Accounts Receivable Management by Sun Knowledge

ACCOUNTS RECEIVABLE
MANAGEMENT SERVICES

SUN KNOWLEDGE 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

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, Home Health Care and Pharmacies
Payers – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs

SERVICE PORTFOLIO
PRACTICE
MANAGEMENT
Order Entry
Eligibility &
Authorization
Verification
Prior
Authorization
BILLING &
COLLECTIONS
Billing & Coding
Claims
Submission
Accounts
Receivable
PAYER SERVICES
Claims
Adjudication
Credentialing
Utilization
Management
TELEMEDICINE
Telemedicine
Remote Patient
Monitoring

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

ACCOUNTS RECEIVABLE
MANAGEMENT

ACCOUNTS RECEIVABLE IN THE REVENUE CYCLE
360°
Revenue Cycle
Management
Services
Eligibility &
Authorization
Verification
Prior
Authorization
Billing &
Coding
Scheduling
Payment
Posting
Accounts
Receivable

ACCOUNTS RECEIVABLE MGMT. PROCESS OVERVIEW
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.

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
1
2

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 Payor
• 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

STEPS IN ACCOUNTS RECEIVABLE FOLLOW-UP
Online Claims Follow-Up
Using 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 Representative
If 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

DENIAL
MANAGEMENT

REASONS FOR DENIAL
 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

STEPS IN DENIAL MANAGEMENT
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
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

BENEFIT HIGHLIGHTS
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

SAMPLE
REPORTS

SAMPLE OF AGENT-WISE A/R REPORT
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

SAMPLE OF A/R AGING REPORT
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

SAMPLE SOW OF A/R FOLLOW-UP
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.
…

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 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
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…

Accounts Receivable Management by Sun Knowledge

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