PRACTICE MANAGEMENT & REVENUE CYCLE MANAGEMENTFOR RADIOLOGY PRACTICES

PRACTICE MANAGEMENT & REVENUE CYCLE MANAGEMENT

FOR RADIOLOGY PRACTICES

Private & Confidential 1Phone: (646) 661-7853 | E-mail: [email protected]

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



SUN KNOWLEDGE OVERVIEW

Key Facts Awards, Affiliations & Certifications

‘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

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

SUN KNOWLEDGE 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, Laboratories, Radiologists, Pharmacies and more!

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

Urology Healthcare Facilities and more…

SERVICE HIGHLIGHTS

Over 99% accuracy

Up to 97% overall collection

Instant reduction of billing cost by 70%

FREE medical billing software, EMR & setup*

100% HIPAA-HITECH compliance

Fast denial management using Rapid Automation Technology®

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, Sun Knowledge has been adjudicating claims in radiology/imaging 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 provide complete Revenue Cycle Management (billing & collection) solutions for various radiological procedures such as:

• CT or CAT scan• MRI (Magnetic Resonance Imaging)

• Angiography• Balloon Angioplasty• Fluoroscopy• Chemoembolization• Biopsy• Embolization

• Radiofrequency Ablation (RF/RFA)

• Thrombolysis• Vertebroplasty• X-rays• Bone & Thyroid scans• Thallium Cardiac Stress Test• Positron Emission Tomography (PET scan)

• Ultrasound and more… RADIOLOGY



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



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



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



MEDICAL BILLING SYSTEM

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

Sun Knowledge can handle medical billing - promptly, perfectly and professionally – using any billing system as preferred by the client.



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



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

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)



ACCOUNTS RECEIVABLE

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



COMMON DENIALS FOR RADIOLOGY CLAIMS

Duplicate of a previously processed claim

2 possible scenariosa) the claim was previously processed b) Provider automatically re-files a claim to seek payment if initial claim has not been paid within 30 days

Claim is not covered because the patient is enrolled in a health maintenance organization (HMO)

Because beneficiaries can enroll in, and opt out from, such plans annually, physician offices should verify the patient's eligibility before seeing the patient

The payer does not deem non-covered services as medically necessary

Local coverage determinations (LCDs) should be checked for procedure-to-diagnosis code editing, and the ordered service verified against the LCD to ensure compliance with medical necessity requirements

Routine screening and related exams are not covered

The purpose of the service should be verified, and checked for coverage under Medicare and if it has been billed it correctly

Payment is included in another service received on the same day



DENIAL MANAGEMENT

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

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

SUN KNOWLEDGE 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



THE SUN KNOWLEDGE 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



SPECIAL ADD-ON SERVICE

ACTIVE BRANDING & VIGOROUS LEAD GENERATION THROUGH SOCIAL MEDIA MARKETING

3.4Million

Healthcare

Providers

Tap into our massive, and ever-growing, database of over 3 million healthcare providers from every corner of the US, and discover your next client!

Active

Multi-

Channel

Marketing

Targeted, high quality lead generation through various digital channels for B2B marketing such as Email marketing, SEO (Search Engine Optimization), LinkedIn® marketing, PPC (Pay Per Click)

advertising, and more!

L E A D S



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 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 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 the north-east

“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 the north-east



CLIENTSPEAK

“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 north-eastern 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



CLIENTSPEAK

“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 Avenue, 25th Floor,

New York, NY 10010

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