Complete Prior Authorization Services | Prior Authorization Process Guideline

PRIOR AUTHORIZATION – INTRODUCTION
2Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA

SUN KNOWLEDGE OVERVIEW
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

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

PRIOR AUTHORIZATION FUNDAMENTALS
TIME SPENT PER WEEK ON PRIOR AUTHORIZATION BY VARIOUS PERSONNEL
PRIMARY CARE
PHYSICIANS
NURSING
STAFF
CLERICAL
STAFF
1.1 Hours 13.1 Hours 5.6 Hours
Based on a 2009 study published in Health Affairs

PRIOR AUTHORIZATION PROCESS
a) Authorization Initiation
i. Calling up insurance to find the authorization filing procedure and turnaround time
ii. Gathering prior-authorization form and relevant medical documents from the providers
iii. Submission of the authorization request (fax/online/call) to the payer along with relevant
documentation (if required)
iv. Tracking of Fax receipts
b) Authorization follow up involves communicating with the payer to check the status of the
authorization as per the turnaround time protocol of the payer. It also involves sharing
additional notes as per payers’ requirement
c) Acknowledgement of Authorization approval involves updating approved authorization in
the providers’ practice management system with the start and end date for the
Authorization approval, service information and provider information
WE PROVIDE COMPREHENSIVE SUPPORT IN PRIOR AUTHORIZATION INCLUDING…

SERVICE AREAS
Durable Medical Equipment Prosthetics & Orthotics Sleep Medicine (CPAP BiPAP)
Rehab (Alcohol – Substance Abuse) Gastroenterology Skilled Nursing Facilities
Rheumatology Cardiology Pharmacies
Dermatology Specialty Clinics Home Health & Hospice
Neurology Oncology Orthopedics
Pathology Dermatology Pediatrics
Physicians Radiology Surgery
Healthcare Facilities Gynecology & Obstetrics Physical, Occupational
and Speech Therapy
and more…
WE PROVIDE PRIOR AUTHORIZATION SERVICES IN THE FOLLOWING AREAS:

SERVICE AREAS

SERVICE HIGHLIGHTS
Guaranteed
reduction of
operational cost
by 70%
Increase your
current rate of
Prior Authorization
by 1.5 – 2x
The only
Revenue Cycle
Management
company specializing
in Pre-certification
Prompt service
with a consistent
accuracy rate of
99.9%
Serving major
healthcare
organizations
in prior
authorization
Secret of
our Success?
Our experience in
adjudicating claims
for large Payers!

ADDITIONAL FEATURES
 Full-range service, comprising Authorization Request Follow-up Approval
 100% HIPAA-HITECH compliance
 Turnaround time less than 48 hours max.
 Low service fees with no hidden cost
 Zero lockup service contracts that can be cancelled anytime
 Tons of excellent references from current clients
 Real-time audits and custom reporting
 Excellent visibility and proven expertise
Our services are designed to take the pain out of prior authorization and free
you from the need to engage your resources or spend precious time in tedious
prior authorization tasks.

CASE STUDY ON BOTOX

PRIOR AUTHORIZATION FOR MEDICATION
Tasks involved in carrying out Prior Authorization for medication include the following steps:
 Gathering relevant medical documents from the providers
 Calling up insurance to find the authorization filing procedure and turnaround time
 Submission of the authorization request (fax/online/calling)
 Follow up with the Payer to check authorization status as per the TAT set for each Payer
 Acknowledgement of authorization approval/denial
 Notifying the Pharmacy
 Updating the authorization details (authorization number / duration / quantity)
in the Provider’s billing system

