GoTelecare Medical Billing Services

MEDICAL BILLING & CODING SERVICES

GoTelecare 41 Madison Avenue, 25th Floor, Suite 2511, New York, NY 10010

Presented by

GoTelecare

CONTACT: RONNIE HASTINGS (646) 661-7853

2© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010

Company Overview

‘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 Offices located in US & India

• New York City, US – Situated in Manhattan (facility inbuilt with all redundancies – power, infrastructure and others)

• Kolkata, India – Situated in the IT Hub of Eastern India (facility inbuilt with all redundancies – power, infrastructure and others)

Sun Knowledge, our contracted company, is 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

Key Facts Awards, Affiliations & Certifications


Our Service Offerings

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 & MemberFulfillment

Claims Administration Coding & Medical Billing Credentialing Premium O&P 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 cater to

Prosthetics & Orthotics and DME companies in Revenue Cycle ManagementPhysicians, Hospitals & Specialty Facilities in Revenue Cycle Management

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


REVENUE CYCLE MANAGEMENT


Revenue Cycle Management Overview

360° Revenue Cycle Management

Services

Eligibility Verification & Authorization

Billing

Coding

Scheduling

Payment Posting

Account Receivables


Client Benefits

Significant decrease in operational expenses We charge a flat rate of $10 per hour per employee! Our clients save on other associated costs for employees including Health Insurance Premiums, Payroll Costs,

Medicare Tax, Human Resources, Employee Attrition, additional Real Estate and Infrastructure Costs We guarantee > 50% operational savings effective immediately; e.g. one of our clients reported a $2.1 million

operational savings in Y1 alone!

Heightened collection and increased Accounts Receivables 30% of DME Rx are incomplete when first received. We excel in completing the Rx claim quickly.

Cyclical Data Reporting Data reporting interval customized to meet the needs of the customer Productivity Efficiency Tracking allows for quantifying the team workload

Demonstrated experience handling DME claims Medicare, Medicaid and Commercial Plans Fee for Service and Capitated Plans


Revenue Cycle Management – Service Portfolio

Inpatient/Outpatient Hospital Coding Physician Coding

Patient entry demographics & insurance information Fee Schedule / Charge Entry Scrubbing all entries for correctness and completeness with appropriate billing edits;

correction of identified errors Submission of claims to payers, e.g. EDI or paper Creation and mailing of patient statements Posting of payments received from patient and payer Reconciliation of charges, payments received and adjustments made

Denial Management (understanding denials and making corrections) Resubmission of claims AR calls as follow-up on outstanding issues Closure of a claim once the balance is zero

CODING

BILLING

A/R FOLLOW-UP


Medical Billing & Coding

MEDICAL BILLING & CODING SERVICES


General Highlights

Above 95% Collection Rate Claims Submission TAT 24 – 48 hours max. Error-free Patient Entry Over 99.9% Coding Accuracy Real-time Audits Proactive Follow-up on Rejections Denial Management Methodical and Proactive AR Follow-up 100% HIPAA Compliance Custom Reporting


Areas of Operation

We provide turnkey billing services in the following areas:

Urgent Care Prosthetics & Orthotics DME (Durable Medical Equipment)

Pathology Critical Care Oncology

Hospice Pre-Op / Post-Op Care Radiology

Cardiology Home Healthcare Orthopedic Surgery

Anesthesia Family Practice Inpatient Hospitalization

Drug/Alcohol Rehab Pharmacy Physicians, and more…


PHYSICIAN SERVICES

Billing & Coding Services for…


Physician Billing Highlights

Transition & Implementation• Project initiation & transition planning• Process and applications training by the client• Knowledge transfer and detailed as-is process mapping• Validation of process training materials• Setting up and configuring the billing system• Setting up the infrastructure• Starting operations

Typical components of our medical billing and denial management services• Entry of patients' demographic information• Verification of Eligibility and Insurance• Determination of pre authorization requirements & obtaining auth, if required• Code review• Charge entry• Claims generation and submission• Rejection and denial management• Cash posting and AR follow up


