Practice Management & Revenue Cycle Management for Radiology
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Transcript of Practice Management & Revenue Cycle Management for Radiology
PRACTICE MANAGEMENT & REVENUE CYCLE MANAGEMENT
FOR RADIOLOGY & IMAGING
Sun Knowledge 41 Madison Avenue, 25th Floor, New York, NY 10010
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 toPROVIDERS – 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
HIPAA COMPLIANCE SUMMARY
4Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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 MANAGEMENTSERVICE OVERVIEW
5Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SUMMARY OF SERVICES
6Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRACTICE MANAGEMENT
Scheduling
Eligibility & Authorization Verification
Prior Authorization
Customer Care
REVENUE CYCLE MANAGEMENT SERVICES
7Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
360° Revenue Cycle Management
Services
REVENUE CYCLE MANAGEMENT – SERVICE SNIPPETS
8Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Eligibility checking and obtaining prior authorization Credentialing as per the carrier’s guidelines
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 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 (understanding denials and making corrections) Resubmission of claims A/R calls as follow-up on outstanding issues Closure of a claim once the balance is zero
CODING
BILLING
A/R FOLLOW-UP
PRE-SERVICE CHECKS
AREAS OF OPERATION
9Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
We provide turnkey revenue cycle management services in the following areas:
Radiology / Imaging Prosthetics & Orthotics Urgent Care
Pathology Critical Care Durable Medical Equipment
Internal Medicine EKG Compounding Pharmacies
Cardiology ENT Orthopedic Surgery
Anesthesia Family Practice Specialty Clinics
Rehab Centers Pharmacy Physicians, and more…
SERVICE HIGHLIGHTS
10Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Up to 97% collection rate in accounts receivable
FREE medical billing software, EMR & setup
Real-time eligibility checks & fast authorization
100% HIPAA-HITECH compliance
Rapid Automation Technology® for lightning fast claim status analysis in denial management
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
PRACTICE MANAGEMENT SERVICES
11Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ELIGIBILITY VERIFICATION
12Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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 fast, software-assisted database enquiries)
AUTHORIZATION VERIFICATION
13Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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!
PRIOR AUTHORIZATION
14Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
• Radiology / Imaging• 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
PRIOR AUTHORIZATION – KEY STEPS
15Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Tasks involved in carrying out this Pre Authorization service include the following steps:
Gathering relevant medical documents from the Providers
Calling up insurance to find the authorization filing procedure and turnaround time
Initiation of authorization request (fax/online/calling)
Follow up with the Payer to check the auth. status as per the TAT set for each Payer
Acknowledgement of authorization approval/denial
Updating the authorization details (authorization number / duration / quantity) in the Provider’s billing system
CODING
16Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
MEDICAL BILLING SYSTEM
17Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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 payer 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.
PAYMENT/DENIAL POSTING PROCESS
18Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
PRODUCTIVITY EFFICIENCY TRACKING
19Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Employee Name Note Count Days Worked Hours Worked Notes Per Hour Max Note Time Avg. Note Time
John Smith 977 23 203.55 4.8 1:29:52 0:07:15
Jane Doe 1025 23 214.97 4.77 0:55:14 0:04:56
Rick Williams 913 21 207.07 4.06 1:27:08 0:07:14
Robert Frost 870 21 187.35 4.64 0:42:54 0:04:05
Dan Chesser 910 23 216.47 4.2 3:50:55 0:06:18
Derek Malia 823 23 210.37 3.91 7:01:30 0:04:37
Our clients depend on transparency.
We provide our clients with the ability to maintain detailed tracking for increased productivity and efficiency.
A Sample Report
ACCOUNTS RECEIVABLE
20Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Reduction in accounts receivable
by up to 30% within 1 month
Accounts Receivable recovery cost starts from
1% of collections
Expert handling of accounts receivable by highly experienced staff
Same attention to every cash amount regardless of
its size or source
Demonstrated expertise in working on difficult-to-recover aging A/R
Over 7 years’ experience in claim adjudication for
major US insurance plans
ACCOUNTS RECEIVABLE - STEPS IN FOLLOW-UP
21Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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 our A/R team
DENIAL MANAGEMENT
22Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Auth Related14%
Coding Error5%
OON Issue8%
COB Issues10%Patient info missing
6%
Exceeds Timely Filing8%
Duplicate Claim5%
Service Not Covered6%
Primary Paid Max7%
Pre-Existing Condition5%
Others26%
Distribution of Denied Claims
TRANSITION, OPERATIONS AND COMPLIANCE
FRAMEWORK
23Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
The key resources of the customer are available during the transition phase.
All documents and process materials like P&Ps and SOPs are available to the Service Provider Transition team before the start of transition.
Any change in the Scope of Work will require re-planning.
All data files are made available for data migration work.
Any other assumptions made in the “Statement of Work” are applicable here.
