medical billing services for orthotics & prosthetics

MEDICAL BILLING SERVICESFOR ORTHOTICS & PROSTHETICS

PRACTICE MANAGEMENT | MEDICAL BILLING & CODINGACCOUNTS RECEIVABLE & DENIAL MANAGEMENT

41 Madison Avenue, 25th Floor, New York, NY 10010, USAPhone: (646) 930-4608 | E-mail: [email protected]

Private & Confidential 2Phone: (646) 930-4608 | E-mail: [email protected]

41 Madison Avenue, 25th Floor, New York, NY 10010, USA

SUNKNOWLEDGE OVERVIEW

Key Facts

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

Office at 41 Madison Avenue, 25th Floor, New York, NY 10010

SUNKNOWLEDGE SERVICE PORTFOLIO

Provider Support

Member Support

Member Retention Program

Clinical Help Desk

Contact Center

Utilization Management

Medication Therapy Management

Hospital Re-admission Management

Therapeutic Interchange

Formulary Management

Clinical Services

Medical Coding & Billing

Claims Administration

Enrollment Processing & Member

Fulfillment

Credentialing

Premium billing and collections

Administrative Services

Analytics

Telemedicine Services

Remote Patient Monitoring

Application Development & Support

Technical Support

Technical Documentation

IT Services

Claims /Drug Utilization Analysis

PDE Analysis

RAF Analysis

Payment 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



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



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 AccessSigning 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

7Network &

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 FirewallUnified 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

9VPN (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

10Redundancy

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

11Virus & 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 CYCLEMANAGEMENT



REVENUE CYCLE MANAGEMENT SERVICES

360°Revenue Cycle Management

Services

Eligibility & Authorization Verification

Patient Information

Entry

Coding

Charge Entry

Claim Submission

Payment Posting

Accounts Receivable

Denial Management

Reporting



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

Rapid 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



AREAS OF OPERATION



We provide turnkey revenue cycle management services in the following areas:

Prosthetics & Orthotics Durable Medical Equipment Urgent Care

Pathology Critical Care Skilled Nursing Facilities

Wound Care EKG Pharmacies

Cardiology Specialty Clinics Orthopedic Surgery

Anesthesia Family Practice Radiology

Rehab Centers Dermatology Physicians

Healthcare Facilities and more…

FOCUS ON ORTHOTICS & PROSTHETICS

We provide billing services for a wide range of Orthotic & Prosthetic devices, including:

Splints, Bands & Braces

Shoes & Insoles

Collars, Corsets & Supports

Bandages & Callipers

AFO (ankle-foot-orthosis)

KAFO (knee-ankle-foot orthosis)

TLSO (thoracolumbosacral orthosis)

Spinal Orthoses

Artificial Limbs

Artificial Arms

Exo-skeletal

Prosthetic Knees, and many more…



A NOTE ON O&P COVERAGE

Prosthetics & Orthotics coverage may be subject to a copay or coinsurance. Authorization is required for various devices and this varies from payer to payer. This is considered a part of the member’s benefits provisions.

For Prosthetic & Orthotics devices to be covered, the general billing requirements are:

A prescription from the ordering physician dated prior to delivery date

Consideration of limitations based on time period within which the item can be covered if supplied earlier, e.g. a pair of Orthotics shoes are covered per calendar year by Medicare

Appropriate modifiers must be billed

Letter of medical necessity and additional documentation may be required for some devices, e.g. PPR form for prosthetic devices, Diabetic Verification Form for diabetic patients etc.Coverage for such equipment is subject to medical review by the payer

Coverage of devices also subject to qualifying diagnosis, e.g. orthotic shoes not covered unless diagnosis states diabetic

Repair, replacement and supplies may be eligible for separate reimbursement.



