Prior authorization for dermatology practices by Sun Knowledge
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Transcript of Prior authorization for dermatology practices by Sun Knowledge
PRIOR AUTHORIZATIONFOR
DERMATOLOGY PRACTICES
41 Madison Avenue, 25th Floor, New York, NY 10010, USA Phone: (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, Laboratories, Anesthesiologists and Pharmacies
Payers – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
Private & Confidential 3Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 4Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SERVICE AREAS
We provide our 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…
Private & Confidential 5Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SERVICE HIGHLIGHTS
High levels of accuracy (>95%) across all services
Instant reduction of overall billing cost by 70%... guaranteed!
FREE medical billing software, EMR & setup*
Real-time eligibility and benefits check
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 contracts that can be cancelled anytime
Tons of excellent references from current clients
Real-time audits and custom reporting
* Conditions apply
Private & Confidential 6Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 7Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRIOR AUTHORIZATION
Private & Confidential 8Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRIOR AUTHORIZATION – INTRODUCTION
Private & Confidential 9Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
THE SOLUTION!
Sun Knowledge provides a comprehensive array of prior authorization services for awide range of healthcare areas such as:
Pharmacies 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.
99.9%accuracy!
Private & Confidential 10Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CASE STUDY ON BOTOX
Private & Confidential 11Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SERVICE PORTFOLIO
Full range service, comprising Authorization Request Follow-up Approval
100% HIPAA-HITECH Compliance
Highly streamlined, fast and accurate service
The best prices… period!
• Specialty Pharmacy• Botox• Infusable biologics• Injectable medications for psoriasis and psoriasis arthritis• Hidradenititis suppurative (like Enbrel, Humira, Stelara, Remicade)• Other conditions
We cater to
Private & Confidential 12Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRIOR AUTHORIZATION FOR MEDICATION
Tasks involved in carrying out Prior Authorization for medication include the following steps:
Gathering relevant medical documents from the providers
Calling up insurance to find the authorization filing procedure and turnaround time
Submission of the authorization request (fax/online/calling)
Follow up with the Payer to check authorization status as per the TAT set for each Payer
Acknowledgement of authorization approval/denial
Notifying the Pharmacy
Updating the authorization details (authorization number / duration / quantity) in the Provider’s billing system
Private & Confidential 13Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
EVEN MORE BENEFITS
Private & Confidential 14Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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!
SAMPLE REPORTS
Private & Confidential 15Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE REPORT #1
PRIOR AUTHORIZATION COMPONENTS OF DAILY DETAILED REPORT
INPUT
SL. Date Received
Complete/In Progress Patient ID Patient Name DOB Dx Codes Name of Medication Provider Name Primary Payer Phone #
1 8/18/16 In progress 1234567 Patient 1 1/1/90 L40.0 Adapalene 0.3% Gel Provider 1 Caremark Phone 1
2 8/24/16 In progress 1234568 Patient 2 1/2/90 L21.9, L71.8 Elidel 1 % topical cream Provider 2 Envision Rx Phone 2
3 8/24/16 In progress 1234569 Patient 3 1/3/90 L40.0 Clobetasol Prop 0.05% Foam Provider 3 Caremark Phone 3
4 8/25/16 In progress 1234570 Patient 4 1/4/90 L70.0Sulfacetamide sodium-sulfur
10 %-5 % (w/w) topical cleanser
Provider 4 Magellan Rx Phone 4
5 8/26/16 In progress 1234571 Patient 5 1/5/90 L40.0 Desonide 0.05% Cream Provider 5 Cigna Phone 5
7 8/29/16 Complete 1234573 Patient 7 1/6/90 L70.0 Tretinoin 0.025% cream Provider 7 Caremark Phone 7
8 8/29/16 Complete 1234574 Patient 8 1/7/90 L70.0 Tretinoin 0.025% cream Provider 8 Express Scripts Phone 8
9 8/29/16 Complete 1234575 Patient 9 1/8/90 L70.0 Tretinoin 0.025% cream Provider 9 Caremark Phone 9
10 8/29/16 In progress 1234576 Patient 10 1/9/90 L70.0 Tretinoin 0.025% cream Provider 10 Tufts Health Phone 10
Private & Confidential 16Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE REPORT #2
PRIOR AUTHORIZATION COMPONENTS OF DAILY DETAILED REPORT (Contd.)Authorization Status
Last Worked On Follow Up Date Comments Final Status Approval /Denial Date
8/25/2016 8/25/20168/25/2016- Got reply from NEDA, triaged back for alt. medication suggestion8/18/2016- Notified Triage, since patient requested alternate medication as copay was too high.
In Process
8/26/2016 NA
8/26/2016- SK called insurance and s/w Jenny, she informed that a form is to be filled up and sent back for pre-auth.8/24/2016- SK called insurance company to provide prior authorization information verbally.Medication Name: Elidel 1 % topical creamInsurance Co: Envision Rx | Spoke with: John | Result: Pending
In Process
8/24/2016 NAS/w Jack, PA is In Progress, Ref# M1*******3, Ade informed that it is a non formulary drug and the foam is not covered, she also informed that apart from foam there are alternatives like cream and solution which are covered so she will fax us the available list of alternatives at ***-***-****.
In Process
Pharmacy Status
Pharmacy Name Pharmacy Ph # Auth Status Informed Date of communication Comments Schedule Delivery Date
CVS Phone 1 No Rite Aid Phone 2 No
Walgreens Phone 3 No CVS Phone 4 Yes 8/29/2016 S/w John, informed about the approval
CVS Phone 5 Yes 8/29/2016 S/w Vivian, informed about the non-coverage
Private & Confidential 17Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE REPORT #3
Month Approved Denied In Process NA Pending for additional information Total
08/17/16 9 2 11
08/18/16 14 1 2 2 19
08/19/16 2 1 3
08/22/16 5 1 1 7
08/23/16 8 1 9
08/24/16 10 2 12
08/25/16 6 2 2 10
08/26/16 8 1 9
08/29/16 7 3 4 14
Total 69 4 11 10 94
PRIOR AUTHORIZATION DAILY SUMMARY REPORT
Private & Confidential 18Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE REPORT #4
PRIOR AUTHORIZATION MONTHLY SUMMARY REPORT
Month Approved Denied In Process NA Pending for additional information Total
Mar-16 71 49 2 122
Apr-16 401 160 5 15 1 582
May-16 418 146 4 69 637
Jun-16 377 151 4 94 1 627
Jul-16 343 128 16 65 6 558
Total 1610 634 29 245 8 2526
Private & Confidential 19Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
MEETING CHALLENGES WITH EFFECTIVE RESPONSE
Private & Confidential 20Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 21Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & OUR APPROACH
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
Private & Confidential 22Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & OUR APPROACH
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
Private & Confidential 23Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 24Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
Private & Confidential 25Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 26Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 27Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 28Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Ronnie Hastings(646) 661-7853Email: [email protected]
Sun Knowledge41 Madison Avenue, 25th Floor,
New York, NY 10010
For Additional Information, Please Contact…