A more accurate plan will be given at the time of transition
Transition plan tasks may vary depending on specific project
ASSUMPTIONSSr. No. Phase / Task Description Start
WeekEnd
Week Remarks
1. Project Initiation W + 0 W + 0
2. Transition Planning and Solution Identification W + 1 W + 1
ABC to provide existing SOPs/P&Ps/Flowcharts/Reports before this phase starts.
3. Knowledge transfer and detailed As-Is Process Mapping W + 2 W + 3 Onshore activity at ABC
4. Validation of process mapping document / SOPs / training materials W + 3 W + 4 Onshore activity at ABC
5. Validation of solution customization requirements W + 3 W + 4 Onshore activity at ABC
6. Finalize SLA & reporting requirements W + 4 W + 4 Onshore activity at ABC
7. Staffing & Training W + 4 W + 78. Solution customization W + 4 W + 7
9. Solution testing and verify operation Readiness W + 7 W + 8
ABC to provide sample data and participate in testing exercise.
10. Conduct Pilot W + 9 W + 9
11. Evaluate Pilot results and finalize critical Quality parameters W + 9 W + 9
12. Handover to Operations & start “Go Live” W + 10 Transition work ends and
operations ramp-up
TYPICAL TRANSITION SCHEDULE
Sun Knowledge © 2015-16 Private & Confidential 2441 Madison Avenue, 25th Floor, New York, NY 10010, USA
TRANSITION SUCCESS FACTORS
Executive buy-in
Foster win-win partnership relationship
Strong project leadership for both companies
Client’s involvement in approving key deliverables (i.e. project plan, process documents, etc.)
Maintain key current subject matter experts until knowledge is transferred and the key processes are stable
Availability of key client personnel for training
Accurate identification of desk procedures and processes is critical
Effective governance structure
Communicate, Communicate, Communicate
25Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
OPERATIONAL FRAMEWORK
TRANSITION
Project scoping & planning
Knowledge transfer – Process training and assessment
Process documentation
Solution customization
Infrastructure set up
Pilot/Transition period
TRAINING
Training Need Identification
Customized training program as per client’s requirement
Pre-process & process training
Voice & accent and cultural training
Refresher training
PRODUCTION
Project management approach
Exception handling and reporting
Effective coaching & monitoring practices
Periodic review and evaluation
Service level management and reporting
QUALITY
Regular audit for process and deliverables
Identify and analyze errors to take corrective measures
Flowcharting and root cause analysis for process improvement measures
Management reporting of quality assurance activities
Capacity planning
Forecasting, staffing & scheduling
Real time reporting
Billing and revenue management
MIS / WFM
Ensure 100% adherence to federal / data protection laws
Governance & compliance audits
Organization preparedness for client & third party audits
HIPAA compliance
CONTROL & COMPLIANCE
PROJECT MANAGEMENT & OVERSIGHT
IT INFRASTRUCTURE– TOOLS & TECHNOLOGY
26Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Sun Knowledge Governance
Structure
Steering Committee
Program Management Office
Project Delivery Team
Executive sponsorship
Management oversight
Ensure business goals and engagement goals alignment
Ensure tangible results and demonstrable value
Continuously educate &
report executive leadership on the critical success factors of engagement
Plan and implement change; define, establish performance, metrics aligned to goal
Review project scope, timeline and budget and monitor project progress
Communication, status reporting & escalation to steering committee
Manage cross team dependencies
Identify, initiate & institutionalize process improvements
Oversee knowledge repository building
Project Management
Scope Management
Knowledge Management
Change Management
Ensure successful engagement startup
Quality Management
Resource Management
Communication & Status Reporting
Issue Management
Monitor & measure knowledge transfer process
Incorporate industry best practices
27Sun Knowledge © 2015-16 Private & Confidential
GOVERNANCE MODEL
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
QUALITY ASSURANCE & CONTROL
Quality Control & Assurance processes at Sun Knowledge help us meet our client’s expectations and SLA target. We use Quality Assurance program to set production and quality goals. Our daily
quality audit activities ensure that we evaluate our agents’ work on all relevant criteria. We ensure quality by carrying out rigorous quality assurance and control activities.
Periodic process review
Process audit
Testing deliverables and root cause analysis
Process improvement / re-engineering
Incorporating customer feedback
N% internal quality audit of client deliverables & review reporting
Weekly/monthly monitoring of productivity reports
28Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
• Regular process test and appraisals
• Work in-sync with Operations & QA
• Preparation of training Modules
• Preparation of training Plan in ‘Knowledge Net’ training module
• Process training and refreshers
• Availability of training documents in ‘Knowledge Net’ portal
• V&A, Soft skills training
• Post-training assessment• Training feedback• Review of training program
Training Need Identification
Training Program Planning
Conduct TrainingTraining Evaluation
TRAINING METHODOLOGY
29Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
COMPLIANCE – KEY FACTS
Well defined policies to cover compliance aspects
Written procedures covering compliance aspects
Proactive compliance reporting and issue escalation
Action list for changes in rules and regulations by regulatory authorities
Compliance evaluation framework
Periodical training on compliance issues and update
Periodic audit and review mechanism to address potential compliance risks
Implementation of data privacy and security standards like HIPAA-HITECH and ISO 27001
Incident reporting for data security violation
Compliance awareness among the employees and reward on compliance reporting
Compliance violation by employees leads to employee retraining and reassessment
Sun Knowledge has defined and established a process and system to avoid compliance risks while carrying out operations and encourage employees to proactively report compliance issues
to the higher management
Sun Knowledge has defined and established a process and system to avoid compliance risks while carrying out operations and encourages employees to proactively report compliance issues to the
higher management.
30Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
COMPLIANCE - ESCALATION STRUCTURE
Service DeliveryService Delivery Mgr
(Service Delivery POC)
Head of Operations
(1st Level Escalation POC)
Operations
CEO & MD
(Final Escalation POC)
Executive Board
Board of Directors
ComplianceCompliance Mgr
(Compliance Escalation POC)
Head of ComplianceCompliance
Team LeadProcess Team Lead
(Service Delivery POC)
TechnologyTechnology Mgr
QualityQuality Mgr
HR/TrainingHR/Training Mgr
Compliance Issue
Trigger Point
Process Team Leader will inform Service Delivery Manager and Compliance Manager immediately after occurrence of the event
Compliance Manager/ Service Delivery Manager will assign the severity of the compliance issue
Compliance Escalation Path
Severe Compliance Escalation Path
31Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
IT INFRASTRUCTURE
Service continuity supported by BCP and disaster management mechanisms 100% redundancy in all IT assets, providing high-availability and reliability 40 Mbps leased line internet connectivity provided by two ISPs in load sharing and automatic failover
configuration Data protection and security provided by Fortigate 300D firewall combined with other physical and logical
access controls Voice telephony infrastructure built using E1 lines provided by two IPLC providers IP Network-based PBX system with IVR, ACD and CTI functionalities and 100% call recording & reporting
features Data center with over 20 IBM servers with dedicated UPS Polycom VSX 7000A video conference system for remote training and client communication 24/7/365 IT-Infrastructure support personnel for user support, using ticket management system 120 KVA on-line UPS power backup systems and additional backup provided by 180 KVA power generator
32Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
DATA SECURITY AND END USER PRIVACY
Information security management system is aligned with ISO 27001:2013 standard Implementation of policies and procedures with respect to PHI comply with HIPAA-HITECH regulations Data replication between Sun Knowledge’s servers in NY and India via site-to-site IPsec VPN tunnels helps strong
business continuity management Daily off-site backup process to mitigate data loss risk in case of disaster Implementation of physical access control system in office premises restricts access to sensitive areas housing
application and database Physical and logical segregation of internal network into VLAN segments to control and protect data storage and
transmission between business/process units Implementation of perimeter security devices, like firewall and segregation of sensitive information systems Access to all information systems through two levels of authorization Implementation of two levels of end point malware protection network and system level anti-malware systems Use of secure e-mail system for e-mails with sensitive PHI information Implementation of access restrictions to prevent unauthorized deletion or movement of data using external storage
devices like optical discs, pen drives, etc. Security incident monitoring, reporting and resolution system Periodic employee awareness training on data privacy & protection and HIPAA regulations
33Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & RESPONSESAND BENEFITS
34Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & OUR APPROACH
35Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
CHALLENGES & OUR APPROACH
36Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
TASK DESCRIPTION CHALLENGES APPROACH
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
CHALLENGES & OUR APPROACH
37Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
TASK DESCRIPTION CHALLENGES APPROACH
Accumulation of backlog Denials not posted Claims reconciliation issue
CLIENT BENEFITS
38Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Significant decrease in operational expenses We charge as low as $10 per hour per employee! Our clients save on other associated costs for employees including Health Insurance Premiums, Payroll Costs,
Medicare Tax, Human Resources, Employee Attrition, additional Real Estate and Infrastructure Costs We guarantee > 50% operational savings effective immediately; e.g. one of our clients reported a $2.1 million
operational savings in Y1 alone!
Heightened collection and increased Accounts Receivables 30% of DME Rx are incomplete when first received. We excel in completing the Rx claim quickly.
Cyclical Data Reporting Data reporting interval customized to meet the needs of the customer Productivity Efficiency Tracking allows for quantifying the team workload
Demonstrated experience handling DME claims Medicare, Medicaid and Commercial Plans Fee for Service and Capitated Plans
SUMMARY OF BENEFITS
39Sun Knowledge © 2015-16 Private & Confidential
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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
40Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
41Sun Knowledge © 2015-16 Private & Confidential
“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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
42Sun Knowledge © 2015-16 Private & Confidential
“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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
43Sun Knowledge © 2015-16 Private & Confidential
“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
For Additional Information, Please Contact…
41 Madison Avenue, 25th Floor, New York, NY 10010, USA