Practice management & Revenue Cycle Management Services for Home Healthcare

PRACTICE MANAGEMENT &REVENUE CYCLE MANAGEMENT

FOR HOME HEALTHCARE(WITH OASIS SERVICES)

Phone: (646) 930-4608 | E-mail: [email protected]

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

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


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, DME, P&O, Laboratories, Home Health Care, Physical Therapists 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

Tele-radiology



SERVICE AREAS

We provide our services in the following areas:

Nursing Homes Prosthetics & Orthotics Urgent Care

Durable Medical Equipment Home Healthcare Skilled Nursing Facilities

Wound Care Pain Management Pharmacies

Cardiology Specialty Clinics Surgery

Physical Therapy Family Practice Radiology

Rehab Centers Dermatology Diabetics

Anesthesia Healthcare Facilities and more…



SERVICE HIGHLIGHTS

Up to 97% in overall collection

Instant reduction of billing cost by 70%

FREE medical billing software, EMR & setup*

Real-time eligibility checks & quick authorization

100% HIPAA-HITECH compliance

Fast claim-status analysis using Rapid Automation Technology®

Proprietary tools that increase accuracy and reduce time

Turnaround time less than 48 hours max.

Low service fees with no hidden cost

Zero lockup service contract that can be cancelled anytime

Backed by excellent references from reputed clients across the US

Real-time audits and custom reporting* Conditions apply



A UNIQUE EDGE

Since 2011, Sunknowledge has been adjudicating claims in Home Health Care for major health insurance companies* in New York and California.

This has given us a unique edge over other medical billing companies, in better understanding various Payer guidelines and how to submit clean claims that meet with no denials and get paid quickly!

We are constantly tutored in the latest policy updates and guidelines as set by the

Insurance companies from time to time

We are regularly exposed to Home Health Care claims of many different kinds, leading to full familiarity with such claims and how

to handle them efficiently

* Sunknowledge is proud to be associated with



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 CYCLE MANAGEMENT



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



IMPORTANT TASKS

Inpatient/Outpatient Hospital Coding

Physician Coding

Patient entry demographics & insurance information

Fee Schedule / Charge Entry

Scrubbing all entries for correctness and completeness with appropriate billing edits; correction of identified errors

Submission of claims to payers, e.g. EDI or paper

Creation and mailing of patient statements

Posting of payments received from patient and payer

Reconciliation of charges, payments received and adjustments made

Denial Management, e.g. understanding denials and making corrections

Resubmission of claims

AR calls as follow-up on outstanding issues

Closure of a claim once the balance is zero

CODING

BILLING

A/R FOLLOW-UP



A WORD ABOUT DME BILLING

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.

Examples:

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.



GENERAL MEDICAL BILLING CYCLE

Rx Order Entry

Patient Demographics and Insurance

Entry

Product Code /Rx & Dx Entry

Eligibility Verification/

Authorization

Collection of complete Rx

Collection of documents for Auth Approval

Submission

Rejection/Denial Management

A/R Follow-up



BILLING

MEDICAL BILLING CYCLE

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



BILLING

MEDICAL BILLING SYSTEM

Sunknowledge handles medical coding - promptly, perfectly and professionally –using Kareo® or any other billing system as preferred by the client.

Our billers and coders are proficient in using a wide range of billing and practice management software suites that cover the entire billing cycle.

BILLING

Private & Confidential 15


Phone: (646) 930-4608 | E-mail: [email protected]

MEDICAL CODING OVERVIEW

Service Offerings

• Place of Service Based Coding – Inpatient, Outpatient Coding

• Provider Specialty Based Coding– Dentistry, 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 (CDT/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



BILLING

MEDICAL CODING – PROCESS



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

BILLING

MEDICAL CODING – HIGHLIGHTS

• Our coders deliver error-free charge sheets within agreed TAT provided by the client

• We monitor, analyze and improve coding documentation to avoid denials and guarantee reimbursements

• We carefully determine the codes according to the clinical information provided by the Healthcare Provider/Professionals and report back accordingly

• Our coders have undergone extensive medical coding training and are well aware of updated coding guidelines

• All our coders are ICD-10 certified (CPC)



BILLING

MEDICAL CODING – QUALITY

Collecting patient documentation

Assigning accurate diagnosis codes

Collaborating with clinicians, physicians and/or managers/administrators

Ensuring that all activities are done in a legal and ethical manner that supports home health agency policy, regulatory and professional guidelines

Our coders specializing in Home Healthcare coding are highly-skilled professionals, with extensive knowledge in medical terminology, anatomy / physiology, disease processes, pathophysiology, and pharmacology.