O&P MEDICAL BILLING – KEY STEPS

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



O&P MEDICAL BILLING – KEY STEPS EXPLAINED

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



OUR COMPLETE APPROACH TO O&P BILLING

• Initial Visit Appointment Setup (done by Practice)• Order Entry

Patient Account Creation Patient’s demographic entry Prescription information entry

• Initial Eligibility Verification Creation of Insurance verification form

• Checking general eligibility and benefits information and updation in OPIE

• Initial Evaluation Appointment (done by Practitioner) LCodes assignment Measurements (If required) Creation of Evaluation form/Notes/Other Medical Records

• Detailed Eligibility Verification & Authorization Requirement Checking

Re-verification of eligibility with assigned codes• Updating detailed code specific benefits

Checking authorization requirements (Code Specific) Creation of Service Estimates (Payer Specific and Reasonable

and Customary) Sending detailed written order/diabetic verification form and

other paperwork to doctor’s office for signature• Doctor’s Office Follow-up

Contacting doctor’s office for pending detailed written order/diabetic verification form and other paperwork

• Authorization/Pre-Determination/Referral Initiation Creation of Insurance Authorization Form Requesting Authorization/Pre-Determination/Referral

(Via Phone/Fax/Email)

Private & Confidential 14

• Authorization/Pre-Determination/Referral Follow-up Follow-up with payer on Authorization/

Pre-Determination/Referral status Completion of authorization form based on the

outcome of the request• Final Eligibility Verification or Pre-delivery Check

Creation of patient financial responsibility form Notes updating Work In Progress (WIP) updating

• Office Coordinator Notification Patient responsibility ABN creation

• Schedule Delivery• Delivery (done by Practice)

Signing Delivery Ticket (Soft copy/Hard copy)• Claim Submission

Primary/Secondary/Tertiary claim submission(via paper/fax/electronic)

• Rejection Management Online rejection checking (via Clearing House) Correction and resubmission of the rejected claims

(via Clearing House)• AR Follow-up & Denial Management

Follow-up on pending AR balance and working on denials Follow-up on possible reconsideration requests Filing reconsideration requests & appeals

• Payment Posting Patient payment posting and adjustments Insurance payment posting and adjustments

Phone: (646) 930-4608 | E-mail: [email protected]


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 quickverification 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)



ELIGIBILITY VERIFICATION – SERVICE FEATURES

Our eligibility check covers the following:

Policy active for date of service

Co-pay / Coinsurance / OOP

Rx & Dx entry (with appropriate timeframe)

Provider status (INN / OON)

CSI check

Authorization requirement

Obtaining authorization

Patient responsibility

Our comprehensive verification process helps eliminate unpleasant surprises at the time of submitting claims, and removes most uncertainties about insurance coverage and reimbursement.



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!



SAMPLE REPORTS

0

20

40

60

80

100

120

140

4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015

96

83

94 9

8

96

29

11

6

31 32

12

5

94 1

00

12

9

12

8

41

32

26 3

0

28

ELIGIBILITY VERIFICATION

Number of New Patient Patient Brought Forward

Primary Checked Secondary Checked (if applicable)

0

5

10

15

20

25

30

35

40

45

50

4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015

45

25

38

4446

20

15

26

22 21

25

1012

22

25

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!



BILLING & CODING



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



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

Private & Confidential Phone: (646) 930-4608 | E-mail: [email protected]

41 Madison Avenue, 25th Floor, New York, NY 10010, USA23

TYPICAL 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

We use OPIE 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

Sunknowledge handles medical billing - promptly, perfectly and professionally – using OPIE Software® or other billing systems as preferred by the client.



OTHER 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



PRODUCTIVITY EFFICIENCY TRACKING

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 RECEIVABLEMANAGEMENT



STEPS IN A/R 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 our A/R team



SAMPLE SOW FOR A/R FOLLOW-UP

Sunknowledge will make outbound calls to reach out to the Payers to gather information about the status of claims as per the list provided by Customer. Key tasks involved in carrying out this work are detailed below.

Planning to start calling Payers as per the list of claims based on the downloaded AR Reports

Research details of the claims in the AR list in the Clients system

Making outbound calls to the respective Payers for claims aged 31 days and more

Document finding of the calls

Preparation of claims reports with status information gathered during the call

Modifications, removal or adding tasks to this are agreed upon between client and Sunknowledge.

