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REVENUE CYCLE MANAGEMENTSERVICE PORTFOLIO
CONTACT: RONNIE HASTINGS (646) 661-7853
GoTelecare 41 Madison Avenue, 25th Floor, New York, NY 10010
2© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Company Overview
‘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 facility inbuilt with all redundancies –
power, infrastructure and others
Sun Knowledge, our contracted company, is ISO 27001:2013 and ISO 9001:2008 certified
CMMi-SVC implementation in progress under KPMG guidance
Member of NASSCOM, a leading Governing Industry body for IT/ITES
Awarded ‘Best Emerging BPO Company of the year 2010’ by The Economic Times
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 on 3rd December 2015
Key Facts Awards, Affiliations & Certifications
Office at 41 Madison Avenue, 25th Floor, New York, NY 10010
3© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Our Service Offerings
Provider Support
Member Support
Member Retention Program
Clinical Help Desk
Contact Center
Utilization ManagementMedication Therapy ManagementHospital Re-admission ManagementTherapeutic InterchangeFormulary Management
Clinical Services
Enrollment Processing & MemberFulfillment
Claims Administration Coding & Medical Billing Credentialing Premium O&P Billing and Collections
Administrative Services
Analytics
Telemedicine Services
Application Development
Data Modeling & Data Warehousing
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
4© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
REVENUE CYCLE MANAGEMENT
5© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management Services
360° Revenue Cycle Management
Services
6© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management – Service Snippets
Inpatient/Outpatient Hospital Coding Physician Coding
Patient entry demographics & insurance information Fee Schedule / Charge Entry Scrubbing all entries for correctness and completeness with appropriate billing edits;
correction of identified errors Submission of claims to payers, e.g. EDI or paper Creation and mailing of patient statements Posting of payments received from patient and payer Reconciliation of charges, payments received and adjustments made
Denial Management (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
7© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management Experience
HOSPITAL
Accounts Receivable Follow - Up
Denial Management
Claims Resubmission
DME
Order Entry Eligibility
Verification/ Authorization
Follow up on Auth Approval
Delivery Scheduling
Submission of claim
Rejection Management
Payment Posting A/R Follow-Up Denial
Management CPAP Compliance
Tracking
O&P
Rx Order Entry Patient
Demographics and Insurance Entry
Product Code entry/Rx & Dx Entry
Eligibility Verification/ Authorization
Collection of complete Rx
Collection of Documents for Auth Approval
Submission Rejection/Denial
Management A/R Follow-Up
URGENT CARE
Order Entry – Patient Information, Ordering Physician, Rx & Diagnosis
Eligibility Verification
Medical Document Collection
Authorization Approval
Order Audit Confirmation
Submission of Claims
Rejection Management
Payment Posting A/R Follow-Up
Patient Entry: Demographics & Insurance
Eligibility Verification
Authorization Follow-Up
Charge Entry Submission of
Claims (EDI/Paper)
Rejection Management
Payment Posting A/R Follow-Up Denial
Management
PHYSICIAN
Patient Entry: Demographics & Insurance
Charge Entry Submission of
Claims (EDI/Paper)
Rejection Management
Payment Posting A/R Follow-Up Denial
Management
HOME HEALTH
8© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Areas of Operation
We provide turnkey billing & coding services in the following areas:
DME / HME Prosthetics & Orthotics Urgent Care
Pathology Critical Care Radiology
Internal Medicine EKG Compounding Pharmacies
Cardiology ENT Orthopedic Surgery
Anesthesia Family Practice Specialty Clinics
Rehab Centers Pharmacy Physicians, and more…
9© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
ELIGIBILITY & AUTHORIZATION
VERIFICATION
10© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
Insurance Claim Eligibility Verification – Highlights
11© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Insurance Claim Eligibility Verification
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
12© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Insurance Claim Authorization Verification
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
13© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
14© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Highlights
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
15© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
PRIOR AUTHORIZATION SERVICES
16© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Prior Authorization – Highlights
• Full Range Service 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
17© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
No Authorization
Certain procedures require prior authorization
Submitting a request does not guarantee approval
If an authorization was not previously requested, a retro-authorization may be requested for services already provided
The same guidelines as for requesting an authorization prior to service are followed
Dates specific for retro-authorizations are used
Once the authorization is approved, the bill is resubmitted
18© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
CODING SERVICES
19© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
20© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Coding – Key Facts
• Our coders deliver error-free charge sheets within agreed TAT provided by the client
• We monitor, analyze and improve coding documentation to avoid denials and guarantee reimbursements
• We carefully determine the codes according to the clinical information provided by the Healthcare Provider/Professionals and report back accordingly
• Our coders have undergone extensive medical coding training and are well aware of updated coding guidelines
