Coding & Billing Services for DME (Durable Medical Equipment), Prosthetics & Orthotics

Medical Billing Service Offerings
Durable Medical Equipment and Orthotics & Prosthetics
41 Madison Avenue, 25th Floor, New York, NY 10010

2© GoTelecare 2014-15| All Rights Reserved Private & Confidential
 Sun Knowledge is our closely affiliated company under
the same ownership.
 ‘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 process knowledge
 Structured training, feedback and coaching
 HIPAA-HITECH compliant
 Offices located in USA& India
• New York City, USA – Situated in Manhattan (facility
inbuilt with all redundancies – power, infrastructure
and others)
• Kolkata, India – Situated in the IT Hub
(facility inbuilt with all redundancies – power,
infrastructure and others)
 ISO 27001:2005 and ISO 9001:2008 certified company
 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
Overview
Key Facts Awards, Affiliations & Certifications

GOTELECARE 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
 Enrollment Processing & Member
Fulfillment
 Claims Administration
 Coding & Medical Billing
 Credentialing
 Premium 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
Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
Private & Confidential© GoTelecare 2014-15| All Rights Reserved 3

ADVANTAGES & BENEFITS
• Significant decrease in operational expenses
• With over 5 years of successful DME and O&P experience, Sun Knowledge/GoTelecare provides
professional consulting to best allocate resources to increase profit margins.
• We guarantee > 50% operational savings effective immediately.
• For Example: New York Home Health Care Equipment reported to Sun Knowledge a $2.1 million
operational savings in Y1*
• Heightened collection and increased Account Receivables
• 30% of DME and O&P Rx are incomplete when first received. We excel in completing the Rx claim quickly.
• Cyclical Data Reporting
• Data reporting interval can be customized to meet the needs of the customer.
• Demonstrated experience handling DME and O&P claims
• Medicare, Medicaid, and Commercial Plans  Fee for Service and Capitated Plans
* New York Home Health Care Equipment is the largest DME
company in New York City servicing residents in 13 counties in 3
states since 1982.

Durable medical equipment (DME) is any equipment that provides therapeutic benefits to a member because of
certain medical conditions and/or illnesses that can withstand repeated use, is primarily and customarily used to
serve a medical purpose, and is appropriate for use in the home.
Example:
 Ambulatory equipment: rollator, cane, crutch
 Chairs: Geriatric chair, wedge cushions, Wheel chairs etc.
 Breast pump
 CPAP & BiPAP machines & supplies
 Continuous Passive Motion machine
 Perenteral & enteral feeding equipment & products
 Hospital bed: Semi electric, fully electric, Side rails, gel overlay mattress etc.
 Blood pressure, Glucose monitoring devices
 Orthotics: Splint, brace , inserts etc.
 Oxygen devices: Concentrator & supplies
 Respiratory equipment: Nebulizer compressor, Suction machines etc.
BILLING FOR DURABLE MEDICAL EQUIPMENT

DME coverage may be subject to a copay or coinsurance. Authorization is required for various DME and this varies
from payer to payer. This is considered a part of the member’s DME benefits provisions. For DME to be covered the
general billing requirements are:
 A prescription from the ordering physician dated prior to delivery date
 Certain items must be rented prior to being converted to purchase and therefore must be billed as rentals
 Consideration of limitations based on time period within which the item can be covered if supplied earlier.
E.g. CPAP machines cannot be ordered more than once every 5 years while most CPAP supplies are
available every 3 months
 Appropriate modifiers must be billed with DME
 Letter of medical necessity and additional documentation may be required for some DME, e.g. orthotics,
beds & mattresses, BiPAP machines etc. Coverage for such equipment is subject to medical review.
 Coverage of DME is also subject to qualifying diagnosis, E.g. CPAP machines – Obstructive Sleep Apnea
 Maintenance, repair, or replacement and supplies may be eligible for separate reimbursement under a
contracted maintenance fee with a DME supplier acceptable by the payer.
DME COVERAGE & BILLING

The billing cycle for DME involves the following activities:
 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 auth requirement enquiry
 Collection of documents required by payer for auth approval, E.g. face to face consultation notes,
Polysomnography / Titration report etc. and obtaining of authorization from payer.
 Determination that payer criteria is met before delivery of DME, E.g. some DME have time / frequency / annual
cost limitations for DME (if criteria is not met the patient needs to be 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
DME BILLING CYCLE

DME AND O&P BILLING
Challenges Vs 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 Auth
Eligibility verification
DME BILLING – CHALLENGES VS. APPROACH
9Sun Knowledge © 2015-16 Private & Confidential
Patient Demographics /
Insurance / Initial Rx
Entry
Transaction audit to minimize error that
will reduce 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 and payers to collect
documentation, 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
 Payment reconciliation issue
 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

ELIGIBILITY VERIFICATION & AUTHORIZATION – SAMPLE REPORT
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
Auth Required Auth Obtained Auth Pending

DENIAL MANAGEMENT – SAMPLE REPORT
Auth Related
14%
Coding Error
5%
OON Issue
8%
COB Issues
10%
Patient info missing
6%
Exceeds Timely Filing
8%
Duplicate Claim
5%
Service Not Covered
6%
Primary Paid Max
7%
Pre-Existing Condition
5%
Others
26%
Distribution of Denied Claims

TELEMEDICINE
DME and Orthotics and Prosthetics

 Very Little Risk
 GoTelecare is experienced in handling complex contracts/claims
 GoTelecare is experienced working with various claims & billing systems
 Quick and efficient resource for special projects when needed e.g. member retention program, etc.
 Quick and efficient temporary resource when needed e.g. inventory back up, annual enrollment period, etc.
 Significant Upside Potential
 GoTelecare has a good understanding of US Health Care industry. We work both for the payers and providers.
 Extremely competitive rates, greater productivity, improved accuracy of claims, increased provider
satisfaction, reduction in overtime cost  Reduced Admin Cost
 Leverage partial outsourcing to increase and/or create operational expansion opportunities
 Proven process performance
 Claims Processing: Accuracy > 98%; TAT: 5 - 10 days
 Efficient coding & billing process – special focus on rejection and denial management
 Contact Center: Abandonment Rate < 2%, ASA within 30 Seconds for 90% of calls, High CSAT
 Clear Communication And Quick Response Time At All Times
 End user data privacy and protection through implementation of industry standard like ISO 27001:2005 & HIPAA
ADVANTAGES OF UTILIZING OUR SERVICES

CUSTOMER TESTIMONIALS & ADDITIONAL
INFORMATION
David Musiker
Regional Director
561-305-5392
david.musiker@gotelecare.com
For Additional Information, Please Contact

Coding & Billing Services for DME (Durable Medical Equipment), Prosthetics & Orthotics

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