Medical Billing for Home Healthcare by Sun Knowledge

MEDICAL BILLING &
COLLECTION SERVICES
FOR HOME HEALTH AGENCIES
Ronnie.Hastings@SunKnowledge.com brucebeg@gmail.com

SUN KNOWLEDGE OVERVIEW
2Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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, Home Health Care and Pharmacies
Payers – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs

SERVICE PORTFOLIO SUMMARY
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

SERVICE AREAS
We provide revenue cycle management services in the following areas:
Home Healthcare Agencies Prosthetics & Orthotics Urgent Care
Durable Medical Equipment Critical Care Skilled Nursing Facilities
Wound Care Pathology Pharmacies
Cardiology Specialty Clinics Orthopedic Surgery
Anesthesia Family Practice Radiology
Rehab Centers Dermatology Physicians
Nursing Homes and more…

SERVICE HIGHLIGHTS
 Up to 97% collection rate in accounts receivable
 Instant reduction of billing cost by 70%
 Vigorous lead generation through multi-channel Social Media Marketing
 FREE medical billing software, EMR & setup*
 Real-time eligibility checks & fast authorization
 100% HIPAA-HITECH compliance
 Claim status analysis 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
 Excellent references from reputed clients across the US
 Real-time audits and custom reporting
* Conditions apply

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 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

REVENUE CYCLE
MANAGEMENT

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

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

MEDICAL BILLING CYCLE
BILLING
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

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
BILLING

MEDICAL BILLING SYSTEM
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 payor billing
 Denial Management
 Patient statement generation and mailing
Sun Knowledge handles medical billing - promptly, perfectly and
professionally – using Kareo® or any other billing system as
preferred by the client.
BILLING

MEDICAL CODING OVERVIEW
Service Offerings
• Place of Service Based Coding – Inpatient, Outpatient Coding
• Provider Specialty Based Coding– E/M, Cardiology, Orthopedics, Physical Medicine etc.
• Review medical notes and clinical documents
• Assign ICD-10 codes for the diagnosis identified by the physician and Procedure codes
(CPT/ ICD 10 PCS)
• Assign modifiers as applicable
• Code review and quality assurance
• Communication with Physician’s office for
additional medical documentation and clarification
Key Tasks
CODING

MEDICAL CODING – PROCESS
CODING
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)
CODING

ELIGIBILITY & AUTHORIZATION VERIFICATION
• Full range of verification services
• Fast 24-hour turnaround time
• 96 – 99.9% accuracy
• Detailed documentation
• 100% HIPAA compliance
• Experience with national and private carriers
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
ELIGIBILITY VERIFICATION
AUTHORIZATION VERIFICATION

SAMPLE REPORTS
VERIFICATION
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

PRIOR AUTHORIZATION
• Full Range Service (Authorization Request Follow-up Approval)
• 100% HIPAA-HITECH Compliance
• Low prices with no hidden cost
• Highly streamlined, fast and accurate service
• Home Health Care / DME / Oxygen & Related Equipment and Services
• Long Term Care (LTC) Nursing Facilities
• Infusion
• TPN (Total Parenteral Nutrition)
• Wound pumps
• Telehealth
• Palliative Care
• Other conditions
We cater to
PRIOR
AUTHORIZATION

ACCOUNTS RECEIVABLE
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.

STEPS IN AR FOLLOW-UP
ACCOUNTS
RECEIVABLE
 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

DENIAL MANAGEMENT
ACCOUNTS
RECEIVABLE
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

DISTRIBUTION OF DENIED CLAIMS
ACCOUNTS
RECEIVABLE
24%
11%
3%
35%
17%
10%
Distribution of Denied Claims
Auth Related
Coding Correction Required
OON Issue
Others
Patient info missing
Timely Filing

AR AGING REPORT SAMPLE
ACCOUNTS
RECEIVABLE
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

HELPING YOU GROW
ACTIVE BRANDING & VIGOROUS LEAD GENERATION THROUGH SOCIAL MEDIA MARKETING
3.4
Million
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
LEAD-GEN
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!

PRICING
Actual cost of services can only be determined only after
a full understanding of the client’s specific requirements.
However, we have a very attractive pricing model that you’d like.
If you have already received a price offer from another vendor,
tell us about it. We promise to meet or beat it!

