complete durable medical equipment (dme) billing guide | sun knowledge
TRANSCRIPT
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 SupportMember SupportMember Retention ProgramClinical Help Desk
Contact Center
Utilization ManagementMedication Therapy ManagementHospital Re-admission
ManagementTherapeutic InterchangeFormulary Management
Clinical Services
Medical Coding & BillingClaims AdministrationEnrollment Processing &
MemberFulfillmentCredentialing Premium billing and collections
Administrative Services
Analytics
Telemedicine ServicesRemote Patient MonitoringApplication Development & SupportTechnical SupportTechnical Documentation
IT Services
Claims /Drug Utilization AnalysisPDE AnalysisRAF AnalysisPayment 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 & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SUMMARY OF SERVICES
4Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRACTICE MANAGEMENT
Scheduling
Eligibility & Authorization Verification
Prior Authorization
Customer Care
HIPAA COMPLIANCE SUMMARY
5Sun Knowledge © 2015-16 Private & Confidential41 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 & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
REVENUE CYCLEMANAGEMENT
REVENUE CYCLE MANAGEMENT – KEY PROCESSES
7Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
360° Revenue Cycle Management
Services
SERVICE HIGHLIGHTS
8Sun Knowledge © 2015-16 Private & Confidential41 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 & Confidential41 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 & Confidential41 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 & Confidential41 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 & Confidential41 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 & Confidential41 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 & Confidential41 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 efficiencyProcess 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 & Confidential41 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 & Confidential41 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 & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
DME BILLING SERVICES
DME BILLING – KEY FACTS
18Sun Knowledge © 2015-16 Private & Confidential41 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 & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
INVENTORY RECEIVED
Category Breast Pump CPAP Nebulizer Closet
Nebulizer IntegraMonth
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 IntegraMonth
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
Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16
0
100
200
300
400
500
600
700
800
900
1000
INVENTORY RECEIVED
Breast PumpCPAPNebulizerCloset NebulizerIntegra
Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16
0
100
200
300
400
500
600
700
800
900
1000
INVENTORY COMPLETED
Breast PumpCPAPNebulizerCloset NebulizerIntegra
ELIGIBILITY & AUTH. VERIFICATION – SAMPLE REPORT
20Sun Knowledge © 2015-16 Private & Confidential41 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-098651Follow-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 YesSleep study report missing. Dr.'s office contactedFollow-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 & Confidential41 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 PatientsNo. of Non-Compliant
Patients
No. of Patients with No Data
Available PendingNo. of Compliant
PatientsNo. 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
Day30th Day
60th Day
90th Day Patient # Patient Name Doctor System Status
Therapy Report Imaged
Report Faxed to Dr.
Email /Faxed Sales
personPayer 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 & Confidential41 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 RemainingAARP HEALTH CARE OPTIONS 26 23 3 17 16 1 44 41 3 37 32 5AMERICAN 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 2MAGNACARE 13 12 1 9 9 0 23 22 1 11 10 1HIP_PALLADIAN HEALTH 6 6 0 12 9 3 12 10 2 15 15 0MANAGED PHYSICAL NETWORK 12 10 2 8 7 1 10 10 0 10 8 2MAGNACARE 7 7 0 2 11 -9 5 5 0 8 3 5OXFORD 12 9 3 17 12 5 23 22 1 22 16 6STATE FARM INSURANCE 7 6 1 4 4 0 5 5 0 4 4 0TOUCHSTONE HEALTH 5 5 0 8 6 2 6 4 2 16 12 4UNITED 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 PaidCalled 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 PaidCalled 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 PaidPer 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 7/29/2015Health 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 & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Auth Related14%
Coding Error5%
OON Issue8%
COB Issues10%
Patient info missing6%
Exceeds Timely Fil-ing8%
Duplicate Claim5%
Service Not Covered
6%
Primary Paid Max7%
Pre-Existing Con-dition
5%
Others26%
Distribution of Denied Claims
BENEFITS PROPOSITION
24Sun Knowledge © 2015-16 Private & Confidential41 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) 661-7853Email: [email protected]
Sun Knowledge41 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