Typical tasks performed by them include:

Certified by

BILLING



ELIGIBILITY & AUTHORIZATION VERIFICATION

• Full range of verification services

• Fast 24-hour turnaround time

• 96 – 99.9% accuracy

• Detailed documentation

• 100% HIPAA compliance

• Experience with national and private carriers

VERIFICATION

• 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

ELIGIBILITY VERIFICATION

AUTHORIZATION VERIFICATION



SAMPLE REPORTS

0

20

40

60

80

100

120

140

4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015

96

83

94 9

8

96

29

11

6

31 32

12

5

94 1

00

12

9

12

8

41

32

26 3

0

28

ELIGIBILITY VERIFICATION

Number of New Patient Patient Brought Forward

Primary Checked Secondary Checked (if applicable)

0

5

10

15

20

25

30

35

40

45

50

4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015

45

25

38

4446

20

15

26

22 21

25

1012

22

25

AUTHORIZATION VERIFICATION

Auth Required Auth Obtained Auth Pending

VERIFICATION



PRIOR AUTHORIZATION

• Full Range Service (Authorization Request Follow-up Approval)

• 99.9% accuracy

• 100% HIPAA-HITECH Compliance

• Low prices with no hidden cost

• Highly streamlined, fast and accurate service

• Home Health Care

• DME

• Oxygen & Related Equipment

• Physical Therapy

• Diabetes

• Many other conditions…

We cater to

PRIORAUTHORIZATION



ACCOUNTS RECEIVABLE

ACCOUNTSRECEIVABLE

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.



STEPS IN AR FOLLOW-UP

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 the A/R team



ACCOUNTSRECEIVABLE

DENIAL MANAGEMENT

ACCOUNTSRECEIVABLE

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

ACCOUNTSRECEIVABLE

24%

11%

3%35%

17%

10%

Distribution of Denied Claims

Auth Related

Coding Correction Required

OON Issue

Others

Patient info missing

Timely Filing



AR AGING REPORT SAMPLE

ACCOUNTSRECEIVABLE

Sunknowledge WEEKLY AR AGING 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

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



OASIS HANDLING

O A S I S

We take care of all OASIS requirements and ensure that every claim handled by us maintains full compliance with the OASIS data tool.

We ensure that every Home Health Care claim meets the CMS requirements with regard to:

• Effectiveness

• Efficiency

• Equity

• Patient Centeredness

• Safety

• Timeliness

The Outcome and ASsessment Information Set (OASIS) is a group of data elements that:

• Represent core items of a comprehensive assessment for an adult home care patient; and

• Form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).

Source:



OASIS RELATED ASSISTANCE

O A S I S

We provide complete assistance for successful OASIS transmissions to ensure maximum reimbursement.

These include:

Accurately encoding for OASIS

Maintaining the correct data format

Timely transmission of OASIS data



OASIS TRANSMISSION

O A S I S

Complete adherence to CMS standards for accuracy, encoding & completeness, as required for successful OASIS transmission

Fully conversant with both the OASIS-C1/ICD-9 and OASIS-C1/ICD-10 versions*

Full familiarity in working with transmission tools and interfaces such as jHAVEN(Home Assessment Validation and Entry System)

Our OASIS coders are highly experienced and are BCHH-C certified by the National Credentialing Board of Home Health & Hospice

HIGHLIGHTS

We are also OASIS-C2/ICD-10

ready!



Our telemedicine solution is highly customizable and can be tailored to a specific program –hospitals, nursing homes, home healthcare and providers.

It brings unparalleled benefits – Improved Access, Highly Convenient, Availability on Demand and Reduction in Supplementary Cost.

TELEMEDICINE SOLUTION

TELEMEDICINE

Our proprietary Telemedicine platform enables patients to have tele-consultation with physicians at remote locations through secure video conference. A Home Health Agency can use our

vast network of specialist doctors for remote consultation with a patient in need.

Our Telemedicine solution supports end-to-end workflow for tele-consultation and is bundled with our medical billing services.

Patient registration & Appointment scheduling

Patient’s health records

Alert/Reminder management through mail

Secured video conference

Electronic payment

Reporting services



THE Sunknowledge ADVANTAGE

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

Reduction in accounts receivable by 30% within 1 month

Expert handling of accounts receivable by highly experienced staff with demonstrated expertise

Claim submission within 48 hours of receipt of billing input

Provider can focus more on core services

Adherence to CMS billing requirements

Proper records maintenance and visibility through reporting



CHALLENGES & RESPONSES



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



SUMMARY OF BENEFITS

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



TESTIMONIALS



CLIENTSPEAK

“We have had the pleasure of working with the Sunknowledge 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 Sunknowledge.”

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



CLIENTSPEAK

“My firm has evaluated an outsourcing transaction with Sunknowledge. 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 Sunknowledge 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



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/