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Complete Durable Medical Equipment (DME) Billing Guide | Sun Knowledge

The document provides an overview of a DME (Durable Medical Equipment) company specializing in medical billing and coding services for the healthcare sector, detailing its compliant practices, awards, and certifications. It outlines its service offerings, infrastructure, and the revenue cycle management processes that ensure high efficiency and compliance with regulations like HIPAA. The company boasts a high collection rate, rapid turnaround times, and tools for optimizing billing processes to enhance client profitability.

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MEDICAL BILLING & COLLECTION FOR DME
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
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
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 PAYER SERVICES Claims Adjudication Credentialing Utilization Management Customer Care TELEMEDICINE Telemedicine Remote Patient Monitoring
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
6Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA REVENUE CYCLE MANAGEMENT
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
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
REVENUE CYCLE MANAGEMENT 9Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA • Physicians / Hospitals • DMEPOS • Pharmacy (WC/ PIP) Work with physicians to enroll them with payers, setup billing systems with fee schedules, review clinical notes, code CPT/ICD, submit claims, payment posting and follow-up with payers and patients Setup DME companies in DME billing system, receive orders, generate claims, payment posting and follow-up with payers and patients Setup billing systems for submission of WC/PIP claims, code and apply correct modifiers, check eligibility with adjusters, generate claims, payment posting and follow-up Sun Knowledge provides medical billing & coding services - prompt, perfect and professional. We are HIPAA compliant.
REVENUE CYCLE MANAGEMENT SERVICES 10Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA End-to-End Billing Services:  Hospitals/ Physicians  DMEPOS  Pharmacy (WC/PIP) Stand Alone Billing Services:  AR Follow-up & Collection  Eligibility & Auth Verification  Pre-Auth Service  Credentialing  Patient Collection  Coding
PRACTICE MANAGEMENT & BILLING SYSTEM 11Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Sun Knowledge billing executives have experience in working on several industry standard practice management and billing software: Sun Knowledge can provide medical billing & coding services using customer’s billing system or can setup customer’s practice in a billing system managed by Sun Knowledge.  Kareo  SOS  Emdeon / Capario One  Meditech  Brightree  Alpha Collector  Fastrack  OPIE  CPR+ HME  Futura  DME Works  PrimeRx  Team DME
CHALLENGES & OUR APPROACH 12Sun 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
CHALLENGES & OUR APPROACH 13Sun 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
CHALLENGES & OUR APPROACH 14Sun 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
ADDRESSING PROBLEMS WITH EFFECTIVE SOLUTIONS 15Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA We address problems like: Reduced profit margins Caused by • Claims denial • Delayed submission of claims • Inefficient processes • Low productivity Reduced strategic directives Caused by • Operation reports lacking focus on orders received/delivered • Reports on claims submission lacking functional clarity We produce benefits like: Process optimization Achieved through  No backlogs in inventory/open order  Significant reduction in payment realization cycle  Reduction in average cost by 40%  Improved efficiency leading to higher productivity Improved financials Achieved through  Timely claims submission, leading to improved cash flow and payment realization by 10%  Significant reduction in denial rate  Increased revenue by 7%