ELIGIBILITY VERIFICATION & AUTHORIZATION

OUR OTHER SERVICES


Eligibility Verification & Authorization Services

Eligibility check covers the following:

Policy active for date of service

DME coverage

Copay / Coinsurance / OOP

Rx & Dx entry (with appropriate timeframe)

Provider status (INN / OON)

CSI check

Authorization requirement

Obtaining pre authorization

Patient responsibility


Sample SOW (Statement of Work)

Each pre-authorization service consists of three transactions. Tasks involved in carrying out this Pre Authorization service include the following steps:a) Authorization Initiation transaction involves the following activities:

Calling up insurance to find the authorization filing procedure and turnaround time Gathering pre-authorization form and relevant medical documents from the providers Submission of the authorization request (fax/online) to the payer along with relevant

documentation Tracking of Fax receipts

b) Authorization Follow up transaction will involve following up with the payer to check the status of the authorization as per the TAT set for each payer.

c) Acknowledgement of Authorization approval transaction will involve updating approved authorization in the clients billing system with the start and end date for the Authorization approval. If required by the client, scanned image of the approval will be uploaded into the clients system.


Sample Reports

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


ACCOUNTS RECEIVABLES (AR) FOLLOW-UP


Reasons for AR Management

Authorization Issues Referral Issues Medical Necessity and Medical

Records requests Non-Participation with Insurance

Network Terminated Insurance Coordination of Benefits

Wrong Diagnosis Inclusive Procedures Partial Payments Out-of-network Claim Status and

Deductibles EDI Rejections No Status and No Claim on File PIP cases


Steps in AR Follow-up

A/R Analysis 14% of all claims submitted to the payers are denied and have to be resubmitted, appealed

or written off by providers 50% of denied claims are never re-filed 50-70% of denied claims have higher chance of being recovered

Reducing days in A/R, claims submission and improving collection ratio with an increase the probability of payment through timely follow-up is the responsibility of the A/R team

Follow-up with payer Aggressive follow up with the insurance company's on all accounts at any stage of the aging

bucket plays an important part in A/R follow up activities.

Closure of claim


Sample SOW of AR Follow-up

Go Telecare will make outbound calls to reach out to the Payers to gather information about the status of claims as per the list provided by Customer. Key tasks involved in carrying out this work are detailed below. Planning to start calling Payers as per the list of claims based on the downloaded AR Reports Research details of the claims in the AR list in the Clients system Making outbound calls to the respective Payers for claims aged 31 days and more Document finding of the calls Preparation of claims reports with status information gathered during the call

Modifications, removal or adding tasks to this are agreed upon between client and Go Telecare


Medical Coding – Overview

Downloading Allocation

CodingQuality Check

Uploading Feedbacks & Updates

Encrypted reports are downloaded from SFTP site

Reports are allocated to coders according to specialty

Quality checked for LCDs, updates and client specs.

Analysis of reports, allocation of ICD and Service codes

Analysis of reports, allocation of ICD and CPT codes

Client reports back with feedbacks and updates

Medical Coding Process Flow


Medical Billing Cycle

Encounter (SOAP) notes

review

Superbill generation and code

review

Claims edit checking

and correction

EDI claims submission

through clearing house

Rejection management

ERA/EOB posting and reconciliation

Automatic secondary

payer billing

Denial Management

AR Follow-up


Billing Cycle – Details Order entry based on the Rx received from the Physician

• Patient demographics & insurance entry• Provider information entry• Product code, Rx & Dx entry• If necessary, a telemedicine consultation can be completed to obtain a Rx to expedite the order entry process

Eligibility verification and authorization requirement enquiry Patient’s appointment with Practitioner for Practitioner to assign codes Collection of detailed Rx from ordering Physician’s office Collection of documents required by Payer for authorization approval, e.g. Diabetic Verification Form, initial

evaluation, medical notes to support K level, PPR Form Calculation of service estimates (Patient and Payer responsibility) Determination that payer criteria are met before delivery of device (if criteria are not met,

the Patient needs to be contacted & informed of the additional financial liabilities) 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

For the exclusive use of


Coding & Billing System

We use Kareo for coding and billing services that covers the complete billing cycle:

SOAP notes review

Superbill generation and coding

Claims edit checking and correction

Claims submission through EDI clearing house at a scheduled time

Rejection management

ERA/EOB posting and reconciliation

Automatic secondary payer billing

Denial Management

Patient statement generation and mailing

We also work on a wide range of other billing software platforms as desired by our clients!