…



SAMPLE OF AGENT-WISE A/R REPORT

User IDTouched Accounts

Note Count

Days WorkedHours

WorkedNotes Per

HourMax Note Time

AverageNote Time

XX12_GT 37 37 1 8.22 4.5 0:20:06 0:02:00

XX13_GT 50 51 1 8.83 5.77 0:35:44 0:05:45

XX14_GT 37 37 1 8.9 4.16 0:15:26 0:02:19

XX15_GT 41 41 1 8.65 4.74 0:38:47 0:09:48

XX16_GT 34 48 1 9.32 5.15 0:23:57 0:03:45

XX17_GT 83 83 1 9.63 8.62 0:42:35 0:02:37

XX18_GT 50 50 1 9.3 5.38 0:35:14 0:05:18

XX19_GT 45 46 1 9.65 4.77 0:24:11 0:05:05

XX20_GT 53 53 1 8.87 5.98 0:33:47 0:04:01

XX21_GT 14 14 1 9.93 1.41 0:37:20 0:08:23

Total Touched 444 460 Total time 91.30 5.04

Average Touched 44 46 Average time 9.13



SAMPLE OF A/R AGING REPORT

SUNKNOWLEDGE WEEKLY AR AGEING 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

MAGNACARE 7 7 0 11 9 2 5 5 0 8 3 5

OXFORD 12 9 3 17 12 5 23 22 1 22 16 6

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



BENEFIT HIGHLIGHTS

Reduction in accounts receivable

by 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



DENIAL MANAGEMENT



REASONS FOR DENIAL

Authorization Issues

Referral Issues

Medical Necessity and Medical Records requests

Non-Participation with Insurance Network

Terminated Insurance

Coordination of benefits

Wrong Diagnosis

Inclusive Procedures

Partial Payments

Out-of-network claim status and deductibles

EDI Rejections

No status and No claim on File

PIP cases



STEPS IN 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 Related

Coding Correction Required

OON Issue

Others

Patient info missing

Timely Filing

Claims denied as Others are due to the following reasons:

Claim denied as duplicate

Claim previously paid

Patient not eligible on DOS

Payer didn’t receive EOB from primary payer

Provider needs to verify if item billed is rental or purchase

Bill Primary

Patient not covered due to pre-existing condition

Plan doesn’t cover medical services such as DME

Not covered by member’s plan

Claim exceed maximum number times it can be billed



TECHNOLOGY, OPERATIONAL & COMPLIANCE FRAMEWORK



IT INFRASTRUCTURE

Service continuity supported by BCP and disaster management mechanisms

100% redundancy in all IT assets, providing high-availability and reliability

12 Mbps leased line internet connectivity provided by two ISPs in load sharing and automatic failover configuration

Data protection and security provided by a leading firewall system combined with other physical and logical access controls

Voice telephony infrastructure built using E1 lines provided by two IPLC providers

Avaya PBX with IVR, ACD and CTI functionalities and 100% call recording & reporting features

Data center with 13 IBM x3650 rack servers with rack mounted 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



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



Sunknowledge

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

GOVERNANCE MODEL



QUALITY ASSURANCE & CONTROL

Our Quality Control & Assurance processes 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.

The highest quality is ensured by carrying out rigorous quality assurance and control activities such as,

Periodic process review

Process audit

Testing deliverables and root cause analysis

Process improvement / re-engineering

Incorporating customer feedback

Internal quality audit of client deliverables & review reporting

Weekly/monthly monitoring of productivity reports



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

Sunknowledge 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.



COMPLIANCE ESCALATION STRUCTURE

Service Delivery

Service Delivery Mgr

(Service Delivery POC)

Head of Operations

(1st Level Escalation POC)

Operations

CEO & MD

(Final Escalation POC)

Executive Board

Board of Directors

Compliance

Compliance Mgr

(Compliance Escalation POC)

Head of Compliance

Compliance

Team Lead

Process Team Lead

(Service Delivery POC)

Technology

Technology Mgr

Quality

Quality Mgr

HR/Training

HR/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



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 efficiency

Process 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

• 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 Sunknowledge 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 Sunknowledge.”

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 Sunknowledge. 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 Sunknowledge 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. Sunknowledge provided extraordinary deliverables on

a timely basis which led to cost cutting considerably for us.”

CEO of a leading MA-PD Plan



READ ALL TESTIMONIALS

For Additional Information, Please Contact…

Michael SmithPhone: (646) 930-4608Email: [email protected]

Sunknowledge Services Inc.41 Madison Ave., Suite 2503, 25th Floor

New York, NY 11001, USA

http://sunknowledge.com/testimonials/