FACTS FROM A CASE STUDY 16Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Sun Knowledge recently helped a leading DME Provider in New York improve their complex billing process and achieve long-term bottom-line growth. Here’s how we added value to the client’s existing processes: OLD BILLING PROCESS OPTIMIZED BILLING PROCESS PROCESS STABILITY: Achieved consistent and better productivity; and higher accuracy through the application of an improvement methodology QUALITY AND EFFICIENCY IMPROVEMENT: Developed clear understanding of peculiarities of DME billing as compared to physician billing; Initiated an internal audit mechanism to identify and rectify errors; Enforced corrective and preventive action scheme INCREASED PRODUCTIVITY AND REDUCED OPEN ORDERS: Removed redundant process steps to focus on the critical ones; Created tools / cheat sheets and introduced various process checks to improve productivity REDUCED DENIAL RATES: Drastically reduced incorrect coding and combination in bills and developed a thorough understanding of qualifying diagnosis and payer guidelines
17Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA DME BILLING SERVICES
DME BILLING – KEY FACTS 18Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  Secure Information & Data Flow between Sun knowledge and our partners enabled with reliable networking software & hardware (includes secured Virtual Private Networks and FTP sites)  All low pay and no pays reports are sent to the client  Work on re-processing of the denied claims starts immediately after receipt of ERA  ERAs are posted to the respective patients’ accounts  Quality check is conducted at all stages of process  Turn Around Time for this process is 24 - 48 hours
ORDER ENTRY – SAMPLE REPORT 19Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA INVENTORY RECEIVED Category Breast Pump CPAP Nebulizer Closet Nebulizer Integra Month Jun-15 330 114 34 45 0 Jul-15 664 265 0 55 447 Aug-15 957 278 0 49 552 Sep-15 867 248 0 35 400 Oct-15 835 303 0 74 722 Nov-15 923 244 0 105 632 Dec-15 947 299 0 133 637 Jan-16 779 230 0 142 655 INVENTORY COMPLETED Category Breast Pump CPAP Nebulizer Closet Nebulizer Integra Month Jun-15 330 114 33 45 0 Jul-15 664 265 0 55 447 Aug-15 957 278 0 49 552 Sep-15 867 248 0 35 400 Oct-15 835 303 0 72 690 Nov-15 923 241 0 105 592 Dec-15 946 290 0 127 637 Jan-16 752 209 0 134 655 0 100 200 300 400 500 600 700 800 900 1000 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 INVENTORY RECEIVED Breast Pump CPAP Nebulizer Closet Nebulizer Integra 0 100 200 300 400 500 600 700 800 900 1000 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 INVENTORY COMPLETED Breast Pump CPAP Nebulizer Closet Nebulizer Integra
ELIGIBILITY & AUTH. VERIFICATION – SAMPLE REPORT 20Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA SUN KNOWLEDGE ELIGIBILITY VERIFICATION & AUTHORIZATION DETAILED FOR ABC - (7/10/2015) Sl. No. Patient # Equipment Category Eligibility Checked Primary Checked Secondary Checked Auth Required Auth Obtained Fax sent Auth Pending Comment 1 221359 Beds / Mattress Yes Yes No Yes No Yes Yes Pending Auth# Ak-098651 Follow-up : 07/15/2015 2 328547 Beds / Mattress Yes Yes No Yes No Yes Yes Follow-up : 07/14/2015 3 190398 CPAP - Machine Yes Yes No Yes No No Yes Sleep study report missing. Dr.'s office contacted Follow-up : 07/13/2015 4 215604 Diabetic Supplies Yes Yes Yes No Yes Yes No Follow-up : 07/14/2015 5 218219 CPAP - Machine Yes Yes No Yes No Yes No Follow-up : 07/17/2015 EIGIBILITY VERIFICATION & AUTHORIZATION SUMMARY REPORT FOR ABC - 07/10/2015 Equipment Category Number of New Patients Patients Brought Forward Total Patients Primary Checked Secondary Checked Auth Required Auth Obtained Fax sent Auth Pending Beds / Mattress 25 0 25 25 4 19 2 2 17 CPAP (Supplies) 44 3 47 47 12 9 7 6 2 CPAP (Machine) 15 0 15 15 3 11 3 3 8 Other DME 50 12 62 61 18 23 5 21 18 Diabetic Supplies 27 0 27 27 6 8 6 8 2 Total 161 15 176 175 43 70 23 40 47
