Prior Authorization for Sleep Medicine
-
Upload
michael-smith -
Category
Healthcare
-
view
72 -
download
1
Transcript of Prior Authorization for Sleep Medicine
PRIOR AUTHORIZATION
FOR SLEEP MEDICINE& SLEEP THERAPY
PRIOR AUTHORIZATION – INTRODUCTION
2Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Please view in full screen slideshow to watch the video
SUN KNOWLEDGE OVERVIEW
Key Facts Awards, Affiliations & Certifications
3Sun 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
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
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Office at 41 Madison Avenue, 25th Floor, New York, NY 10010
SERVICE PORTFOLIO SUMMARY
4Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
PRIOR AUTHORIZATION STATE OF THE INDUSTRY
5Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TIME SPENT PER WEEK ON PRIOR AUTHORIZATION BY VARIOUS PERSONNEL
PRIMARY CAREPHYSICIANS
NURSINGSTAFF
CLERICALSTAFF
1.1 Hours 13.1 Hours 5.6 Hours
Based on a 2009 study published in Health Affairs
PRIOR AUTHORIZATION PROCESS
6Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
a) Authorization Initiation
i. Calling up insurance to find the authorization filing procedure and turnaround time
ii. Gathering prior-authorization form and relevant medical documents from the providers
iii. Submission of the authorization request (fax/online/call) to the payer along with relevant documentation (if required)
iv. Tracking of Fax receipts
b) Authorization follow up involves communicating with the payer to check the status of the authorization as per the turnaround time protocol of the payer. It also involves sharing additional notes as per payers’ requirement
c) Acknowledgement of Authorization approval involves updating approved authorization in the providers’ practice management system with the start and end date for the Authorization approval, service information and provider information
WE PROVIDE COMPREHENSIVE SUPPORT IN PRIOR AUTHORIZATION INCLUDING…
We submit Prior Authorization requests to all insurance plans, by phone, online or by fax
SERVICE AREAS
7Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Durable Medical Equipment Prosthetics & Orthotics Sleep Medicine (CPAP BiPAP)
Rehab (Alcohol – Substance Abuse) Gastroenterology Skilled Nursing Facilities
Rheumatology Cardiology Pharmacies
Dermatology Specialty Clinics Home Health & Hospice
Neurology Oncology Orthopedics
Pathology Dermatology Pediatrics
Physicians Radiology Surgery
Healthcare Facilities Gynecology & Obstetrics Physical, Occupational and Speech Therapy
and more…
WE PROVIDE PRIOR AUTHORIZATION SERVICES IN THE FOLLOWING AREAS:
PRIOR AUTHORIZATION SERVICE HIGHLIGHTS
8Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Guaranteedreduction of
operational cost
by 70%
Increase your current rate of
Prior Authorization
by 1.5 – 2x
The only Revenue CycleManagement
company specializingin Pre-certification
Prompt servicewith a consistentaccuracy rate of
99.9%
Serving majorhealthcare
organizations in prior
authorization
Secret of our Success?
Our experience inadjudicating claims
for large Payers!
ADDITIONAL FEATURES
9Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
Full-range service, comprising Authorization Request Follow-up Approval
100% HIPAA-HITECH compliance
Turnaround time less than 48 hours max.
Low service fees with no hidden cost
Zero lockup service contracts that can be cancelled anytime
Tons of excellent references from current clients
Real-time audits and custom reporting
Excellent visibility and proven expertise
Our services are designed to take the pain out of prior authorization and free you from the need to engage your resources or spend precious time in tedious prior authorization tasks.
