Revenue Cycle Management for Oncology by Sun Knowledge

REVENUE CYCLEMANAGEMENT SERVICES

FOR ONCOLOGY

SUN KNOWLEDGE 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

SUN KNOWLEDGE 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, Home Health Care and Pharmacies

Payors – 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

SERVICE PORTFOLIO SUMMARY


PRACTICE MANAGEMENT

Scheduling

Eligibility & Authorization Verification

Prior Authorization

Customer Care

SERVICE AREAS


We provide revenue cycle management services in the following areas:

Durable Medical Equipment Prosthetics & Orthotics Urgent Care

Pathology Critical Care Skilled Nursing Facilities

Wound Care Oncology Pharmacies

Cardiology Specialty Clinics Orthopedic Surgery

Anesthesia Family Practice Radiology

Rehab Centers Dermatology Physicians

Healthcare Facilities and more…

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

Claim status analysis 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

Excellent references from reputed clients across the US

Real-time audits and custom reporting

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 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 CYCLE MANAGEMENT

REVENUE CYCLE MANAGEMENT – KEY PROCESSES


360° Revenue Cycle Management

Services

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

THE REVENUE CYCLE MANAGEMENT EXPERIENCE


HOSPITAL

Accounts Receivables Follow - Up

Denial Management

Claims Resubmission

DME

Order Entry Eligibility

Verification/ Authorization

Follow up on Auth Approval

Delivery Scheduling

Submission of claim

Rejection Management

Payment Posting A/R Follow-Up Denial

Management CPAP Compliance

Tracking

O&P

Rx Order Entry Patient

Demographics and Insurance Entry

Product Code entry/Rx & Dx Entry

Eligibility Verification/ Authorization

Collection of complete Rx

Collection of Documents for Auth Approval

Submission Rejection/Denial

Management A/R Follow-Up

URGENT CARE

Order Entry – Patient Information, Ordering Physician, Rx & Diagnosis

Eligibility Verification

Medical Document Collection

Authorization Approval

Order Audit Confirmation

Submission of Claims


Payment Posting A/R Follow-Up

Patient Entry: Demographics & Insurance


Authorization Follow-Up

Charge Entry Submission of

Claims (EDI/Paper)



Management

PHYSICIAN

Patient Entry: Demographics & Insurance

Charge Entry Submission of

Claims (EDI/Paper)



Management

HOME HEALTH

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


We use Kareo for coding and billing services that covers the complete billing cycle:

SOAP notes review

Superbill generation and coding

Claims edit checking and correction

Claims submission through EDI clearing house at a scheduled time

Rejection management

ERA/EOB posting and reconciliation

Automatic secondary payor billing

Denial Management

Patient statement generation and mailing

Sun Knowledge handles medical billing - promptly, perfectly and professionally – using Kareo® or other billing systems as preferred by the client.

BILLING

MEDICAL CODING OVERVIEW


Service Offerings

• Place of Service Based Coding – Inpatient, Outpatient Coding

• Provider Specialty Based Coding– 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 (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

CODING

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

CODING

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)

CODING

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


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 VERIFICATION

Auth Required Auth Obtained Auth Pending

VERIFICATION

PRIOR AUTHORIZATION


• Full Range Service Authorization Request Follow-up Approval

• 100% HIPAA-HITECH Compliance

• Low prices with no hidden cost

• Highly streamlined, fast and accurate service

• Imaging Techniques for Screening and Identification of Cervical Cancer• Autologous Cellular Immunotherapy• High Intensity Focused Ultrasound (HIFU)• Hyperthermia for Cancer Therapy• Cytoreduction, hyperthermic intraperitoneal chemotherapy (HIPEC)• Cryosurgical ablation of tumors• Radiation Oncology• Organ, Bone Marrow, Stem Cell Transplants and other similar procedures• 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


ACCOUNTSRECEIVABLE

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

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 RelatedCoding Correction RequiredOON IssueOthersPatient info missingTimely Filing

AR AGING REPORT SAMPLE


ACCOUNTSRECEIVABLE

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 (95% + 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


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


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

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• High billing & coding accuracy; 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 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 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 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 New York based 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 Ave., Suite 2511, 25th Floor

New York, NY 11001, USA

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