CPAP USER COMPLIANCE & TRACKING – SAMPLE REPORT 21Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA CPAP USER COMPLIANCE TRACKING SUMMARY REPORT FOR ABC - 07/10/2015 Day No. of Patients Compliant Patients No. of Non- Compliant Patients No. of Patients with No Data Available PendingNo. of Compliant Patients No. of Patients Compliant based on best 30 days 90th day Compliance Report 5 3 0 0 0 2 60th day Compliance Report 4 1 3 0 0 0 30th day Compliance Report 7 3 0 2 1 1 15th day Compliance Report 0 0 0 0 0 0 5th day Compliance Report 1 1 0 0 0 0 TOTAL 17 11 2 1 3 SUN KNOWLEDGE CPAP USER COMPLIANCE TRACKING STATUS REPORT - 07/10/2015 S No. Set Up Date 5th Day 15th Day 30th Day 60th Day 90th Day Patient # Patient Name Doctor System Status Therapy Report Imaged Report Faxed to Dr. Email /Faxed Sales person Payer Name Comment / Notes 1 4/8/2015 N/A N/A N/A N/A 83.45% 213765 DOE, JOHN Paez Encore Complete Yes Yes No OXFORD HEALTH PLANS 2 4/8/2015 N/A N/A N/A N/A 65.60% 218619 DOE, DAVID Smith Resmed Complete Yes Yes No OXFORD HEALTH PLANS Best of 30 days- 73.3% 3 6/6/2015 N/A N/A 100% N/A N/A 125354 DAY, JULIE Ricardo Encore Complete Yes Yes No MEDICARE 4 6/5/2015 N/A N/A 96.70% N/A N/A 295695 ROE, JANE Paez Encore Complete Yes Yes No HEALTH FIRST NY 5 6/30/2015 80% N/A N/A N/A N/A 233432 DOE, JULIE Paez Encore Complete N/A N/A N/A HEALTH FIRST NY 6 5/27/2015 N/A N/A 100% N/A N/A 196476 SMITH, JOE Jones Resmed Complete Yes Yes No MEDICARE 7 5/23/2015 N/A N/A 73% N/A N/A 215604 BLOGGS, JOE Jones ICODE Complete Yes Yes No AETNA HEALTH PLAN 8 6/3/2015 N/A N/A 57% N/A N/A 217849 SMITH, JULIE Smith Resmed Complete Yes Yes No MEDICARE 9 6/27/2015 100% N/A N/A N/A N/A 168488 ROE, JOHN Jones ICODE Complete N/A N/A N/A MEDICARE 10 5/1/2015 N/A N/A N/A 67.00% N/A 214535 RODRIGUEZ, P Jones Encore Complete Yes Yes No HEALTH FIRST NY
AR & AR CALLING – SAMPLE REPORT 22Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA 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 BCBCS 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 2 11 -9 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 S No. Date Payer Patient Name DOB DOS Claim No. Charge Amount Status Comments Ref # 1 7/21/2015 Healthfirst Doe, John 8/29/1974 6/26/2015 1063051526 $195.00 Paid Called Healthfirst spoke with Gary - Rep stated that claim received on 06/30/15 and processed on 07/17/15. Per rep ins paid $173.47 on check# 3023659 having bulk amount $11909.23. Check was issued on 07/17/15 and is not cashed yet. 1063051526 2 7/21/2015 Healthfirst Roe, Julie 5/3/1983 6/16/2015 1091527510 $195.00 Paid Called Healthfirst spoke with Gary - Rep stated that claim received on 06/19/15 and processed on 07/10/15. Per rep ins paid $173.47 on check# 3019387 having bulk amount $25091.99. Check was issued on 07/10/15 and is not cashed yet. 1061915510 3 7/24/2015 Magna Care (Oscar) Roe, David 8/11/1942 5/26/2015 P0449302 $3,800.00 Paid Per Ashley- rep stated that claim received on 06/05/15 and ins applied $292.60 towards pt as coins and paid 2633.40 by ck# 69783. Check issued on 07/10/15 and not yet cashed. CL725541 4 7/24/2015 Magna Care (Oscar) Bloggs, Joe 8/10/1952 6/17/2015 Q0487598 $252.11 In Process Per Ashley - Rep stated that claim received on 07/06/15 and still in process CL8765541 5 7/29/2015 Health Republic Insurance of New York Bokhari, Shahid 3/4/1958 6/19/2015 16478355-01 $100.00 Allowed Per Andriya stated that claim processed on 07/08/15 and ins applied $82.89 towards in-network deductible, Per rep the annual in-network deductible is $2000. 18441664 6 7/31/2015 Oxford Health Plan Smith, P 4/25/002 6/8/2015 5184T02894 $59.62 Paid Per Kelly stated that claim paid $42.58 on ck# 13357299 having bulk amount $221.32 issued on 07/28/15 and not cashed yet. 15298601
DENIAL MANAGEMENT – SAMPLE REPORT 23Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA 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
BENEFITS PROPOSITION 24Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  Increased revenue – reduced collection Time (up to 97% collection rate)  Claim submission within 48 hours of receipt of billing input  Adherence to CMS billing requirements  Proper records maintenance and visibility through reporting  Standardization of billing operations
CLIENTSPEAK 25Sun 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

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Complete Durable Medical Equipment (DME) Billing Guide | Sun Knowledge

  • 1.
