Practice Management & Revenue Cycle Management Services for DME Billing Services

Practice Management & Revenue

Cycle Management Servicesfor DME

41 Madison Avenue, 25th Floor, New York, NY 10010, USAPhone: (646) 930-4608 | E-mail: [email protected]

Private & Confidential 2Phone: (646) 930-4608 | E-mail: [email protected]

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

WHY SUNKNOWLEDGE



SUNKNOWLEDGE OVERVIEW

Key Facts

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

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

SUNKNOWLEDGE SERVICE PORTFOLIO

Provider Support

Member Support

Member Retention Program

Clinical Help Desk

Contact Center

Utilization Management

Medication Therapy Management

Hospital Re-admission Management

Therapeutic Interchange

Formulary Management

Clinical Services

Medical Coding & Billing

Claims Administration

Enrollment Processing & Member

Fulfillment

Credentialing

Premium billing and collections

Administrative Services

Analytics

Telemedicine Services

Remote Patient Monitoring

Application Development & Support

Technical Support

Technical Documentation

IT Services

Claims /Drug Utilization Analysis

PDE Analysis

RAF Analysis

Payment 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



SERVICE PORTFOLIO

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



OUR 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 AccessSigning 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

7Network &

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 FirewallUnified 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

9VPN (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

10Redundancy

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

11Virus & 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

Eligibility & Authorization Verification

Patient Information

Entry

Coding

Charge Entry

Claim Submission

Payment Posting

Accounts Receivable

Denial Management

Reporting



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

Sunknowledge 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

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

Sunknowledge can provide medical billing & coding servicesusing customer’s billing system or can setup customer’s practicein a billing system managed by Sunknowledge.

Kareo SOS

Emdeon / Capario One Meditech

Brightree Alpha Collector

Fastrack OPIE

CPR+ HME Futura

DME Works PrimeRx

Team DME



CHALLENGES & RESPONSESAND BENEFITS



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 efficiency

Process 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

Sunknowledge 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 Sunknowledge 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

Integra

Month

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

Integra

Month

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

0

100

200

300

400

500

600

700

800

900

1000

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

INVENTORY RECEIVED

Breast Pump

CPAP

Nebulizer

Closet Nebulizer

Integra

0

100

200

300

400

500

600

700

800

900

1000

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

INVENTORY COMPLETED

Breast Pump

CPAP

Nebulizer

Closet Nebulizer

Integra



ELIGIBILITY & AUTH. VERIFICATION – SAMPLE REPORT

Sunknowledge 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 sentAuth

PendingComment

1 221359 Beds / Mattress Yes Yes No Yes No Yes YesPending 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

Patients

No. of Patients Compliant based on

best 30 days

90th day Compliance Report 5 3 0 0 0 2





TOTAL 17 11 2 1 3

Sunknowledge CPAP USER COMPLIANCE TRACKING STATUS REPORT - 07/10/2015

S No.Set Up

Date5th Day

15th

Day

30th

Day

60th

Day

90th

DayPatient # Patient Name Doctor System Status

Therapy

Report

Imaged

Report

Faxed to Dr.

Email

/Faxed

Sales

person

Payer NameComment /

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 PLANSBest 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 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

BCBCS 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 2 11 -9 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

S No.

Date PayerPatient Name

DOB DOS Claim No.Charge

AmountStatus Comments Ref #

1 7/21/2015 Healthfirst Doe, John 8/29/1974 6/26/2015 1063051526 $195.00 Paid

Called 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 Paid

Called 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 ProcessPer 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 AllowedPer 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 PaidPer 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 missing

6%

Exceeds Timely Filing

8%

Duplicate Claim5%

Service Not Covered

6%

Primary Paid Max7%

Pre-Existing Condition

5%Others

26%

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

“I was always against the idea of outsourcing our back end claims processing

work but I was wrong. Sunknowledge provided extraordinary deliverables on

a timely basis which led to cost cutting considerably for us.”

CEO of a leading MA-PD Plan



READ ALL TESTIMONIALS

For Additional Information, Please Contact…

Michael SmithPhone: (646) 930-4608Email: [email protected]

Sunknowledge Services Inc.41 Madison Ave., Suite 2503, 25th Floor

New York, NY 11001, USA

http://sunknowledge.com/testimonials/

Healthcare

Practice Management & Revenue Cycle Management Services for DME Billing Services