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Medical Billing Services for Urgent Care Centers by Sun Knowledge (compressed)
- 2. COMPANY OVERVIEW
Key Facts Awards, Affiliations & Certifications
2Sun Knowledge © 2015-16 Private & Confidential
‘Onshore /Offshore’ KPO & BPO services
Serving US healthcare industry since 2007
Robust & scalable infrastructure
State-of-the-art technology and systems
Highly skilled and trained staff with good
communication skills and in-depth knowledge of process
Structured training, feedback and coaching
HIPAA-HITECH compliant
State-of-the-art office inbuilt with all redundancies –
power, infrastructure and others
ISO 27001:2013 and ISO 9001:2008 certified
CMMi-SVC implementation in progress under KPMG
guidance
Member of NASSCOM, the Governing Industry body for
IT/ITES in India
Awarded ‘Best Emerging BPO Company of the year 2010’
by The Economic Times, India
Recognized as one of the foremost 'Emerging companies in
Eastern India' by NASSCOM in 2011
Awarded Asia-wide “Healthcare BPO Provider of the Year”
at the Asia BPO Excellence Awards ceremony hosted by
Asia BPO Summit on 14th February 2013 in Mumbai, India
Awarded the prestigious “Outsourcing Service Provider of
the Year” award in the Asian Outsourcing Excellence
Awards ceremony hosted by CMO Asia on 1st August 2013
in Singapore
Awarded “Highest New Job Creator (IT/ITES)” by STPI
(Software Technology Parks of India) on 3rd December 2015
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Office at
41 Madison Avenue, 25th Floor,
New York, NY 10010
- 3. 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, Urgent Care, Home Health Care and Pharmacies
Payers – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
3Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
- 4. SUMMARY OF SERVICES
4Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRACTICE
MANAGEMENT
Scheduling
Eligibility &
Authorization
Verification
Prior Authorization
Customer Care
BILLING &
COLLECTIONS
Coding
Charge Posting
Claims Submission
Payment Posting
Denial Management
Accounts Receivable
PAYOR SERVICES
Claims
Adjudication
Credentialing
Utilization
Management
Customer Care
TELEMEDICINE
Telemedicine
Remote Patient
Monitoring
- 5. HIPAA COMPLIANCE SUMMARY
5Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SL. COMPLIANCE ASPECT HIGHLIGHTS
1 Physical Access Authorized access only | Bio-metric access | Proximity card system | Photo ID cards | Access log review
2 General Security 24 hour security personnel | Logging of visitor details | Physical register retained for 10 years
3 Monitoring CCTV monitoring (with recording) of production area | Daily review of recording
4 Vendor Access
Signing confidentiality agreement before accessing sensitive areas | Accompanied by security personnel/employee during
all times
5 Mobile Phones All employees (except managers) are required to deposit mobile phones in the locker box before entering facility
6 Personal Baggage No backpacks or other bags allowed | All baggage to be deposited in locker box before entering facility
7
Network &
Application Usage
Unique user IDs created using Microsoft Active Directory | Access to storage devices, shared drives, USB/mass
storage devices, printers – controlled by Domain Group Policy | No wireless access points
8 Firewall
Unified Threat Management System | Internet traffic regulation using multiple filters | Network Address Translation (NAT) |
Intrusion Prevention Systems (IPS) | Port-mapping for traffic between Virtual LANs | Default setting to deny all traffic
9
VPN (Virtual
Private Network)
Site-to-site IPSec VPN tunnels | Authorized access via client-to-site VPN connections | Access authorization
controlled by Active Directory's authentication service
10
Redundancy
Management
Fully redundant network stack | Two ISP links configured in active-active mode | Power backup supplied by 130 KVA UPS
and 750 KVA generator | 22 KVA UPS backup for server and network systems
11
Virus & Malware
Protection
Central anti-malware system | Automatic updates | Extra protection by gateway firewall |
Centralized OS patch management system (using Microsoft's WSUS server)
12 Other Measures Fire extinguishers at key areas | Half-yearly fire drills
- 6. 6Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REVENUE CYCLE
MANAGEMENT
- 7. REVENUE CYCLE MANAGEMENT – KEY PROCESSES
7Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
360°
Revenue Cycle
Management
Services
Eligibility &
Authorization
Verification
Patient
Information
Entry
Coding
Charge Entry
Claim
Submission
Payment
Posting
Accounts
Receivable
Denial
Management
Reporting
- 8. SERVICE HIGHLIGHTS
8Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Up to 97% collection rate in accounts receivable
FREE medical billing software, EMR & setup
Real-time eligibility checks & fast authorization
100% HIPAA-HITECH compliance
Rapid 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
- 9. SERVICE AREAS
9Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
We provide turnkey revenue cycle management services in the following areas:
Durable Medical Equipment Prosthetics & Orthotics 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…
- 10. 10Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ELIGIBILITY &
AUTHORIZATION
VERIFICATION
- 11. ELIGIBILITY VERIFICATION – HIGHLIGHTS
11Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Full range of verification services
Fast 24-hour turnaround time
Above 99.9% accuracy
Detailed documentation
100% HIPAA compliance
Experience with national and private carriers
We have the experience, training and resources to complete quick
verification checks, a feature that Urgent Care Centers love us for.
