Medical Billing Service Offerings Durable Medical Equipment and Orthotics & Prosthetics
Jan 17, 2017
Medical Billing Service Offerings Durable Medical Equipment and Orthotics & Prosthetics
41 Madison Avenue, 25th Floor, New York, NY 10010
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Sun Knowledge is our closely affiliated company under the same ownership.
‘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 process knowledge Structured training, feedback and coaching HIPAA-HITECH compliant Offices located in USA& India
• New York City, USA – Situated in Manhattan (facility inbuilt with all redundancies – power, infrastructure and others)
• Kolkata, India – Situated in the IT Hub(facility inbuilt with all redundancies – power, infrastructure and others)
ISO 27001:2005 and ISO 9001:2008 certified company 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
Overview
Key Facts Awards, Affiliations & Certifications
GOTELECARE SERVICE PORTFOLIO
Provider Support
Member Support
Member Retention Program
Clinical Help Desk
Contact Center
Utilization ManagementMedication Therapy ManagementHospital Re-admission
ManagementTherapeutic InterchangeFormulary Management
Clinical Services
Enrollment Processing & Member
FulfillmentClaims AdministrationCoding & Medical BillingCredentialing Premium billing and collections
Administrative Services
Analytics
Telemedicine Services
Application Development
Data Modeling & Data Warehousing
Technical Support
Technical Documentation
IT Services
Claims /Drug Utilization Analysis
PDE Analysis
RAF Analysis
Payment Reconciliation
We provide services to
Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
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ADVANTAGES & BENEFITS
• Significant decrease in operational expenses
• With over 5 years of successful DME and O&P experience, Sun Knowledge/GoTelecare provides professional consulting to best allocate resources to increase profit margins.
• We guarantee > 50% operational savings effective immediately.
• For Example: New York Home Health Care Equipment reported to Sun Knowledge a $2.1 million operational savings in Y1*
• Heightened collection and increased Account Receivables
• 30% of DME and O&P Rx are incomplete when first received. We excel in completing the Rx claim quickly.
• Cyclical Data Reporting
• Data reporting interval can be customized to meet the needs of the customer.
• Demonstrated experience handling DME and O&P claims
• Medicare, Medicaid, and Commercial Plans Fee for Service and Capitated Plans
* New York Home Health Care Equipment is the largest DME company in New York City servicing residents in 13 counties in 3 states since 1982.
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Durable medical equipment (DME) is any equipment that provides therapeutic benefits to a member because of certain medical conditions and/or illnesses that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and is appropriate for use in the home.Example:
Ambulatory equipment: rollator, cane, crutch Chairs: Geriatric chair, wedge cushions, Wheel chairs etc. Breast pump CPAP & BiPAP machines & supplies Continuous Passive Motion machine Perenteral & enteral feeding equipment & products Hospital bed: Semi electric, fully electric, Side rails, gel overlay mattress etc. Blood pressure, Glucose monitoring devices Orthotics: Splint, brace , inserts etc. Oxygen devices: Concentrator & supplies Respiratory equipment: Nebulizer compressor, Suction machines etc.
BILLING FOR DURABLE MEDICAL EQUIPMENT
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DME coverage may be subject to a copay or coinsurance. Authorization is required for various DME and this varies from payer to payer. This is considered a part of the member’s DME benefits provisions. For DME to be covered the general billing requirements are:
A prescription from the ordering physician dated prior to delivery date Certain items must be rented prior to being converted to purchase and therefore must be billed as rentals Consideration of limitations based on time period within which the item can be covered if supplied earlier.
E.g. CPAP machines cannot be ordered more than once every 5 years while most CPAP supplies are available every 3 months
Appropriate modifiers must be billed with DME Letter of medical necessity and additional documentation may be required for some DME, e.g. orthotics,
beds & mattresses, BiPAP machines etc. Coverage for such equipment is subject to medical review. Coverage of DME is also subject to qualifying diagnosis, E.g. CPAP machines – Obstructive Sleep Apnea Maintenance, repair, or replacement and supplies may be eligible for separate reimbursement under a
contracted maintenance fee with a DME supplier acceptable by the payer.
