiency leading to higher productivity

Improved financials

Achieved through

Timely claims submission, leading to improved cash flow and payment realization by 10%

Significant reduction in denial rate Increased revenue by 7%

FACTS FROM A CASE STUDY


Sun Knowledge recently helped a leading DME Provider in New York improve their complex billing process and achieve long-term bottom-line growth. Here’s how we added value to the client’s existing processes:

OLD BILLING PROCESS

OPTIMIZED BILLING PROCESS

PROCESS STABILITY: Achieved consistent and better productivity; and higher accuracy through the application of an improvement methodology

QUALITY AND EFFICIENCY IMPROVEMENT: Developed clear understanding of peculiarities of DME billing as compared to physician billing; Initiated an internal audit mechanism to identify and rectify errors; Enforced corrective and preventive action scheme

INCREASED PRODUCTIVITY AND REDUCED OPEN ORDERS: Removed redundant process steps to focus on the critical ones; Created tools / cheat sheets and introduced various process checks to improve productivity

REDUCED DENIAL RATES: Drastically reduced incorrect coding and combination in bills and developed a thorough understanding of qualifying diagnosis and payer guidelines


DME BILLING SERVICES

DME BILLING – KEY FACTS


Secure Information & Data Flow between Sun knowledge and our partners enabled with reliable networking software & hardware (includes secured Virtual Private Networks and FTP sites)

All low pay and no pays reports are sent to the client

Work on re-processing of the denied claims starts immediately after receipt of ERA

ERAs are posted to the respective patients’ accounts

Quality check is conducted at all stages of process

Turn Around Time for this process is 24 - 48 hours

ORDER ENTRY – SAMPLE REPORT


INVENTORY RECEIVED

Category Breast Pump CPAP Nebulizer Closet

Nebulizer IntegraMonth

Jun-15 330 114 34 45 0

Jul-15 664 265 0 55 447

Aug-15 957 278 0 49 552

Sep-15 867 248 0 35 400

Oct-15 835 303 0 74 722

Nov-15 923 244 0 105 632

Dec-15 947 299 0 133 637

Jan-16 779 230 0 142 655

INVENTORY COMPLETED

Category Breast Pump CPAP Nebulizer Closet

Nebulizer IntegraMonth

Jun-15 330 114 33 45 0

Jul-15 664 265 0 55 447

Aug-15 957 278 0 49 552

Sep-15 867 248 0 35 400

Oct-15 835 303 0 72 690

Nov-15 923 241 0 105 592

Dec-15 946 290 0 127 637

Jan-16 752 209 0 134 655

Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

0

100

200

300

400

500

600

700

800

900

1000

INVENTORY RECEIVED

Breast PumpCPAPNebulizerCloset NebulizerIntegra

Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

0

100

200

300

400

500

600

700

800

900

1000

INVENTORY COMPLETED

Breast PumpCPAPNebulizerCloset NebulizerIntegra

ELIGIBILITY & AUTH. VERIFICATION – SAMPLE REPORT


SUN KNOWLEDGE ELIGIBILITY VERIFICATION & AUTHORIZATION DETAILED FOR ABC - (7/10/2015 )

Sl. No. Patient # Equipment Category

Eligibility Checked

Primary Checked

Secondary Checked

Auth Required

Auth Obtained Fax sent Auth

Pending Comment

1 221359 Beds / Mattress Yes Yes No Yes No Yes Yes Pending Auth# Ak-098651Follow-up : 07/15/2015

2 328547 Beds / Mattress Yes Yes No Yes No Yes Yes Follow-up : 07/14/2015

3 190398 CPAP - Machine Yes Yes No Yes No No YesSleep study report missing. Dr.'s office contactedFollow-up : 07/13/2015

4 215604 Diabetic Supplies Yes Yes Yes No Yes Yes No Follow-up : 07/14/2015

5 218219 CPAP - Machine Yes Yes No Yes No Yes No Follow-up : 07/17/2015

EIGIBILITY VERIFICATION & AUTHORIZATION SUMMARY REPORT FOR ABC - 07/10/2015 Equipment Category

Number of New Patients

Patients Brought Forward

Total Patients

Primary Checked

Secondary Checked Auth Required Auth Obtained Fax sent Auth Pending

Beds / Mattress 25 0 25 25 4 19 2 2 17

CPAP (Supplies) 44 3 47 47 12 9 7 6 2

CPAP (Machine) 15 0 15 15 3 11 3 3 8

Other DME 50 12 62 61 18 23 5 21 18

Diabetic Supplies 27 0 27 27 6 8 6 8 2

Total 161 15 176 175 43 70 23 40 47

CPAP USER COMPLIANCE & TRACKING – SAMPLE REPORT


CPAP USER COMPLIANCE TRACKING SUMMARY REPORT FOR ABC - 07/10/2015

Day No. of Patients

Compliant PatientsNo. of Non-Compliant

Patients

No. of Patients with No Data

Available PendingNo. of Compliant

PatientsNo. of Patients

Compliant based on best 30 days

90th day Compliance Report 5 3 0 0 0 2





TOTAL 17 11 2 1 3

SUN KNOWLEDGE CPAP USER COMPLIANCE TRACKING STATUS REPORT - 07/10/2015

S No. Set Up Date 5th Day 15th

Day30th Day

60th Day

90th Day Patient # Patient Name Doctor System Status

Therapy Report Imaged

Report Faxed to Dr.

