MEDICAL BILLING & CODING SERVICES
GoTelecare 41 Madison Avenue, 25th Floor, Suite 2511, New York, NY 10010
Presented for 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
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3© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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 provide services to
PROVIDERS – Physicians, Hospitals, DME, P&O, Home Health Care and Pharmacies
PAYERS – Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
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4© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
REVENUE CYCLE MANAGEMENT
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5© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management Overview
360° Revenue Cycle Management
Services
Eligibility Verification & Authorization
Billing
Coding
Scheduling
Payment Posting
Accounts Receivable
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6© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management Overview
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
GoTelecare provides medical billing & coding services – promptly, perfectly and professionally!
We are 100% HIPAA compliant.
CALL: (646) 661-7853
7© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management Services
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
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8© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Practice Management & Billing System
GoTelecare billing executives have experience in working on several industry standard practice management and billing software systems such as:
We can provide medical billing & coding services using customer’s billing system or can set up customer’s practice in a billing system managed by us.
Kareo SOS
Emdeon / Capario One Meditech
Brightree Alpha Collector
Fastrack OPIE
CPR+ HME Futura
DME Works PrimeRx
Team DME
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9© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Medical Billing – 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
CALL: (646) 661-7853
10© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Medical Billing – Challenges and Our Approach
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
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11© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Medical Billing – Challenges and Our Approach
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
CALL: (646) 661-7853
12© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
General Billing Highlights
FREE Billing Software FREE EMR FREE Setup, upgrades and support Above 97% Collection Rate Claims Submission within 48 hours max. Error-free Patient Entry Over 99.9% Coding Accuracy Real-time Audits Methodical and Proactive AR Follow-up 100% HIPAA Compliance Custom Reporting
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13© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
DME BILLING SERVICES
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14© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Billing for DME
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CPAP / BiPAP Machines Insulin Pumps Continuous Glucose Monitor (CGM) Systems Nebulizers Negative Pressure Wound Therapy (NPWT) Breast Pumps Urology Supplies Hospital Beds Sleep Apnea Chairs Ostomy Supplies, and more…
We provide billing services for a wide range of DME product categories including:
15© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
DME Billing Coverage
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DME coverage may be subject to a copay or coinsurance. Authorization is required for various devices and this varies from payer to payer. This is considered a part of the member’s benefits provisions.
For DME products to be covered, the general billing requirements are:
A prescription from the ordering physician dated prior to delivery date
Consideration of limitations based on time period within which the item can be covered if supplied earlier
Appropriate modifiers must be billed
Letter of medical necessity and additional documentation may be required for some devices, e.g. Diabetic Verification Form for diabetic patients; coverage for such equipment is subject to medical review by the Payer
Coverage of devices also subject to qualifying diagnosis
Repair, replacement and supplies may be eligible for separate reimbursement
16© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
DME Billing Cycle
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The billing cycle for DMEPOS 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
17© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
DME Billing – Key Facts
Secure Information & Data Flow between GoTelecare 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
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18© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Order Entry – Sample Report
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
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19© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Eligibility Verification & Authorization – Sample Report
GOTELECARE 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
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20© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
CPAP User Compliance & Tracking – Sample Report
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
GOTELECARE 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 ImagedReport
Faxed to Dr.Email /Faxed Sales person Payer 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 ROE, JANE 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 DOE, JANE Ricardo Encore Complete Yes Yes No MEDICARE
4 6/5/2015 N/A N/A 96.70% N/A N/A 295695 SMITH, JOHN Paez Encore Complete Yes Yes No HEALTH FIRST NY
5 6/30/2015 80% N/A N/A N/A N/A 233432 BLOGGS, JOHN 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 EVERYMAN, A Jones ICODE Complete Yes Yes No AETNA HEALTH PLAN
8 6/3/2015 N/A N/A 57% N/A N/A 217849 SMITH, JANE Smith Resmed Complete Yes Yes No MEDICARE
9 6/27/2015 100% N/A N/A N/A N/A 168488 BLOGGS, JOE 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 IPSUM, L Jones Encore Complete Yes Yes No HEALTH FIRST NY
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21© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Accounts Receivable & A/R Calling – Sample Report
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 5TOUCHSTONE 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 Bloggs, Joe 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) Smith, Mary 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) Smith, John 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
Doe, Janine 3/4/1958 6/19/2015 16478355-01 $100.00 AllowedPer 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 Peters, Joe 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
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22© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
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23© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Benefits Proposition
Increased revenue – reduced collection time (97% collection rate)
Claim submission within 48 hours of receipt of billing input
Adherence to CMS billing requirements
Proper records maintenance and visibility in reporting
Standardization of billing operations
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24© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
TRANSITION, OPERATIONS & COMPLIANCE FRAMEWORK
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25© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Typical Transition Schedule
The key resources of the customer are available during the transition phase.