SAMPLE REPORTS

SAMPLE REPORT #1
PRIOR AUTHORIZATION COMPONENTS OF DAILY DETAILED REPORT
INPUT
SL.
Date
Received
Complete/
In Progress
Patient ID Patient Name DOB Dx Codes Name of Medication Provider Name Primary Payer Phone #
1 8/18/16 In progress 1234567 Patient 1 1/1/90 L40.0 Adapalene 0.3% Gel Provider 1 Caremark Phone 1
2 8/24/16 In progress 1234568 Patient 2 1/2/90 L21.9, L71.8 Elidel 1 % topical cream Provider 2 Envision Rx Phone 2
3 8/24/16 In progress 1234569 Patient 3 1/3/90 L40.0 Clobetasol Prop 0.05% Foam Provider 3 Caremark Phone 3
4 8/25/16 In progress 1234570 Patient 4 1/4/90 L70.0
Sulfacetamide sodium-sulfur
10 %-5 % (w/w) topical
cleanser
Provider 4 Magellan Rx Phone 4
5 8/26/16 In progress 1234571 Patient 5 1/5/90 L40.0 Desonide 0.05% Cream Provider 5 Cigna Phone 5
7 8/29/16 Complete 1234573 Patient 7 1/6/90 L70.0 Tretinoin 0.025% cream Provider 7 Caremark Phone 7
8 8/29/16 Complete 1234574 Patient 8 1/7/90 L70.0 Tretinoin 0.025% cream Provider 8 Express Scripts Phone 8
9 8/29/16 Complete 1234575 Patient 9 1/8/90 L70.0 Tretinoin 0.025% cream Provider 9 Caremark Phone 9
10 8/29/16 In progress 1234576 Patient 10 1/9/90 L70.0 Tretinoin 0.025% cream Provider 10 Tufts Health Phone 10

SAMPLE REPORT #2
PRIOR AUTHORIZATION COMPONENTS OF DAILY DETAILED REPORT (Contd.)
Authorization Status
Last Worked On Follow Up Date Comments Final Status
Approval /
Denial Date
8/25/2016 8/25/2016
8/25/2016- Got reply from NEDA, triaged back for alt. medication suggestion
8/18/2016- Notified Triage, since patient requested alternate medication as copay
was too high.
In Process
8/26/2016 NA
8/26/2016- SK called insurance and s/w Jenny, she informed that a form is to be
filled up and sent back for pre-auth.
8/24/2016- SK called insurance company to provide prior authorization information
verbally.
Medication Name: Elidel 1 % topical cream
Insurance Co: Envision Rx | Spoke with: John | Result: Pending
In Process
8/24/2016 NA
S/w Jack, PA is In Progress, Ref# M1*******3, Ade informed that it is a non
formulary drug and the foam is not covered, she also informed that apart from
foam there are alternatives like cream and solution which are covered so she will
fax us the available list of alternatives at ***-***-****.
In Process
Pharmacy Status
Pharmacy Name Pharmacy Ph # Auth Status Informed Date of communication Comments Schedule Delivery Date
CVS Phone 1 No
Rite Aid Phone 2 No
Walgreens Phone 3 No
CVS Phone 4 Yes 8/29/2016 S/w John, informed about the approval
CVS Phone 5 Yes 8/29/2016 S/w Vivian, informed about the non-coverage

SAMPLE REPORT #3
Month Approved Denied In Process NA Pending for additional information Total
08/17/16 9 2 11
08/18/16 14 1 2 2 19
08/19/16 2 1 3
08/22/16 5 1 1 7
08/23/16 8 1 9
08/24/16 10 2 12
08/25/16 6 2 2 10
08/26/16 8 1 9
08/29/16 7 3 4 14
Total 69 4 11 10 94
PRIOR AUTHORIZATION DAILY SUMMARY REPORT

SAMPLE REPORT #4
PRIOR AUTHORIZATION MONTHLY SUMMARY REPORT
Month Approved Denied In Process NA Pending for additional information Total
Mar-16 71 49 2 122
Apr-16 401 160 5 15 1 582
May-16 418 146 4 69 637
Jun-16 377 151 4 94 1 627
Jul-16 343 128 16 65 6 558
Total 1610 634 29 245 8 2526

MEETING CHALLENGES
WITH EFFECTIVE RESPONSE

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 & payers 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

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

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…

Complete Prior Authorization Services | Prior Authorization Process Guideline

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