In some cases, such services can even be rendered in real-time
(with the help of fast, software-assisted database enquiries)
- 12. ELIGIBILITY VERIFICATION – SERVICE FEATURES
12Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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.
- 13. AUTHORIZATION VERIFICATION – HIGHLIGHTS
13Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Diligent follow-up till resolution and closure
Uniform importance given to every account irrespective of size, age or claim value
Fast completion of authorization process
Periodic follow-ups to maintain authorization validity
Years of experience in working at
claims adjudication for major
insurance companies in the US has
given us a unique understanding of
the authorization process, allowing
us to complete the process faster
than others!
- 14. SAMPLE REPORTS
14Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
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 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
44
46
20
15
26
22 21
25
10
12
22
25
AUTHORIZATION VERIFICATION
Auth Required Auth Obtained Auth Pending
- 15. BENEFITS OVERVIEW
15Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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!
- 16. 16Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
BILLING & CODING
- 17. MEDICAL CODING OVERVIEW
17Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Service Offerings
• Place of Service Based Coding – Inpatient, Outpatient Coding
• Provider Specialty Based Coding– E/M, Cardiology, Orthopedics, Physical Medicine etc.
• Review medical notes and clinical documents
• Assign ICD-10 codes for the diagnosis identified by the physician and Procedure codes
(CPT/ ICD 10 PCS)
• Assign modifiers as applicable
• Code review and quality assurance
• Communication with Physician’s office for additional medical
documentation and clarification
Key Tasks
- 18. MEDICAL CODING – PROCESS
18Sun Knowledge © 2015-16 Private & Confidential
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
- 19. TYPICAL MEDICAL BILLING CYCLE
19Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
- 20. MEDICAL BILLING SYSTEM
20Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
We use Kareo for coding and billing services that covers the complete billing cycle:
SOAP notes review
Superbill generation and coding
Claims edit checking and correction
Claims submission through EDI clearing house at a scheduled time
Rejection management
ERA/EOB posting and reconciliation
Automatic secondary payer billing
Denial Management
Patient statement generation and mailing
Sun Knowledge handles medical billing - promptly, perfectly and
professionally – using Kareo® or other billing systems as preferred
by the client.
- 21. 21Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
OTHER SERVICES
- 22. PAYMENT/DENIAL POSTING PROCESS
22Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Payment posting is crucial to the billing process. Due to the sensitivity of this process,
accurate and efficient payment posting process is indispensable.
Our billers are known to be highly efficient and analytical in the payment posting process.
Payment Entry Process
Select Patient Account
Select EncounterSelect Encounter
If not found
Refer Client SpecifiesDenial
Denial Code
Hold Transfer BalanceTransfer BalanceWrite-off
Post Payment
Payment
- 23. PRODUCTIVITY EFFICIENCY TRACKING
23Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Employee Name Note Count Days Worked Hours Worked Notes Per Hour Max Note Time Avg. Note Time
John Smith 977 23 203.55 4.8 1:29:52 0:07:15
Jane Doe 1025 23 214.97 4.77 0:55:14 0:04:56
Rick Williams 913 21 207.07 4.06 1:27:08 0:07:14
Robert Frost 870 21 187.35 4.64 0:42:54 0:04:05
Dan Chesser 910 23 216.47 4.2 3:50:55 0:06:18
Derek Malia 823 23 210.37 3.91 7:01:30 0:04:37
Our clients depend on transparency.
We provide our clients with the ability to maintain detailed tracking for increased productivity
and efficiency.