DME COVERAGE & BILLING
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The billing cycle for DME involves the following activities: Order entry based on the Rx received from the physician
• Patient demographics & insurance entry• Provider information entry• Product code entry• Rx &Dx entry (with appropriate timeframe)• If necessary, a telemedicine consultation can be completed to obtain a Rx to expedite the order entry
process. Eligibility verification and auth requirement enquiry Collection of documents required by payer for auth approval, E.g. face to face consultation notes,
Polysomnography / Titration report etc. and obtaining of authorization from payer. Determination that payer criteria is met before delivery of DME, E.g. some DME have time / frequency / annual
cost limitations for DME (if criteria is not met the patient needs to be contacted and informed of the financial responsibility)
Generation of delivery ticket (based on which delivery is made to the patient) Creation of claim after receipt of confirmation of delivery Submission of EDI / paper claim to payers Cash posting Rejection & Denial Management A/R follow-up
DME BILLING CYCLE
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DME AND O&P BILLINGChallenges Vs 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 Auth
Eligibility verification
DME BILLING – CHALLENGES VS. APPROACH
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Patient Demographics / Insurance / Initial Rx Entry
Transaction audit to minimize error that will reduce 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 and payers to collect documentation, obtain authorizationProper 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 Payment reconciliation issue
Delayed correction and resubmissionPossible loss of payment
Payment Posting
Rejection management
DME BILLING – CHALLENGES VS. APPROACH
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Paper claim submission
Proper tracking of every submission of paper claimsMoving 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 guidelinesReview of patient payments Define KPI – TAT & Accuracy Denial posting and review
Proper documentation – process manual, guidelines & checklistsDefining proper tracking mechanism through various reports -Ageing, Status, Daily, ExceptionGenerate exception reports and regular audit of every process tasksDefining 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
DME BILLING – CHALLENGES VS. APPROACH
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AR Follow-up & Denial Management
Regular analysis, follow-up and review Transaction audit
TASK DESCRIPTION CHALLENGES APPROACH
Accumulation of backlogDenials not postedClaims reconciliation issue
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ELIGIBILITY VERIFICATION & AUTHORIZATION – SAMPLE REPORT
4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/20150
20
40
60
80
100
120
140
96
83
94
98 96
29
11
6
31 32
125
94
100
129
128
41
32
26
30 28
ELIGIBILITY VERIFICATION
Number of New Patient Patient Brought ForwardPrimary Checked Secondary Checked (if applicable)
4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/20150
5
10
15
20
25
30
35
40
45
5045
25
38
4446
20
15
26
22 21
25
1012
2225
AUTHORIZATION
Auth Required Auth Obtained Auth Pending
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DENIAL MANAGEMENT – SAMPLE REPORT
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 Condition
5%
Others26%
Distribution of Denied Claims
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TELEMEDICINE DME and Orthotics and Prosthetics
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Very Little Risk GoTelecare is experienced in handling complex contracts/claims GoTelecare is experienced working with various claims & billing systems Quick and efficient resource for special projects when needed e.g. member retention program, etc. Quick and efficient temporary resource when needed e.g. inventory back up, annual enrollment period, etc.
Significant Upside Potential GoTelecare has a good understanding of US Health Care industry. We work both for the payers and providers. Extremely competitive rates, greater productivity, improved accuracy of claims, increased provider
satisfaction, reduction in overtime cost Reduced Admin Cost Leverage partial outsourcing to increase and/or create operational expansion opportunities
Proven process performance Claims Processing: Accuracy > 98%; TAT: 5 - 10 days Efficient coding & billing process – special focus on rejection and denial management Contact Center: Abandonment Rate < 2%, ASA within 30 Seconds for 90% of calls, High CSAT
Clear Communication And Quick Response Time At All Times End user data privacy and protection through implementation of industry standard like ISO 27001:2005 & HIPAA
ADVANTAGES OF UTILIZING OUR SERVICES
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CUSTOMER TESTIMONIALS & ADDITIONAL INFORMATION
David MusikerRegional Director
For Additional Information, Please Contact