THE SUN KNOWLEDGE ADVANTAGE
 Increased revenue – reduced collection time (95% + 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
 Dedicated digital marketing for every client to help in new customer acquisition

CHALLENGES & RESPONSES

CHALLENGES & OUR APPROACH
 Assignment of adequate staff
 Completion of secondary verification
 Rigorous audit
 Time consuming with limited staff
 Documentation collection requires
continuous follow-up
 Increased TAT
 Time consuming with limited staff
 Secondary verification not carried out
Checking Authorization
Requirement and
Obtaining Authorization
Eligibility Verification
Patient Demographics /
Insurance / Charge Entry
 Transaction audit to minimize errors;
reduces denial due to missing patient
information
TASK DESCRIPTION CHALLENGES APPROACH
 Missing information / Key-in errors
 Increased denial rate
 Increased TAT
 Assignment of adequate staff
 Systematic and regular follow-up with
physicians’ offices & payors to collect
documentation and obtain authorization
 Proper tracking mechanism

 Defining KPI for rejection management
process and assigning responsibility
 Claims reconciliation and exception
report generation
 Unapplied balance
 Accumulation of backlog
 Manual posting
 Denials not posted
 Delayed correction and resubmission
 Possible loss of payment
Payment Posting
Rejection Management
Paper Claim Submission
 Proper tracking of every submission of
paper claims
 Moving to EDI based submission
whenever possible will reduce cost of
manual work and faster payment cycle
 Additional work for printing and
faxing/mailing
 Delayed filing leading to denials
 Lack of information about the actual
status
 Defining guidelines
 Review of patient payments
 Define KPI – TAT & Accuracy
 Denial posting and review

 Proper documentation – process
manual, guidelines & checklists
 Defining proper tracking mechanism
through various reports -Ageing, Status,
Daily, Exception
 Generate exception reports and regular
audit of every process tasks
 Defining KPIs and assigning
responsibility
 Lack of clarity of claims volume and
current status affects management
decision making process
 Impact on overall billing process
performance and improvement
 Decreased productive efficiency
Process Administration
and Reporting
AR Follow-up &
Denial Management
 Regular analysis, follow-up and review
 Transaction audit
 Accumulation of backlog
 Denials not posted
 Claims reconciliation issue

SUMMARY OF BENEFITS
 Very Little Risk
• Proven track record in providing healthcare BPO/KPO services
• Experienced in providing services to both payers and providers
• Experienced working with various software platforms
• Quick and efficient resource for special projects requiring technical and process expertise
 Significant Upside Potential
• Great understanding of the Healthcare Industry. Operation scale-up with a short notice
• Extremely competitive rates, greater productivity, improved quality, increased member and provider
satisfaction
 Proven Process Performance
• Low denial rate  reduced collection time  increase in revenue collection
• High billing & coding accuracy; TAT: 24 – 48 hours
• Adherence to CMS billing requirements
 Clear Communication and Quick Response Time at All Times
 ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection

TESTIMONIALS

CLIENTSPEAK
“We have had the pleasure of working with the 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

CLIENTSPEAK
“My firm has evaluated an outsourcing transaction with Sun Knowledge. They
provide superior service at a very attractive rate and have demonstrated to us their
commitment to this partnership. Their expertise across various process areas in the
PDP/MAPD domain and unique cost structure puts them in an incredible position to
work with plans throughout the healthcare industry.”
Chairman, President and CEO of a major New York based Health Plan
“Our company is very pleased with the administrative, and business analytical
solutions which Sun Knowledge delivers to our company from a quality & cost
perspective. They have been a true partner in bringing industry expertise, and
innovative solutions to the table. Their ability to grow with our evolving needs for
higher end services such as clinical services is a significant differentiator among
healthcare business process outsourcing firms.”
Executive Vice President of Operations of a leading MSO

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
For Additional Information, Please Contact…
Bruce Begley
Ex-CEO at Methodist Hospital of Henderson, Kentucky
Cell: (270) 860 5610
Email: brucebeg@gmail.com
Ronnie Hastings, Executive Assistant to Bruce Begley
Ronnie.Hastings@SunKnowledge.com
Sun Knowledge
41 Madison Ave., Suite 2511, 25th Floor
New York, NY 11001, USA

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