Insurance Eligibility and Authorization Verification Guide for Hospitals by Sun Knowledge

INSURANCE ELIGIBILITY & AUTHORIZATION VERIFICATION

41 Madison Avenue, 25th Floor, New York, NY 10010, USAPhone: (646) 661-7853 | E-mail: [email protected]

Private & Confidential 2Phone: (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 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

Payers – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs



SUMMARY OF SERVICES

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



ELIGIBILITY & AUTHORIZATION

VERIFICATION



ELIGIBILITY VERIFICATION – HIGHLIGHTS

Full range of verification services

Fast 24-hour turnaround time

Above 99.9% accuracy

Detailed documentation

100% HIPAA compliance

Experience with national and private carriers

We have the experience, training and resources to complete quick verification checks, a feature that Urgent Care Centers love us for. In some cases, such services can even be rendered in real-time (with the help of rapid database accessthrough appropriate lookup software applications)



AUTHORIZATION VERIFICATION – HIGHLIGHTS

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

Years of experience in working at claims adjudication for major insurance companies in the US have given us a unique understanding of the authorization process, allowing us to complete the process faster than others!



ELIGIBILITY VERIFICATION – SERVICE FEATURES

Eligibility check covers the following:

Policy active for date of service

DME coverage

Copay / Coinsurance / OOP

Rx & Dx entry (with appropriate timeframe)

Provider status (INN / OON)

CSI check

Authorization requirement

Obtaining authorization

Patient responsibility



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



BENEFITS OVERVIEW

360o operations support in medical benefit coverage

Quick authorization process

Detailed documentation

100% HIPAA-HITECH compliance

Experience in working with both Payers and Providers

Highly accurate eligibility data maintenance (in sync with CMS)

Excellent references from more than 7 years of successful operation



PRIOR AUTHORIZATION



PRIOR AUTHORIZATION – A CONSUMMATE SOLUTION

Sun Knowledge provides a comprehensive array of prior authorization services for awide range of healthcare areas such as:

Hospitals

Nursing Homes

DME

Orthotics & Prosthetics

Physicians’ Offices

Radiology/Imaging Services

Dermatology Practices, and many more!

Our services are designed to take the pain out of prior authorization and free you from the need to engage your resources or spend precious time in tedious prior authorization tasks.



PRIOR AUTHORIZATION – SERVICE PORTFOLIO

Full range service, comprising Authorization Request Follow-up Approval

100% HIPAA-HITECH Compliance

Low prices with no hidden cost

Highly streamlined, fast and accurate service

• DME• Hospitalization• Outpatient Surgery requiring general anesthesia• Skilled Nursing • Organ, Bone Marrow, Stem Cell Transplants and other similar procedures• Inpatient rehabilitation – Treatment for alcohol or drug abuse• Other conditions

We cater to



BILLING & CODING



SERVICE HIGHLIGHTS

FREE Billing Software FREE EMR FREE Setup, upgrades and support Up to 97% Collection Rate Claims Submission within 48 hours max. Error-free Patient Entry Over 99.9% Coding Accuracy Real-time Audits Methodical and Proactive AR Follow-up 100% HIPAA Compliance Custom Reporting



MEDICAL BILLING CYCLE

Encounter (SOAP) notes review

Superbill generation and code

review

Claims edit checking

and correction

EDI claims submission through clearing house

Rejection management

ERA/EOB posting and

reconciliation

Automatic secondary

payer billing

Denial Management

AR Follow-up



BILLING CYCLE – DETAILS Order entry based on the Rx received from the Physician

• Patient demographics & insurance entry• Provider information entry• Product code, Rx & Dx entry• If necessary, a telemedicine consultation can be completed to obtain a Rx to expedite the order entry process

Eligibility verification and authorization requirement enquiry Patient’s appointment with Practitioner for Practitioner to assign codes Collection of detailed Rx from ordering Physician’s office Collection of documents required by Payer for authorization approval, e.g. Diabetic Verification Form, initial

evaluation, medical notes to support K level, PPR Form Calculation of service estimates (Patient and Payer responsibility) Determination that payer criteria are met before delivery of device (if criteria are not met,

the Patient needs to be contacted & informed of the additional financial liabilities) 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



CODING SERVICES – OVERVIEW

Service Offerings

Medical Coding• Place of Service Based Coding – Inpatient, Outpatient Coding

• Provider Specialty Based Coding– E/M, Cardiology, Orthopedics, Physical Medicine etc.

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

• 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



PRACTICE MANAGEMENT AND BILLING SYSTEM

GoTelecare billing executives have experience in working on several industry standard practice management and billing software systems such as:

We can provide medical billing & coding services using customer’s billing system or can set up customer’s practice in a billing system managed by us.

Kareo SOS

Emdeon / Capario One Meditech

Brightree Alpha Collector

Fastrack OPIE

CPR+ HME Futura

DME Works PrimeRx

Team DME



OTHER PRACTICE MANAGEMENT SERVICES



PAYMENT/DENIAL POSTING PROCESS

Payment posting is crucial to the billing process. Due to the sensitivity of this process, accurate and efficient payment posting process is indispensable.

Our billers are known to be highly efficient and analytical in the payment posting process.

Payment Entry Process

Select Patient Account

Select EncounterSelect Encounter If not found

Refer Client SpecifiesDenial

Denial Code

Hold Transfer BalanceTransfer BalanceWrite-off

Post Payment

Payment



DENIAL MANAGEMENT

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%

Others26%

Distribution of Denied Claims



HIPAA COMPLIANCE& BENEFITS SUMMARY



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



SOCIAL MEDIA MARKETING



EVEN MORE BENEFITS



ACTIVE BRANDING & VIGOROUS LEAD GENERATION THROUGH SOCIAL MEDIA MARKETING

3.4Million

HealthcareProviders

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-

ChannelMarketing

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!

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 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 Avenue, 25th Floor,

New York, NY 10010

For Additional Information, Please Contact…

Insurance Eligibility and Authorization Verification Guide for Hospitals by Sun Knowledge

Healthcare

Transcript of Insurance Eligibility and Authorization Verification Guide for Hospitals by Sun Knowledge