prior authorization for radiology by sunknowledge

PRIOR AUTHORIZATIONFOR RADIOLOGY

Presented by

Sun Knowledge 41 Madison Avenue, 25th Floor, New York, NY 10010

SUN KNOWLEDGE 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

41 Madison Avenue, 25th Floor, New York, NY 10010, USA

Office at 41 Madison Avenue, 25th Floor, New York, NY 10010

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

SUN KNOWLEDGE 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, Home Health Care and Pharmacies

PAYORS – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs

SERVICE PORTFOLIO



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

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 AccessSigning 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

7Network &

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 FirewallUnified 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

9VPN (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

10Redundancy

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

11Virus & 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

PRIOR AUTHORIZATION



PRIOR AUTHORIZATION – SERVICE PORTFOLIO


Full range service, comprising Authorization Request Follow-up Approval

100% HIPAA-HITECH Compliance

Low prices with no hidden cost

Highly streamlined, fast and accurate service

• PET/SPECT scans

• CT

• CTA

• MRI

• MRA

• IMRT

• MEG

• Add-on Procedures, and many more

We handle Prior Authorization for


RETRO AUTHORIZATION


Certain procedures require prior authorization

Submitting a request does not guarantee approval

If an authorization was not previously requested, a retro-authorization may be requested for services already provided

The same guidelines as for requesting an authorization prior to service are followed

Dates specific for retro-authorizations are used

Once the authorization is approved, the bill is resubmitted


AUTHORIZATION EOB CODES


EOB code 529 – Case is denied

EOB code 530 – No authorization on file

EOB Code 531 – Authorization for claimant, not for provider

EOB Code 532 – Authorization for claimant and provider, not for dates of service

EOB Code 533 – Authorization for claimant, provider, and dates of service; not for procedure


PRIOR AUTHORIZATION – KEY STEPS


Tasks involved in carrying out this Pre Authorization service include the following steps:

Gathering relevant medical documents from the Providers

Calling up insurance to find the authorization filing procedure and turnaround time

Initiation of authorization request (fax/online/calling)

Follow up with the Payer to check the auth. status as per the TAT set for each Payer

Acknowledgement of authorization approval/denial

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

ReceivedComplete/In Progress

Patient ID Patient Name DOB Dx Codes Name of Process Provider Name Primary Payer Phone #

1 8/18/16 In progress 1234567 Patient 1 1/1/90 71250 CAT scan Provider 1 Aetna Phone 1

2 8/24/16 In progress 1234568 Patient 2 1/2/90 75571 Coronary Calcium Scan Provider 2 Cigna Phone 2

3 8/24/16 In progress 1234569 Patient 3 1/3/90 71270 CAT scan Provider 3 Centene Corp Phone 3

4 8/25/16 In progress 1234570 Patient 4 1/4/90 77080Bone Densitometry

(DEXA Scan)Provider 4 Aetna Phone 4

5 8/26/16 In progress 1234571 Patient 5 1/5/90 93307 Echocardiography Provider 5 Cigna Phone 5

7 8/29/16 Complete 1234573 Patient 7 1/6/90 71260 CAT scan Provider 7 Blue Shield Phone 7

8 8/29/16 Complete 1234574 Patient 8 1/7/90 93314 Echocardiography Provider 8 Centene Corp Phone 8

9 8/29/16 Complete 1234575 Patient 9 1/8/90 76815 Perinatal Ultrasound Provider 9 Aetna Phone 9

10 8/29/16 In progress 1234576 Patient 10 1/9/90 37243Uterine Fibroid Embolization

(UFE)Provider 10 Blue Shield Phone 10

SAMPLE REPORT #2



PRIOR AUTHORIZATION COMPONENTS OF DAILY DETAILED REPORT (Contd.)

AUTHORIZATION STATUS

Last Worked On Follow Up Date Comments Final StatusApproval /Denial Date

8/25/2016 8/25/20168/25/2016- Got reply from Cigna, triaged back for alt. suggestion8/18/2016- Notified Triage, since patient requested alternate procedure as copaywas 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.Procedure Name: EchocardiographyInsurance Co: Aetna | Spoke with: John | Result: Pending

In Process

8/24/2016 NA

S/w Jack, PA is In Progress, Ref# M1*******3, Ade informed that the procedure is not covered. He also informed that apart from the prescribed procedure, there are alternatives which are covered. He will fax us the available list of alternatives at ***-***-****.

In Process

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

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

• Billing & Coding Accuracy > 99.9%; 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


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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