Payment/Denial Posting Process

Payment posting is crucial to the billing process. Due to the sensitivity of this process, accurate and efficient payment posting process is indispensable.

Our billers are known to be highly efficient and analytical in the payment posting process.

Payment Entry Process

Select Patient Account

Select EncounterSelect Encounter If not found

Refer Client SpecifiesDenial

Denial Code

Hold Transfer BalanceTransfer BalanceWrite-off

Post Payment

Payment


Productivity Efficiency Tracking

Employee Name Note Count Days Worked Hours Worked Notes Per

Hour Max Note Time Avg. Note Time

John Smith 977 23 203.55 4.8 1:29:52 0:07:15

Jane Doe 1025 23 214.97 4.77 0:55:14 0:04:56

Rick Williams 913 21 207.07 4.06 1:27:08 0:07:14

Robert Frost 870 21 187.35 4.64 0:42:54 0:04:05

Dan Chesser 910 23 216.47 4.2 3:50:55 0:06:18

Derek Malia 823 23 210.37 3.91 7:01:30 0:04:37

Our clients depend on transparency.

We provide our clients with the ability to maintain detailed tracking for increased productivity and efficiency.

A Sample Report


Denial Management

Auth Related14%

Coding Error5%

OON Issue8%

COB Issues10%Patient info missing

6%

Exceeds Timely Filing8%

Duplicate Claim5%

Service Not Covered6%

Primary Paid Max7%

Pre-Existing Con-dition

5%

Others26%

Distribution of Denied Claims


Challenges and 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


Technology, Operational & Compliance Framework

TECHNOLOGY, OPERATIONAL & COMPLIANCE FRAMEWORK


Software Development

Some of the applications which we have developed include, GoTelecare - A full fledged Telehealth application for providers, hospitals and patients with integrated EMR,

practice management system and video conferencing system Integration of DICOM server, DCM4CHE with EMR software mHealth – Remote patient monitoring and health data collection through medical devices and QUALCOMM

cloud services PDP Manager – To manage Medicare Part D processes Medication Therapy Management (MTMpro) application

Our technology development team works with Java (Enterprise Edition) and technology components include, Web application technologies like servlets, JSP, JSTL, JSF, JSON, web sockets, applets Open source frameworks like Struts, Spring, Hibernate Enterprise technologies like dependency injection, messaging services, transaction management services,

persistence management services, annotations, javamail, java enterprise beans, interceptors, connector architecture

Web service technologies like RESTful web services, enterprise web services, JAX -WS, JAX- RPC Database servers like MS SQL server, Oracle, MySQL


IT Infrastructure

Service continuity supported by BCP and disaster management mechanisms 100% redundancy in all IT assets, providing high-availability and reliability 12 Mbps leased line internet connectivity provided by two ISPs in load sharing and automatic

failover configuration Data protection and security provided by Fortigate® 310B firewall combined with other physical

and logical access controls Voice telephony infrastructure built using E1 lines provided by two IPLC

providers Avaya PBX with IVR, ACD and CTI functionalities and 100% call recording