Sample Report
- 24. 24Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
ACCOUNTS RECEIVABLE
MANAGEMENT
- 25. STEPS IN A/R FOLLOW-UP
25Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
A/R Analysis
14% of all claims submitted to the payers are denied and have to be resubmitted, appealed
or written off by providers
50% of denied claims are never re-filed
50-70% of denied claims have higher chance of being recovered
Follow-up with payer
Aggressive follow up with the insurance company's on all accounts at any
stage of the aging bucket plays an important part in A/R follow up activities.
Closure of claim
Reducing days in A/R, claims submission and
improving collection ratio with an increase in the
probability of payment through timely follow-up is
the responsibility of our A/R team
- 26. SAMPLE SOW FOR A/R FOLLOW-UP
26Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Sun Knowledge 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 Sun
Knowledge.
…
- 27. SAMPLE OF AGENT-WISE A/R REPORT
27Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
User ID
Touched
Accounts
Note
Count
Days Worked
Hours
Worked
Notes Per
Hour
Max Note Time
Average
Note 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
- 28. SAMPLE OF A/R AGING REPORT
28Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SUN KNOWLEDGE 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
- 29. BENEFIT HIGHLIGHTS
29Sun Knowledge © 2015-16 Private & Confidential
Reduction in
accounts receivable
by up to 30%
within 1 month
Accounts Receivable
recovery cost starts from
1%
of collections
Expert handling of accounts
receivable by highly
experienced staff
Same attention to every
cash amount regardless of
its size or source
Demonstrated expertise in
working on difficult-to-
recover aging A/R
Over 7 years’ experience
in claim adjudication for
major US insurance plans
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
- 30. 30Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
DENIAL MANAGEMENT
- 31. REASONS FOR DENIAL
31Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
- 32. STEPS IN DENIAL MANAGEMENT
32Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Claim Correction and Resubmission
These 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
- 33. DISTRIBUTION OF DENIED CLAIMS
33Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
- 34. 34Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TECHNOLOGY, OPERATIONAL &
COMPLIANCE FRAMEWORK
- 35. IT INFRASTRUCTURE
35Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
- 36. OPERATIONAL FRAMEWORK
36Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
- 37. GOVERNANCE MODEL
37Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Sun Knowledge
Governance
Structure
Steering Committee
Program Management Office
Project Delivery Team
Executive sponsorship
Management oversight
Ensure business goals and
engagement goals alignment
Ensure tangible results and
demonstrable value
Continuously educate & report
executive leadership on the
critical success factors of
engagement
Plan and implement change;
define, establish performance,
metrics aligned to goal
Review project scope, timeline
and budget and monitor project
progress
Communication, status reporting
& escalation to steering
committee
Manage cross team
dependencies
Identify, initiate & institutionalize
process improvements
Oversee knowledge repository
building
Project Management
Scope Management
Knowledge
Management
Change Management
Ensure successful
engagement startup
Quality Management
Resource Management
Communication &
Status Reporting
Issue Management
Monitor & measure
knowledge transfer
process
Incorporate industry
best practices
- 38. QUALITY ASSURANCE & CONTROL
38Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
- 39. COMPLIANCE KEY FACTS
39Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Well defined policies to cover compliance aspects
Written procedures covering compliance aspects
Proactive compliance reporting and issue escalation
Action list for changes in rules and regulations by regulatory authorities
Compliance evaluation framework
Periodical training on compliance issues and update
Periodic audit and review mechanism to address potential compliance risks
Implementation of data privacy and security standards like HIPAA-HITECH and ISO 27001
Incident reporting for data security violation
Compliance awareness among the employees and reward on compliance reporting
Compliance violation by employees leads to employee retraining and reassessment
Sun Knowledge has defined and established a process and system to avoid compliance risks while
carrying out operations and encourages employees to proactively report compliance issues to
the higher management.
