Step by Step Anesthesiology Billing, Coding, Revenue Cycle Management and Practice Management

PRACTICE MANAGEMENT & REVENUE CYCLE MANAGEMENT

FOR ANESTHESIOLOGY PRACTICES

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, Laboratories, Anesthesiologists 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

SERVICE PORTFOLIO SUMMARY


PRACTICE MANAGEMENT

Scheduling

Eligibility & Authorization Verification

Prior Authorization

Customer Care

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


Over 99% accuracy

Up to 97% in overall collection

Instant reduction of billing cost by 70%

FREE medical billing software, EMR & setup*

100% HIPAA-HITECH compliance

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

WHY SUN KNOWLEDGE


Since 2011, Sun Knowledge has been adjudicating claims in anesthesiology & pain management 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 in anesthesiology and pain management for a wide range of healthcare verticals such as:

• Obstetrics & Gynecology• Cardiology• Gastroenterology• Surgery (general / vascular)

• Radiology• Dermatology• Ophthalmology• Orthopedics, and many more!

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


BILLING & CODINGFOR ANESTHESIOLOGY

ANESTHESIOLOGY – OVERVIEW


Anesthesiology is the branch of medicine concerned with anesthesia and anesthetics. It is the practice of medicine specializing in:

The management of patients who are rendered unconscious and/or insensible to pain and emotional stress during surgical, obstetrical and certain other medical procedures

The management of problems in pain relief

The management of cardiopulmonary resuscitation

The management of problems in pulmonary care

The management of critically ill patients in special care units

What is Anesthesiology?

ANESTHESIOLOGY – OVERVIEW


Local Anesthesia

• Numbs a small part of the body for minor procedures

Regional Anesthesia

• Blocks pain to a larger part of the body

MAC/Sedation

• Like general anesthesia but on a smaller level

General Anesthesia

• Affects the brain along with the rest of the body, and renders the patient unconscious

4 Types of Anesthesia

ANESTHESIOLOGY BILLING – OVERVIEW


Anesthesiology billing is a procedure of collecting the required documents and submitting to the healthcare provider in order to get claims paid.

What is Anesthesiology Billing?

Efficient anesthesiology billing & coding requires:

A good understanding of Medicare and state-specific medical policies

Accurate medical coding analysis with ICD-10 and CPT

Experience with leading commercial carriers (Payers)

ANESTHESIOLOGY BILLING FUNDAMENTALS


Know what is being billed

Know your insurance companies and how they want to be billed

• Base Units

• Time Units

• Modifying Units

Billing Basics for Anesthesiology

An anesthetist gets paid on the basis of: Base Units + Time Units + Modifying Units

ANESTHESIOLOGY CODING – OVERVIEW


Examples of CPT codes used in Anesthesiology Billing

Area of the Body CPT Code Range

Head 00100 – 00222

Spine and Spinal Cord 00600 – 00670

Pelvis (except hip) 01112 – 01190

Upper Abdomen 00700 – 00797

Shoulder and Axilla 01610 – 01682

Other Procedure 01990 – 01999

MEDICARE & ANESTHESIOLOGY BILLING


Requires five-digit CPT (Current Procedural Terminology) code + modifier codesAnesthesia administered while performing surgical procedure will require surgery codes

The anesthesiologist and the Qualified Non-physician Anesthetist can bill separately for anesthesia services they personally perform

In cases of medical direction, both the anesthesiologist and the Qualified Non-physician Anesthetist would bill Medicare for their component of the procedure

Providers to use appropriate modifiers

If the surgery is non-covered, the anesthesia is also non-covered

Billing & Coding for Medicare


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

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

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

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 RelatedCoding Correction RequiredOON IssueOthersPatient info missingTimely 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


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 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

For Additional Information, Please Contact…


Ronnie Hastings(646) 661 7853Email: [email protected]

Sun Knowledge41 Madison Ave., Suite 2511, 25th Floor

New York, NY 11001, USA

mailto:[email protected]