complete prior authorization services | prior authorization process guideline

PRIOR AUTHORIZATIONSERVICES

PRIOR AUTHORIZATION – INTRODUCTION

2Sun Knowledge © 2015-16 Private & Confidential41 Madison Avenue, 25th Floor, New York, NY 10010, USA

SUN KNOWLEDGE OVERVIEW

Key Facts Awards, Affiliations & Certifications

3Sun 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 SUMMARY


PRACTICE MANAGEMENT

Scheduling

Eligibility & Authorization Verification

Prior Authorization

Customer Care

PRIOR AUTHORIZATION FUNDAMENTALS


TIME SPENT PER WEEK ON PRIOR AUTHORIZATION BY VARIOUS PERSONNEL

PRIMARY CAREPHYSICIANS

NURSINGSTAFF

CLERICALSTAFF

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


Guaranteedreduction of

operational cost by 70%

Increase your current rate of

Prior Authorizationby 1.5 – 2x

The only Revenue CycleManagement

company specializingin Pre-certification

Prompt servicewith a consistentaccuracy rate of

99.9%

Serving majorhealthcare

organizations in prior

authorization

Secret of our Success?

Our experience inadjudicating 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 L70.0Sulfacetamide 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 8/25/20168/25/2016- Got reply from NEDA, triaged back for alt. medication suggestion8/18/2016- 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 creamInsurance Co: Envision Rx | Spoke with: John | Result: Pending

In Process

8/24/2016 NAS/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 efficiencyProcess 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) 661-7853Email: [email protected]

Sun Knowledge41 Madison Ave., Suite 2511, 25th Floor

New York, NY 11001, USA

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