& reporting features Data center with 13 IBM x3650 rack servers with rack mounted UPS Polycom VSX 7000A video conference system for remote training

and client communication 24/7/365 IT-Infrastructure support personnel for user support, using ticket management system 120 KVA on-line UPS power backup systems and additional backup provided by 180 KVA power

generator


Operational Framework

TRANSITION

Project scoping & planning

Knowledge transfer – Process training and assessment

Process documentation

Solution customization

Infrastructure set up

Pilot/Transition period

TRAINING

Training Need Identification

Customized training program as per client’s requirement

Pre-process & process training

Voice & accent and cultural training

Refresher training

PRODUCTION

Project management approach

Exception handling and reporting

Effective coaching & monitoring practices

Periodic review and evaluation

Service level management and reporting

QUALITY

Regular audit for process and deliverables

Identify and analyze errors to take corrective measures

Flowcharting and root cause analysis for process improvement measures

Management reporting of quality assurance activities

Capacity planning

Forecasting, staffing & scheduling

Real time reporting

Billing and revenue management

MIS / WFM

Ensure 100% adherence to federal / data protection laws

Governance & compliance audits

Organization preparedness for client & third party audits

HIPAA compliance

CONTROL & COMPLIANCE

PROJECT MANAGEMENT & OVERSIGHT

IT INFRASTRUCTURE– TOOLS & TECHNOLOGY


Governance Model

GoTelecare Governance

Structure

Steering Committee

Program Management Office

Project Delivery Team

Executive sponsorship

Management oversight

Ensure business goals and engagement goals alignment

Ensure tangible results and

demonstrable value

Continuously educate & report executive leadership on the critical success factors of engagement

Plan and implement change; define, establish performance, metrics aligned to goal

Review project scope, timeline and budget and monitor project progress

Communication, status reporting & escalation to steering committee

Manage cross team dependencies

Identify, initiate & institutionalize process improvements

Oversee knowledge repository building

Project Management

Scope Management

Knowledge Management

Change Management

Ensure successful engagement startup

Quality Management

Resource Management

Communication & Status Reporting

Issue Management

Monitor & measure knowledge transfer

process

Incorporate industry best practices


Quality Assurance & Control

Our Quality Control & Assurance processes help us meet our client’s expectations and SLA target. We use Quality Assurance program to set production and quality goals. Our daily quality audit activities ensure that we evaluate our agents’ work on all relevant criteria. The highest quality is ensured by carrying out rigorous quality assurance and control activities such as,

Periodic process review

Process audit

Testing deliverables and root cause analysis

Process improvement / re-engineering

Incorporating customer feedback

Internal quality audit of client deliverables & review reporting

Weekly/monthly monitoring of productivity reports


Training Methodology

• Process training and refreshers

• Availability of training documents in ‘Knowledge Net’ portal

• V&A, Soft skills training

• Post-training assessment• Training feedback• Review of training program

• Preparation of training Modules

• Preparation of training Plan in ‘Knowledge Net’ training module

• Regular process test and appraisals• Work in-sync with Operations & QA

Training Need Identification Training

Program Planning

Conduct TrainingTraining

Evaluation


Compliance – Key Facts

Well defined policies to cover compliance aspects

Written procedures covering compliance aspects

Proactive compliance reporting and issue escalation

Action list for changes in rules and regulations by regulatory authorities

Compliance evaluation framework

Periodical training on compliance issues and update

Periodic audit and review mechanism to address potential compliance risks

Implementation of data privacy and security standards like HIPAA-HITECH and ISO 27001

Incident reporting for data security violation

Compliance awareness among the employees and reward on compliance reporting

Compliance violation by employees leads to employee retraining and reassessment

GoTelecare has defined and established a process and system to avoid compliance risks while carrying out operations and encourage employees to proactively report compliance issues to the higher management.