- 40. COMPLIANCE ESCALATION STRUCTURE
40Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
- 41. 41Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CHALLENGES & RESPONSES
- 42. CHALLENGES & OUR APPROACH
42Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Assignment of adequate staff
Completion of secondary verification
Rigorous audit
Time consuming with limited staff
Documentation collection requires
continuous follow-up
Increased TAT
Time consuming with limited staff
Secondary verification not carried out
Checking Authorization
Requirement and
Obtaining Authorization
Eligibility Verification
Patient Demographics /
Insurance / Charge Entry
Transaction audit to minimize errors;
reduces denial due to missing patient
information
TASK DESCRIPTION CHALLENGES APPROACH
Missing information / Key-in errors
Increased denial rate
Increased TAT
Assignment of adequate staff
Systematic and regular follow-up with
physicians’ offices & payors to collect
documentation and obtain authorization
Proper tracking mechanism
- 43. CHALLENGES & OUR APPROACH
43Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Defining KPI for rejection management
process and assigning responsibility
Claims reconciliation and exception
report generation
Unapplied balance
Accumulation of backlog
Manual posting
Denials not posted
Delayed correction and resubmission
Possible loss of payment
Payment Posting
Rejection Management
Paper Claim Submission
Proper tracking of every submission of
paper claims
Moving to EDI based submission
whenever possible will reduce cost of
manual work and faster payment cycle
TASK DESCRIPTION CHALLENGES APPROACH
Additional work for printing and
faxing/mailing
Delayed filing leading to denials
Lack of information about the actual
status
Defining guidelines
Review of patient payments
Define KPI – TAT & Accuracy
Denial posting and review
- 44. CHALLENGES & OUR APPROACH
44Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Proper documentation – process
manual, guidelines & checklists
Defining proper tracking mechanism
through various reports -Ageing, Status,
Daily, Exception
Generate exception reports and regular
audit of every process tasks
Defining KPIs and assigning
responsibility
Lack of clarity of claims volume and
current status affects management
decision making process
Impact on overall billing process
performance and improvement
Decreased productive 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
- 45. SUMMARY OF BENEFITS
45Sun Knowledge © 2015-16 Private & Confidential
Very Little Risk
• Proven track record in providing healthcare BPO/KPO services
• Experienced in providing services to both payers and providers
• Experienced working with various software platforms
• Quick and efficient resource for special projects requiring technical and process expertise
Significant Upside Potential
• Great understanding of the Healthcare Industry. Operation scale-up with a short notice
• Extremely competitive rates, greater productivity, improved quality, increased member and provider
satisfaction
Proven Process Performance
• Low denial rate reduced collection time increase in revenue collection
• Billing & Coding Accuracy > 99.9%; TAT: 24 – 48 hours
• Adherence to CMS billing requirements
Clear Communication and Quick Response at All Times
ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
- 46. 46Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
- 47. CLIENTSPEAK
47Sun Knowledge © 2015-16 Private & Confidential
“We have had the pleasure of working with the Sun Knowledge team
throughout the few months utilizing their services for patient data entry and
eligibility verification. They are a devoted and responsible team that is highly
experience in what they do. They are always concerned about the client’s
needs and are always there to help. I highly recommend the services offered
by Sun Knowledge.”
COO of a leading medical billing and credentialing company in New York
“Your team amazed me with the manual and the amount of info you provided
with that short training session.”
Practice Manager of a major Dermatology group in New York and New Jersey
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
- 48. CLIENTSPEAK
48Sun Knowledge © 2015-16 Private & Confidential
“My firm has evaluated an outsourcing transaction with Sun Knowledge. They provide
superior service at a very attractive rate and have demonstrated to us their commitment to
this partnership. Their expertise across various process areas in the PDP/MAPD domain
and unique cost structure puts them in an incredible position to work with plans
throughout the healthcare industry.”
Chairman, President and CEO of a major New York based Health Plan
“Our company is very pleased with the administrative, and business analytical solutions
which Sun Knowledge delivers to our company from a quality & cost perspective. They
have been a true partner in bringing industry expertise, and innovative solutions to the
table. Their ability to grow with our evolving needs for higher end services such as
clinical services is a significant differentiator among healthcare business process
outsourcing firms.”
Executive Vice President of Operations of a leading MSO
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
- 49. CLIENTSPEAK
49Sun Knowledge © 2015-16 Private & Confidential
“I was always against the idea of outsourcing our back end claims processing
work but I was wrong. Sun Knowledge provided extraordinary deliverables
on a timely basis which led to cost cutting considerably for us.”
CEO of a leading MA-PD Plan
Ronnie Hastings
(646) 661-7853
Email: ronnie.hastings@sunknowledge.com
Sun Knowledge
41 Madison Ave., Suite 2511, 25th Floor
New York, NY 11001, USA
For additional information, please contact…
41 Madison Avenue, 25th Floor, New York, NY 10010, USA