Email /Faxed Sales

personPayer Name Comment /

Notes

1 4/8/2015 N/A N/A N/A N/A 83.45% 213765 DOE, JOHN Paez Encore Complete Yes Yes No OXFORD HEALTH PLANS

2 4/8/2015 N/A N/A N/A N/A 65.60% 218619 DOE, DAVID Smith Resmed Complete Yes Yes No OXFORD HEALTH PLANS Best of 30 days-73.3%

3 6/6/2015 N/A N/A 100% N/A N/A 125354 DAY, JULIE Ricardo Encore Complete Yes Yes No MEDICARE

4 6/5/2015 N/A N/A 96.70% N/A N/A 295695 ROE, JANE Paez Encore Complete Yes Yes No HEALTH FIRST NY

5 6/30/2015 80% N/A N/A N/A N/A 233432 DOE, JULIE Paez Encore Complete N/A N/A N/A HEALTH FIRST NY

6 5/27/2015 N/A N/A 100% N/A N/A 196476 SMITH, JOE Jones Resmed Complete Yes Yes No MEDICARE

7 5/23/2015 N/A N/A 73% N/A N/A 215604 BLOGGS, JOE Jones ICODE Complete Yes Yes No AETNA HEALTH PLAN

8 6/3/2015 N/A N/A 57% N/A N/A 217849 SMITH, JULIE Smith Resmed Complete Yes Yes No MEDICARE

9 6/27/2015 100% N/A N/A N/A N/A 168488 ROE, JOHN Jones ICODE Complete N/A N/A N/A MEDICARE

10 5/1/2015 N/A N/A N/A 67.00% N/A 214535 RODRIGUEZ, P Jones Encore Complete Yes Yes No HEALTH FIRST NY

AR & AR CALLING – SAMPLE REPORT


Payer>120 Days 91 – 120 Days 61 – 90 Days 31 – 60 Days

Claims Completed Remaining Claims Completed Remaining Claims Completed Remaining Claims Completed RemainingAARP HEALTH CARE OPTIONS 26 23 3 17 16 1 44 41 3 37 32 5AMERICAN TRANSIT INSURANCE COMPANY 12 11 1 6 5 1 15 15 0 10 10 0

BCBCS 28 24 4 16 13 3 41 37 4 32 30 2MAGNACARE 13 12 1 9 9 0 23 22 1 11 10 1HIP_PALLADIAN HEALTH 6 6 0 12 9 3 12 10 2 15 15 0MANAGED PHYSICAL NETWORK 12 10 2 8 7 1 10 10 0 10 8 2MAGNACARE 7 7 0 2 11 -9 5 5 0 8 3 5OXFORD 12 9 3 17 12 5 23 22 1 22 16 6STATE FARM INSURANCE 7 6 1 4 4 0 5 5 0 4 4 0TOUCHSTONE HEALTH 5 5 0 8 6 2 6 4 2 16 12 4UNITED HEALTHCARE 31 28 3 23 20 3 49 43 6 41 39 2

S No. Date Payer Patient

Name DOB DOS Claim No. Charge Amount Status Comments Ref #

1 7/21/2015 Healthfirst Doe, John 8/29/1974 6/26/2015 1063051526 $195.00 PaidCalled Healthfirst spoke with Gary - Rep stated that claim received on 06/30/15 and processed on 07/17/15. Per rep ins paid $173.47 on check# 3023659 having bulk amount $11909.23. Check was issued on 07/17/15 and is not cashed yet.

1063051526

2 7/21/2015 Healthfirst Roe, Julie 5/3/1983 6/16/2015 1091527510 $195.00 PaidCalled Healthfirst spoke with Gary - Rep stated that claim received on 06/19/15 and processed on 07/10/15. Per rep ins paid $173.47 on check# 3019387 having bulk amount $25091.99. Check was issued on 07/10/15 and is not cashed yet.

1061915510

3 7/24/2015 Magna Care (Oscar) Roe, David 8/11/1942 5/26/2015 P0449302 $3,800.00 PaidPer Ashley- rep stated that claim received on 06/05/15 and ins applied $292.60 towards pt as coins and paid 2633.40 by ck# 69783. Check issued on 07/10/15 and not yet cashed.

CL725541

4 7/24/2015 Magna Care (Oscar) Bloggs, Joe 8/10/1952 6/17/2015 Q0487598 $252.11 In Process Per Ashley - Rep stated that claim received on 07/06/15 and still in process CL8765541

5 7/29/2015Health Republic Insurance of New York

Bokhari, Shahid 3/4/1958 6/19/2015 16478355-01 $100.00 Allowed

Per Andriya stated that claim processed on 07/08/15 and ins applied $82.89 towards in-network deductible, Per rep the annual in-network deductible is $2000.

18441664

6 7/31/2015 Oxford Health Plan Smith, P 4/25/002 6/8/2015 5184T02894 $59.62 Paid Per Kelly stated that claim paid $42.58 on ck# 13357299 having bulk amount $221.32 issued on 07/28/15 and not cashed yet. 15298601

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 Con-dition

5%

Others26%

Distribution of Denied Claims

BENEFITS PROPOSITION


Increased revenue – reduced collection Time (up to 97% collection rate)

Claim submission within 48 hours of receipt of billing input

Adherence to CMS billing requirements

Proper records maintenance and visibility through reporting

Standardization of billing operations

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

mailto:[email protected]