All documents and process materials like P&Ps and SOPs are available to the Service Provider Transition team before the start of transition.
Any change in the Scope of Work will require re-planning.
All data files are made available for data migration work.
Any other assumptions made in the “Statement of Work” are applicable here.
A more accurate plan will be given at the time of transition
Transition plan tasks may vary depending on specific project
ASSUMPTIONSSr. No. Phase / Task Description Start
WeekEnd
Week Remarks
1. Project Initiation W + 0 W + 0
2. Transition Planning and Solution Identification W + 1 W + 1
ABC to provide existing SOPs/P&Ps/Flowcharts/Reports before this phase starts.
3. Knowledge transfer and detailed As-Is Process Mapping W + 2 W + 3 Onshore activity at ABC
4. Validation of process mapping document / SOPs / training materials W + 3 W + 4 Onshore activity at ABC
5. Validation of solution customization requirements W + 3 W + 4 Onshore activity at ABC
6. Finalize SLA & reporting requirements W + 4 W + 4 Onshore activity at ABC
7. Staffing & Training W + 4 W + 78. Solution customization W + 4 W + 7
9. Solution testing and verify operation Readiness W + 7 W + 8
ABC to provide sample data and participate in testing exercise.
10. Conduct Pilot W + 9 W + 9
11. Evaluate Pilot results and finalize critical Quality parameters W + 9 W + 9
12. Handover to Operations & start “Go Live” W + 10 Transition work ends and
operations ramp-up
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26© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Transition Success Factors
Executive buy-in
Foster win-win partnership relationship
Strong project leadership for both companies
Client’s involvement in approving key deliverables (i.e. project plan, process documents, etc.)
Maintain key current subject matter experts until knowledge is transferred and the key
processes are stable
Availability of key client personnel for training
Accurate identification of desk procedures and processes is critical
Effective governance structure
Communicate, Communicate, Communicate
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27© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
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28© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
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29© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
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30© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Training Methodology
• Regular process test and appraisals
• Work in-sync with Operations & QA
• Preparation of training Modules
• Preparation of training Plan in ‘Knowledge Net’ training module
• 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
Training Need Identification
Training Program Planning
Conduct Training
Training Evaluation
CALL: (646) 661-7853
31© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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.
CALL: (646) 661-7853
32© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
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33© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
CALL: (646) 661-7853
34© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Data Security and End-User Privacy
Information security management system is aligned with ISO 27001:2013 standard Implementation of policies and procedures with respect to PHI comply with HIPAA-HITECH regulations Data replication between GoTelecare’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
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35© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
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36© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
WHY US?
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37© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
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38© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Advantages & Benefits
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Significant decrease in operational expenses
• With over 7 years of successful DME and O&P experience, GoTelecare provides professional consulting to best allocate resources to increase profit margins
• We guarantee > 50% operational savings effective immediatelyFor example, one of our clients reported 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 Rx claims 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
39© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
7+ 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
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40© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
What are Our Clients 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
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41© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Contact
41 Madison Avenue, 25th Floor, New York, NY 10010
(646) [email protected]
Ronnie Hastings
CALL: (646) 661-7853