  • 2.
    COMPANY OVERVIEW Key FactsAwards, 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  ProviderSupport  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 4SunKnowledge © 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 PAYER SERVICES Claims Adjudication Credentialing Utilization Management Customer Care TELEMEDICINE Telemedicine Remote Patient Monitoring
  • 5.
    HIPAA COMPLIANCE SUMMARY 5SunKnowledge © 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.
    REVENUE CYCLE MANAGEMENT 9SunKnowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA • Physicians / Hospitals • DMEPOS • Pharmacy (WC/ PIP) Work with physicians to enroll them with payers, setup billing systems with fee schedules, review clinical notes, code CPT/ICD, submit claims, payment posting and follow-up with payers and patients Setup DME companies in DME billing system, receive orders, generate claims, payment posting and follow-up with payers and patients Setup billing systems for submission of WC/PIP claims, code and apply correct modifiers, check eligibility with adjusters, generate claims, payment posting and follow-up Sun Knowledge provides medical billing & coding services - prompt, perfect and professional. We are HIPAA compliant.
  • 10.
    REVENUE CYCLE MANAGEMENTSERVICES 10Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA End-to-End Billing Services:  Hospitals/ Physicians  DMEPOS  Pharmacy (WC/PIP) Stand Alone Billing Services:  AR Follow-up & Collection  Eligibility & Auth Verification  Pre-Auth Service  Credentialing  Patient Collection  Coding
  • 11.
    PRACTICE MANAGEMENT &BILLING SYSTEM 11Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Sun Knowledge billing executives have experience in working on several industry standard practice management and billing software: Sun Knowledge can provide medical billing & coding services using customer’s billing system or can setup customer’s practice in a billing system managed by Sun Knowledge.  Kareo  SOS  Emdeon / Capario One  Meditech  Brightree  Alpha Collector  Fastrack  OPIE  CPR+ HME  Futura  DME Works  PrimeRx  Team DME
  • 12.
    CHALLENGES & OURAPPROACH 12Sun 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
  • 13.
    CHALLENGES & OURAPPROACH 13Sun 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
  • 14.
    CHALLENGES & OURAPPROACH 14Sun 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
  • 15.
    ADDRESSING PROBLEMS WITHEFFECTIVE SOLUTIONS 15Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA We address problems like: Reduced profit margins Caused by • Claims denial • Delayed submission of claims • Inefficient processes • Low productivity Reduced strategic directives Caused by • Operation reports lacking focus on orders received/delivered • Reports on claims submission lacking functional clarity We produce benefits like: Process optimization Achieved through  No backlogs in inventory/open order  Significant reduction in payment realization cycle  Reduction in average cost by 40%  Improved efficiency leading to higher productivity Improved financials Achieved through  Timely claims submission, leading to improved cash flow and payment realization by 10%  Significant reduction in denial rate  Increased revenue by 7%
  • 16.
    FACTS FROM ACASE STUDY 16Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA Sun Knowledge recently helped a leading DME Provider in New York improve their complex billing process and achieve long-term bottom-line growth. Here’s how we added value to the client’s existing processes: OLD BILLING PROCESS OPTIMIZED BILLING PROCESS PROCESS STABILITY: Achieved consistent and better productivity; and higher accuracy through the application of an improvement methodology QUALITY AND EFFICIENCY IMPROVEMENT: Developed clear understanding of peculiarities of DME billing as compared to physician billing; Initiated an internal audit mechanism to identify and rectify errors; Enforced corrective and preventive action scheme INCREASED PRODUCTIVITY AND REDUCED OPEN ORDERS: Removed redundant process steps to focus on the critical ones; Created tools / cheat sheets and introduced various process checks to improve productivity REDUCED DENIAL RATES: Drastically reduced incorrect coding and combination in bills and developed a thorough understanding of qualifying diagnosis and payer guidelines
  • 17.
    17Sun Knowledge ©2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA DME BILLING SERVICES
  • 18.
    DME BILLING –KEY FACTS 18Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  Secure Information & Data Flow between Sun knowledge and our partners enabled with reliable networking software & hardware (includes secured Virtual Private Networks and FTP sites)  All low pay and no pays reports are sent to the client  Work on re-processing of the denied claims starts immediately after receipt of ERA  ERAs are posted to the respective patients’ accounts  Quality check is conducted at all stages of process  Turn Around Time for this process is 24 - 48 hours
  • 19.