Compliance Escalation Structure

Service DeliveryService Delivery Mgr

(Service Delivery POC)

Head of Operations

(1st Level Escalation POC)

Operations

CEO & MD

(Final Escalation POC)

Executive Board

Board of Directors

ComplianceCompliance Mgr

(Compliance Escalation POC)

Head of ComplianceCompliance

Team LeadProcess Team Lead

(Service Delivery POC)

TechnologyTechnology Mgr

QualityQuality Mgr

HR/TrainingHR/Training Mgr

Compliance Issue

Trigger Point

Process Team Leader will inform Service Delivery Manager and Compliance Manager immediately after occurrence of the event

Compliance Manager/ Service Delivery Manager will assign the severity of the compliance issue

Compliance Escalation Path

Severe Compliance Escalation Path


Data Security and End-User Privacy

Information security management system is aligned with ISO 27001:2005 standard Implementation of policies and procedures with respect to PHI comply with HIPAA-HITECH regulations Data replication between Sun Knowledge’s servers in NY and India via site-to-site IPsec VPN tunnels helps strong

business continuity management Daily off-site backup process to mitigate data loss risk in case of disaster Implementation of physical access control system in office premises restricts access to sensitive areas housing

application and database Physical and logical segregation of internal network into VLAN segments to control and protect data storage and

transmission between business/process units Implementation of perimeter security devices, like firewall and segregation of sensitive information systems Access to all information systems through two levels of authorization Implementation of two levels of end point malware protection network and system level anti-malware systems Use of secure e-mail system for e-mails with sensitive PHI information Implementation of access restrictions to prevent unauthorized deletion or movement of data using external

storage devices like optical discs, pen drives, etc. Security incident monitoring, reporting and resolution system Periodic employee awareness training on data privacy & protection and HIPAA regulations


Why GoTelecare?

WHY US?


Advantage GoTelecare

1Over 8 Years of Experience in Working as Vendors for

Major Health Insurance

Companies Across US

Deep Knowledge of both the Payer

and the Provider Side

of the US Healthcare Spectrum

2Consistent

Performance in Delivering 97% Collection Rate

to Clients

Already

Recovered over millions in

Account Receivables

and counting…

3The Only

Medical Billing Company with Its Own State-

of-the-Art Telemedicine

Platform

4The Best

References in Every

Segment of US

Healthcare Knowledge &

Business Process

Outsourcing

5The Lowest

Prices* in the Market!

* Only $10 per hour for a dedicated FTE

or just 4% of collections for

Accounts Receivable work


Why Us?

Very Little Risk• Proven track record in providing healthcare BPO/KPO services• Highly experienced in providing services to both payers and providers• Experienced in 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 increase in revenue collection • Verification & authorization accuracy > 99.9%; TAT: 24 hours • High accuracy in Eligibility Data Maintenance (in sync with CMS)

Clear Communication and Quick Response at All Times ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection

For the exclusive use of


The Real Question

But really, why us?

Because we do Six Sigma quality work, validated by excellent client references, at the lowest prices in the market!

We are so confident of the quality of our services that we challenge you to find another company which can deliver better quality services at a cheaper rate!


Our 4 Pillars of Strength

Highest Quality

Excellent References

Unique Profile

Cheapest Rates

Consistently delivering the best quality, with the highest levels of accuracy, efficiency & expertise

Glowing testimonials from every client and not a single customer churn in our 8 years of operation

Huge experience in working for both Payers and Providers and

the only billing company with its own Telemedicine platform

The lowest rates in the market, with custom pricing options to

delight all clients


What Our Clients Are Saying…

"The professionalism I have experienced with GoTelecare’s employees has made them very easy to work with and has improved our operation processes. Any time I have a question, they are literally just a phone call or e-mail away. I love the accessibility!”

- CFO of a major US healthcare company

“I am starting to see an upswing with Medicare and United cash flow”

- CEO of a leading US healthcare organization

“Your productivity is very impressive for your first month. Almost everyone has an average of close to 40 accounts per day. We have gone over a few things with you and each time we talk, I am impressed with how quickly changes and improvements are put in place.

I will continue to share feedback as I get it on additional improvements that can be made and appreciate your attentiveness and questions that you bring to our daily meetings.

- Manager (Revenue Cycle) of a reputed US healthcare company


Contact

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

(646) [email protected]

Ronnie Hastings

https://www.facebook.com/GoTelecare/

https://twitter.com/GoTelecare

https://www.linkedin.com/company/5239333

Documents

GoTelecare Medical Billing Services