CASE STUDY ON BOTOX
10Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
FOCUS ON PRIOR AUTH FOR SLEEP MEDICINE
11Sun Knowledge © 2015-16 Private & Confidential
WE COVER PRIOR AUTHORIZATION FOR A WIDE RANGE OF SLEEP-RELATED SERVICES AND MEDICINE (INCLUDING FACILITY-BASED SLEEP STUDIES)
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
HCPCS Device
E0470 Respiratory assist device, bi-level pressure capability
E0601 Continuous Airway Pressure (CPAP)
E0193 Powered air flotation beds
E0277 Powered air mattresses, and many more…
PRIOR AUTHORIZATION FOR MEDICATION
12Sun Knowledge © 2015-16 Private & Confidential
Typical tasks involved in carrying out Prior Authorization for medication include the following steps:
Gathering relevant medical documents from the providers
Calling up insurance to find the authorization filing procedure and turnaround time
Submission of the authorization request (fax/online/calling)
Follow up with the Payer to check authorization status as per the TAT set for each Payer
Acknowledgement of authorization approval/denial
Notifying the Pharmacy
Updating the authorization details (authorization number / duration / quantity) in the Provider’s billing system
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
13Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
SAMPLE REPORTS
SAMPLE REPORT #1 (Prior Auth for Medication)
14Sun Knowledge © 2015-16 Private & Confidential
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 Medication Provider Name Primary Payer Phone #
1 8/18/16 In progress 1234567 Patient 1 1/1/90 L40.0 Adapalene 0.3% Gel Provider 1 Caremark Phone 1
2 8/24/16 In progress 1234568 Patient 2 1/2/90 L21.9, L71.8 Elidel 1 % topical cream Provider 2 Envision Rx Phone 2
3 8/24/16 In progress 1234569 Patient 3 1/3/90 L40.0 Clobetasol Prop 0.05% Foam Provider 3 Caremark Phone 3
4 8/25/16 In progress 1234570 Patient 4 1/4/90 L70.0Sulfacetamide sodium-sulfur
10 %-5 % (w/w) topical cleanser
Provider 4 Magellan Rx Phone 4
5 8/26/16 In progress 1234571 Patient 5 1/5/90 L40.0 Desonide 0.05% Cream Provider 5 Cigna Phone 5
7 8/29/16 Complete 1234573 Patient 7 1/6/90 L70.0 Tretinoin 0.025% cream Provider 7 Caremark Phone 7
8 8/29/16 Complete 1234574 Patient 8 1/7/90 L70.0 Tretinoin 0.025% cream Provider 8 Express Scripts Phone 8
9 8/29/16 Complete 1234575 Patient 9 1/8/90 L70.0 Tretinoin 0.025% cream Provider 9 Caremark Phone 9
10 8/29/16 In progress 1234576 Patient 10 1/9/90 L70.0 Tretinoin 0.025% cream Provider 10 Tufts Health Phone 10
SAMPLE REPORT #2 (Prior Auth for Medication)
15Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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 NEDA, triaged back for alt. medication suggestion8/18/2016- Notified Triage, since patient requested alternate medication 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.Medication Name: Elidel 1 % topical creamInsurance Co: Envision Rx | Spoke with: John | Result: Pending
In Process
8/24/2016 NA
S/w Jack, PA is In Progress, Ref# M1*******3, Ade informed that it is a non formulary drug and the foam is not covered, she also informed that apart from foam there are alternatives like cream and solution which are covered so she will fax us the available list of alternatives at ***-***-****.
In Process
Pharmacy Status
Pharmacy Name Pharmacy Ph # Auth Status Informed Date of communication Comments Schedule Delivery Date
CVS Phone 1 No
Rite Aid Phone 2 No
Walgreens Phone 3 No
CVS Phone 4 Yes 8/29/2016 S/w John, informed about the approval
CVS Phone 5 Yes 8/29/2016 S/w Vivian, informed about the non-coverage
SAMPLE REPORT #3 (Prior Auth for Medication)
16Sun Knowledge © 2015-16 Private & Confidential
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 (Prior Auth for Medication)
17Sun Knowledge © 2015-16 Private & Confidential
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
18Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
MEETING CHALLENGES WITH EFFECTIVE RESPONSE
CHALLENGES & OUR APPROACH
19Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
CHALLENGES & OUR APPROACH
20Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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
CHALLENGES & OUR APPROACH
21Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
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 efficiency
Process 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
SUMMARY OF BENEFITS
22Sun Knowledge © 2015-16 Private & Confidential
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
• High billing & coding accuracy; 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
OUR HIPAA COMPLIANCE SUMMARY
23Sun Knowledge © 2015-16 Private & Confidential
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
24Sun Knowledge © 2015-16 Private & Confidential
41 Madison Avenue, 25th Floor, New York, NY 10010, USA
TESTIMONIALS
CLIENTSPEAK
25Sun Knowledge © 2015-16 Private & Confidential
“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
26Sun 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
27Sun Knowledge © 2015-16 Private & Confidential
“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