    ORDER ENTRY –SAMPLE REPORT 19Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA INVENTORY RECEIVED Category Breast Pump CPAP Nebulizer Closet Nebulizer Integra Month Jun-15 330 114 34 45 0 Jul-15 664 265 0 55 447 Aug-15 957 278 0 49 552 Sep-15 867 248 0 35 400 Oct-15 835 303 0 74 722 Nov-15 923 244 0 105 632 Dec-15 947 299 0 133 637 Jan-16 779 230 0 142 655 INVENTORY COMPLETED Category Breast Pump CPAP Nebulizer Closet Nebulizer Integra Month Jun-15 330 114 33 45 0 Jul-15 664 265 0 55 447 Aug-15 957 278 0 49 552 Sep-15 867 248 0 35 400 Oct-15 835 303 0 72 690 Nov-15 923 241 0 105 592 Dec-15 946 290 0 127 637 Jan-16 752 209 0 134 655 0 100 200 300 400 500 600 700 800 900 1000 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 INVENTORY RECEIVED Breast Pump CPAP Nebulizer Closet Nebulizer Integra 0 100 200 300 400 500 600 700 800 900 1000 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 INVENTORY COMPLETED Breast Pump CPAP Nebulizer Closet Nebulizer Integra
  • 20.
    ELIGIBILITY & AUTH.VERIFICATION – SAMPLE REPORT 20Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA SUN KNOWLEDGE ELIGIBILITY VERIFICATION & AUTHORIZATION DETAILED FOR ABC - (7/10/2015) Sl. No. Patient # Equipment Category Eligibility Checked Primary Checked Secondary Checked Auth Required Auth Obtained Fax sent Auth Pending Comment 1 221359 Beds / Mattress Yes Yes No Yes No Yes Yes Pending Auth# Ak-098651 Follow-up : 07/15/2015 2 328547 Beds / Mattress Yes Yes No Yes No Yes Yes Follow-up : 07/14/2015 3 190398 CPAP - Machine Yes Yes No Yes No No Yes Sleep study report missing. Dr.'s office contacted Follow-up : 07/13/2015 4 215604 Diabetic Supplies Yes Yes Yes No Yes Yes No Follow-up : 07/14/2015 5 218219 CPAP - Machine Yes Yes No Yes No Yes No Follow-up : 07/17/2015 EIGIBILITY VERIFICATION & AUTHORIZATION SUMMARY REPORT FOR ABC - 07/10/2015 Equipment Category Number of New Patients Patients Brought Forward Total Patients Primary Checked Secondary Checked Auth Required Auth Obtained Fax sent Auth Pending Beds / Mattress 25 0 25 25 4 19 2 2 17 CPAP (Supplies) 44 3 47 47 12 9 7 6 2 CPAP (Machine) 15 0 15 15 3 11 3 3 8 Other DME 50 12 62 61 18 23 5 21 18 Diabetic Supplies 27 0 27 27 6 8 6 8 2 Total 161 15 176 175 43 70 23 40 47
  • 21.
