Prior Authorization For Radiology By SunKnowledge
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Transcript of 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
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
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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
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
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PRIOR AUTHORIZATION – SERVICE PORTFOLIO
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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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
RETRO AUTHORIZATION
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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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
AUTHORIZATION EOB CODES
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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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
PRIOR AUTHORIZATION – KEY STEPS
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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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE REPORTS
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE REPORT #1
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
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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
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
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41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
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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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
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CLIENTSPEAK
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“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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
19Sun Knowledge © 2015-16 Private & Confidential
“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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
CLIENTSPEAK
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“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
For Additional Information, Please Contact…
41 Madison Avenue, 25th Floor, New York, NY 10010, USA