• All our coders are ICD-10 certified (CPC)
21© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Coding – Sample Production Report
Weekly Chart Review Summary Mon Tue Wed Thu Fri
No. of charts to be reviewed/pending brought forward 42 124 110 91 62
No. of charts received 142 48 52 40 51
No. of charts reviewed 65 68 74 70 67
No. of charts with insufficient information to code 34 14 23 20 17
No. of calls made to physicians office to get information 25 18 22 16 12
No. of charts succesfully coded 60 62 71 69 62
No. of charts coding pending/ carried forward 124 110 91 62 51
22© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Sample Coding Report
CPT Codes Billed Report
CPT codes Code description Units Billed Charges Payments Collection %
99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT 158 $$$$ $$$$ 68.18%
99218 INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT 162 $$$$ $$$$ 76.00%
99225 SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT 192 $$$$ $$$$ 70.00%
99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT 161 $$$$ $$$$ 88.57%
99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES OR LESS 254 $$$$ $$$$ 60.00%
99252INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED
HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING
168 $$$$ $$$$ 60.00%
99281 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT 126 $$$$ $$$$ 93.75%
23© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
BILLING SERVICES
24© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Medical Billing Cycle – Overview
Encounter (SOAP) notes review
Superbill generation and code review
Claims edit checking and correction
EDI claims submission through clearing house
Rejection managementERA/EOB posting and reconciliation
Automatic secondary payer billing
Denial Management
A/R Follow-up
25© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
26© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Practice Management & 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
27© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Billing & Coding Services - Highlights
FREE Billing Software FREE EMR FREE Implementation No Hidden Cost Up to 95% Collection Rate 99.9% Coding Accuracy Claims Submission within 24 – 48 hours max. 100% HIPAA-HITECH Compliance Custom Reporting Excellent References Real Time Audits
28© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
ACCOUNTS RECEIVABLE
29© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Accounts Receivable Follow-up by GoTelecare
Our A/R follow-up service is designed to increase the Revenue Collection for our clients.
The process begins after the Provider creates and sends Health Insurance Claims (Electronic/Paper claims or Manual HCFA forms) to various Insurance Companies.
Depending on the transmission type and length of time since submission, we begin our follow-ups.
CALL: (763) 550-1102
30© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Accounts Receivable Follow-up
No Remark Claims:
Any claim in which absolutely no status is known for the claim.
Last Remark Claims:
Claims which remain unpaid for various reasons. These claims are routinely followed up on a monthly basis.
2 types of Claims Follow-ups
CALL: (763) 550-1102
31© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Steps in Accounts Receivable Follow-up
A/R Analysis 14% of all claims submitted to the payers are denied and have to be resubmitted, appealed
or written off by providers 50% of denied claims are never re-filed 50-70% of denied claims have higher chance of being recovered
Follow-up with payer Aggressive follow up with the insurance company's on all accounts at any
stage of the aging bucket plays an important part in A/R follow up activities.
Closure of claim
Reducing days in A/R, claims submission and improving collection ratio with an increase in the probability of payment through timely follow-up is the responsibility of the A/R team
CALL: (763) 550-1102
32© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Steps in Accounts Receivable Follow-up
Online Claims Follow-UpUsing various insurance company websites and Internet payer portals, we check on the status of outstanding claims.
Automated Claims Follow-Up (IVR)By calling insurance companies directly, an Interactive Voice Response (IVR) system will provide the status of unpaid claims.
Insurance Company RepresentativeIf necessary, calling a ‘live’ insurance company representative will give us a more detailed reason for claim denials when such information is not available by the first 2 methods
1
2
3
CALL: (763) 550-1102
33© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
CALL: (763) 550-1102
DENIALMANAGEMENT
34© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Reasons for Denials
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
CALL: (763) 550-1102
35© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
CALL: (763) 550-1102
36© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Distribution of Denied Claims
24%
11%3%
35%
17%
10%
Distribution of Denied Claims
Auth Related Coding Correction Required
OON Issue OthersPatient info missing Timely Filing
24% of denials are due to authorization related issues
17% of denials are due to incorrect/missing patient information
CALL: (763) 550-1102
37© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Distribution of Denied Claims
Claim 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
CALL: (763) 550-1102
38© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Sample A/R Report (Agent-wise Report)
User ID Touched Accounts
Note Count Days Worked Hours
WorkedNotes Per
Hour Max 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
CALL: (763) 550-1102
39© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Sample A/R Aging Report
GOTELECARE 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
CALL: (763) 550-1102
40© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Sample SOW of A/R Follow-up
CALL: (763) 550-1102
GoTelecare 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 GoTelecare.
41© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Benefit Highlights
CALL: (763) 550-1102
Reduction in accounts receivable
by 30% within 1 month
Accounts Receivable recovery cost starts
from 2.5% 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
42© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
OTHER PRACTICE MANAGEMENT SERVICES
43© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
44© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
45© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
CALL: (763) 550-1102
MEETINGCHALLENGES
46© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Challenges and 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 & payers to collect documentation and obtain authorization
Proper tracking mechanism
47© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Challenges and 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
48© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Challenges and 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
49© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Client Benefits
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
50© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Technology, Operational & Compliance Framework
TECHNOLOGY, OPERATIONAL & COMPLIANCE FRAMEWORK
51© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Software Development
Some of the applications which we have developed include, GoTelecare - A full fledged Telehealth application for providers, hospitals and patients with integrated EMR,
practice management system and video conferencing system Integration of DICOM server, DCM4CHE with EMR software mHealth – Remote patient monitoring and health data collection through medical devices and QUALCOMM
cloud services PDP Manager – To manage Medicare Part D processes Medication Therapy Management (MTMpro) application
Our technology development team works with Java (Enterprise Edition) and technology components include, Web application technologies like servlets, JSP, JSTL, JSF, JSON, web sockets, applets Open source frameworks like Struts, Spring, Hibernate Enterprise technologies like dependency injection, messaging services, transaction management services,
persistence management services, annotations, javamail, java enterprise beans, interceptors, connector architecture
Web service technologies like RESTful web services, enterprise web services, JAX -WS, JAX- RPC Database servers like MS SQL server, Oracle, MySQL
52© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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 Fortigate® 310B firewall 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
53© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
54© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Governance Model
GoTelecare 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
55© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
56© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Training Methodology
• 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 Training
Training Evaluation
57© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
GoTelecare 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.
58© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
59© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
60© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Why GoTelecare?
WHY US?
61© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Advantage GoTelecare
1Over 7 Years of Experience in Working as Vendors for
Major Health Insurance
Companies Across US
Deep Knowledge of both the Payer
and the Provider Side
of the US Healthcare Spectrum
2Consistent
Performance in Delivering up
to 95% Collection Rate
to Clients
Already
Recovered over millions in
Account Receivables
and counting…
3The Only
Medical Billing Company with Its Own State-
of-the-Art Telemedicine
Platform
4The Best
References in Every
Segment of US
Healthcare Knowledge &
Business Process
Outsourcing
5The Lowest Prices in
the Market!
62© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Our 4 Pillars of Strength
Highest Quality
Excellent References
Unique Profile
Cheapest Rates
Consistently delivering the best quality, with the highest levels of accuracy, efficiency & expertise
Glowing testimonials from every client and not a single customer
churn in our 7+ years of operation
Huge experience in working for both Payers and Providers and
the only billing company with its own Telemedicine platform
The lowest rates in the market, with custom pricing options to
delight all clients
63© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
GoTelecare vs. Other Staffing Agencies
64© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Why Us?
Very Little Risk• Proven track record in providing healthcare BPO/KPO services• Highly experienced in providing services to both payers and providers• Experienced in 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 increase in revenue collection • Verification & authorization accuracy > 99.9%; TAT: 24 hours • High accuracy in Eligibility Data Maintenance (in sync with CMS)
Clear Communication and Quick Response at All Times ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection
65© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
What are Our Clients Saying
"The professionalism I have experienced with GoTelecare’s employees has made them very easy to work with and has improved our operation processes. Any time I have a question, they are literally just a phone call or e-mail away. I love the accessibility!”
- CFO of a major US healthcare company
“I am starting to see an upswing with Medicare and United cash flow”
- CEO of a leading US healthcare organization
“Your productivity is very impressive for your first month. Almost everyone has an average of close to 40 accounts per day. We have gone over a few things with you and each time we talk, I am impressed with how quickly changes and improvements are put in place.
I will continue to share feedback as I get it on additional improvements that can be made and appreciate your attentiveness and questions that you bring to our daily meetings.
- Manager (Revenue Cycle) of a reputed US healthcare company
66© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Contact
41 Madison Avenue, 25th Floor, New York, NY 10010
(646) 661-7853 [email protected]
Ronnie Hastings