    CPAP USER COMPLIANCE& TRACKING – SAMPLE REPORT 21Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA CPAP USER COMPLIANCE TRACKING SUMMARY REPORT FOR ABC - 07/10/2015 Day No. of Patients Compliant Patients No. of Non- Compliant Patients No. of Patients with No Data Available PendingNo. of Compliant Patients No. of Patients Compliant based on best 30 days 90th day Compliance Report 5 3 0 0 0 2 60th day Compliance Report 4 1 3 0 0 0 30th day Compliance Report 7 3 0 2 1 1 15th day Compliance Report 0 0 0 0 0 0 5th day Compliance Report 1 1 0 0 0 0 TOTAL 17 11 2 1 3 SUN KNOWLEDGE CPAP USER COMPLIANCE TRACKING STATUS REPORT - 07/10/2015 S No. Set Up Date 5th Day 15th Day 30th Day 60th Day 90th Day Patient # Patient Name Doctor System Status Therapy Report Imaged Report Faxed to Dr. Email /Faxed Sales person Payer Name Comment / Notes 1 4/8/2015 N/A N/A N/A N/A 83.45% 213765 DOE, JOHN Paez Encore Complete Yes Yes No OXFORD HEALTH PLANS 2 4/8/2015 N/A N/A N/A N/A 65.60% 218619 DOE, DAVID Smith Resmed Complete Yes Yes No OXFORD HEALTH PLANS Best of 30 days- 73.3% 3 6/6/2015 N/A N/A 100% N/A N/A 125354 DAY, JULIE Ricardo Encore Complete Yes Yes No MEDICARE 4 6/5/2015 N/A N/A 96.70% N/A N/A 295695 ROE, JANE Paez Encore Complete Yes Yes No HEALTH FIRST NY 5 6/30/2015 80% N/A N/A N/A N/A 233432 DOE, JULIE Paez Encore Complete N/A N/A N/A HEALTH FIRST NY 6 5/27/2015 N/A N/A 100% N/A N/A 196476 SMITH, JOE Jones Resmed Complete Yes Yes No MEDICARE 7 5/23/2015 N/A N/A 73% N/A N/A 215604 BLOGGS, JOE Jones ICODE Complete Yes Yes No AETNA HEALTH PLAN 8 6/3/2015 N/A N/A 57% N/A N/A 217849 SMITH, JULIE Smith Resmed Complete Yes Yes No MEDICARE 9 6/27/2015 100% N/A N/A N/A N/A 168488 ROE, JOHN Jones ICODE Complete N/A N/A N/A MEDICARE 10 5/1/2015 N/A N/A N/A 67.00% N/A 214535 RODRIGUEZ, P Jones Encore Complete Yes Yes No HEALTH FIRST NY
  • 22.
    AR & ARCALLING – SAMPLE REPORT 22Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA 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 BCBCS 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 2 11 -9 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 S No. Date Payer Patient Name DOB DOS Claim No. Charge Amount Status Comments Ref # 1 7/21/2015 Healthfirst Doe, John 8/29/1974 6/26/2015 1063051526 $195.00 Paid Called Healthfirst spoke with Gary - Rep stated that claim received on 06/30/15 and processed on 07/17/15. Per rep ins paid $173.47 on check# 3023659 having bulk amount $11909.23. Check was issued on 07/17/15 and is not cashed yet. 1063051526 2 7/21/2015 Healthfirst Roe, Julie 5/3/1983 6/16/2015 1091527510 $195.00 Paid Called Healthfirst spoke with Gary - Rep stated that claim received on 06/19/15 and processed on 07/10/15. Per rep ins paid $173.47 on check# 3019387 having bulk amount $25091.99. Check was issued on 07/10/15 and is not cashed yet. 1061915510 3 7/24/2015 Magna Care (Oscar) Roe, David 8/11/1942 5/26/2015 P0449302 $3,800.00 Paid Per Ashley- rep stated that claim received on 06/05/15 and ins applied $292.60 towards pt as coins and paid 2633.40 by ck# 69783. Check issued on 07/10/15 and not yet cashed. CL725541 4 7/24/2015 Magna Care (Oscar) Bloggs, Joe 8/10/1952 6/17/2015 Q0487598 $252.11 In Process Per Ashley - Rep stated that claim received on 07/06/15 and still in process CL8765541 5 7/29/2015 Health Republic Insurance of New York Bokhari, Shahid 3/4/1958 6/19/2015 16478355-01 $100.00 Allowed Per Andriya stated that claim processed on 07/08/15 and ins applied $82.89 towards in-network deductible, Per rep the annual in-network deductible is $2000. 18441664 6 7/31/2015 Oxford Health Plan Smith, P 4/25/002 6/8/2015 5184T02894 $59.62 Paid Per Kelly stated that claim paid $42.58 on ck# 13357299 having bulk amount $221.32 issued on 07/28/15 and not cashed yet. 15298601
  • 23.
    DENIAL MANAGEMENT –SAMPLE REPORT 23Sun Knowledge © 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA 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
  • 24.
    BENEFITS PROPOSITION 24Sun Knowledge© 2015-16 Private & Confidential 41 Madison Avenue, 25th Floor, New York, NY 10010, USA  Increased revenue – reduced collection Time (up to 97% collection rate)  Claim submission within 48 hours of receipt of billing input  Adherence to CMS billing requirements  Proper records maintenance and visibility through reporting  Standardization of billing operations
  • 25.
    CLIENTSPEAK 25Sun 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