Date post: | 21-Jan-2018 |
Category: |
Healthcare |
Upload: | michael-smith |
View: | 114 times |
Download: | 0 times |
PRACTICE MANAGEMENT & REVENUE CYCLE MANAGEMENT
FOR RADIOLOGY PRACTICES
Private & Confidential 1Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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 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, Laboratories, Radiologists, Pharmacies and more!
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
Tele-radiology
Private & Confidential 4Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SERVICE AREAS
Private & Confidential 5Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
We provide our services in the following areas:
Nursing Homes Prosthetics & Orthotics Urgent Care
Durable Medical Equipment Home Healthcare Skilled Nursing Facilities
Wound Care Pain Management Pharmacies
Cardiology Specialty Clinics Surgery
Physical Therapy Family Practice Radiology
Rehab Centers Dermatology Diabetics
Urology Healthcare Facilities and more…
SERVICE HIGHLIGHTS
Over 99% accuracy
Up to 97% overall collection
Instant reduction of billing cost by 70%
FREE medical billing software, EMR & setup*
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 contract that can be cancelled anytime
Backed by excellent references from reputed clients across the US
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
A UNIQUE EDGE
Since 2011, Sun Knowledge has been adjudicating claims in radiology/imaging for major health insurance companies in New York and California.
This has given us a unique edge over other medical billing companies, in better understanding various Payer guidelines and how to submit clean claims that meet with no denials and get paid quickly!
We provide complete Revenue Cycle Management (billing & collection) solutions for various radiological procedures such as:
• CT or CAT scan• MRI (Magnetic Resonance Imaging)
• Angiography• Balloon Angioplasty• Fluoroscopy• Chemoembolization• Biopsy• Embolization
• Radiofrequency Ablation (RF/RFA)
• Thrombolysis• Vertebroplasty• X-rays• Bone & Thyroid scans• Thallium Cardiac Stress Test• Positron Emission Tomography (PET scan)
• Ultrasound and more… RADIOLOGY
Private & Confidential 7Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 8Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REVENUE CYCLE MANAGEMENT
Private & Confidential 9Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REVENUE CYCLE MANAGEMENT – KEY PROCESSES
360°Revenue Cycle Management
Services
Eligibility & Authorization Verification
Patient Information
Entry
Coding
Charge Entry
Claim Submission
Payment Posting
Accounts Receivable
Denial Management
Reporting
Private & Confidential 10Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
IMPORTANT TASKS
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, e.g. understanding denials and making corrections
Resubmission of claims
AR calls as follow-up on outstanding issues
Closure of a claim once the balance is zero
CODING
BILLING
A/R FOLLOW-UP
Private & Confidential 11Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
MEDICAL BILLING CYCLE
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
Private & Confidential 12Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 13Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
MEDICAL BILLING SYSTEM
Our billers and coders are proficient in using a wide range of billing and practice management software suites that cover the entire billing cycle.
Sun Knowledge can handle medical billing - promptly, perfectly and professionally – using any billing system as preferred by the client.
Private & Confidential 14Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
MEDICAL CODING OVERVIEW
Service Offerings
• Place of Service Based Coding – Inpatient, Outpatient Coding
• Provider Specialty Based Coding– Dentistry, 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 (CDT/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
Private & Confidential 15Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
MEDICAL CODING – PROCESS
Private & Confidential 16Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
MEDICAL CODING – HIGHLIGHTS
• 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)
Private & Confidential 17Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTS RECEIVABLE
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.
Private & Confidential 18Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
STEPS IN AR 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
Private & Confidential 19Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
COMMON DENIALS FOR RADIOLOGY CLAIMS
Duplicate of a previously processed claim
2 possible scenariosa) the claim was previously processed b) Provider automatically re-files a claim to seek payment if initial claim has not been paid within 30 days
Claim is not covered because the patient is enrolled in a health maintenance organization (HMO)
Because beneficiaries can enroll in, and opt out from, such plans annually, physician offices should verify the patient's eligibility before seeing the patient
The payer does not deem non-covered services as medically necessary
Local coverage determinations (LCDs) should be checked for procedure-to-diagnosis code editing, and the ordered service verified against the LCD to ensure compliance with medical necessity requirements
Routine screening and related exams are not covered
The purpose of the service should be verified, and checked for coverage under Medicare and if it has been billed it correctly
Payment is included in another service received on the same day
Private & Confidential 20Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 21Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
Private & Confidential 22Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
AR AGING REPORT SAMPLE
SUN KNOWLEDGE WEEKLY AR AGING 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
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
Private & Confidential 23Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
THE SUN KNOWLEDGE ADVANTAGE
Increased revenue – reduced collection time (up to 97% collection rate)
Reduction in accounts receivable by 30% within 1 month
Expert handling of accounts receivable by highly experienced staff with demonstrated expertise
Claim submission within 48 hours of receipt of billing input
Provider can focus more on core services
Adherence to CMS billing requirements
Proper records maintenance and visibility through reporting
Private & Confidential 24Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SPECIAL ADD-ON SERVICE
ACTIVE BRANDING & VIGOROUS LEAD GENERATION THROUGH SOCIAL MEDIA MARKETING
3.4Million
Healthcare
Providers
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-
Channel
Marketing
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!
L E A D S
Private & Confidential 25Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & RESPONSES
Private & Confidential 26Phone: (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 27Phone: (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 28Phone: (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 efficiency
Process 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 29Phone: (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 30Phone: (646) 661-7853 | E-mail: [email protected]
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
Private & Confidential 31Phone: (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 the north-east
“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 the north-east
Private & Confidential 32Phone: (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 north-eastern 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 33Phone: (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 34Phone: (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…