Medical Billing and Collection
• CORPORATE OVERVIEW
• India BPO Advantage
• About Scandent
• Corporate Structure-IR/PM/SN
• WHY SCANDENT?
• Medical Billing & Collections Value Proposition
• Quality Management
• Infrastructure, Facilities & Data Security
• Scalability
• HIPAA AND REGULATORY COMPLIANCE
• HOW WE WORK WITH YOU
Contents
• CORPORATE OVERVIEW
• India BPO Advantage
• About Scandent
• Corporate Structure-IR/PM/SN
• WHY SCANDENT?
• Medical Billing & Collections Value Proposition
• Quality Management
• Infrastructure, Facilities & Data Security
• Scalability
• HIPAA AND REGULATORY COMPLIANCE
• HOW WE WORK WITH YOU
Contents
4
Advantages of a Global Services Delivery Model
§ Deep Domain ExpertiseHealthcare is a complicated industry witharcane methodologies, mentalities andregulations. This requires a player withdeep domain expertise to navigatesuccessfully
§ Customer ServiceIntense customer service is required andcan be delivered only by a US basedcustomer oriented client service team
§ Perception of DependabilityUse of a US client service team creates theperception of dependability that is criticalin the healthcare sector
United States India
Provides for clear value creation on operating margins, speed of operationalscalability and rigor of service levels to customer base
§ World Class Labor Pool2nd largest English speaking labor pool
Cost of labor ~ 1/10th of US
Largest tech pool in the world
6 million graduates seeking work annually
§ Significant Cost SavingsCompanies save 40-50% of labor costs bymoving work to India
Allows up to 2X the profit margins of similarservice US plays
Savings may grow as India telecom costscontinue to drop
§ Foreign Export Friendly Govt.Technology and global services enablinggovernment policies
Extended 10 year tax holidays
Strong local investments into infrastructuresupport
5
§ Business Process Outsourcing (BPO) is migration of Critical but non-core
activities of business to a 3rd party provider
§ Standardised,centralised and high volume transactions with defined service
levels are ideal for BPO
§ Some examples are:
ü Policy and Claims administration
ü Accounts reconciliation
ü Billing and Collection- coding, charge entry, payment posting, A/R Follow up
ü Web services (email response, co-browsing, etc.)
ü Transaction processing
ü Transcription/Translation services
ü Call center
What is Business Process Outsourcing (BPO)?
6
BPO Solution componentsIncludes…
7
Major reasons for outsourcing
1%
4%
10%
13%
36%
36%
0 5 10 15 20 25 30 35 40
Conserve capital
Foster innovation
Increase speed to market
Improved quality
Focus on core competence
Cost reduction
Source: The 2001 world summit, Michael F.Corbett & Associates
Reasons companies use BPO
8
Distinct Advantages of BusinessProcess Outsourcing
• Move non-core cost center off P&L and Balance Sheet. Replace withlong-term outsourcing contract and/or equity participation.
• Monetize investment in back office operation. Receive stockpotentially worth more than if sold the back office operation whileretaining control of business.
• Reduce overhead costs. Re-deploy supervisory management tomore productive endeavors.
• Reduce capital costs. Obviates need to acquire/upgrade IS.
• Access to best practices and technologies.
• Ability to redirect Management Bandwidth to core businessactivities
Value to Clients
9
Services out of India now a major trend with globalbrand
• Global BPO industry is expected to grow to US $301 billion in 2004(source :
Gartner-Dataquest)
• India share (for global customers) estimated at a revenue of US $ 8.9 billion by
2004
• The share of India growing from 2% in 1999 to 12% of global IT enabled
services market - 64% CAGR
• Growing skills in working with sophisticated process tools like six sigma,
kaizan, etc.
• Over 50% of SEI CMM level 5 entities world wide out of India
• 266 of Fortune 1000 companies have outsourced mission critical
software related functions to India
• Strong support of Central and State Governments
10
Scandent Network is an operating company chartered to build cross border servicebusinesses by providing off shore delivery platforms to enable innovative servicesolutions for global markets.
Company was originated by the senior professionals who helped build the captiveOutsourcing businesses for GE, Pepsi, SAP, Motorola and Microsoft in India. They are nowaligned with a Board of seasoned and very successful multinational executives andinvestors.
q Investors :
Ø Edgar Bronfman Family Trust (Seagram Universal)
Ø Comcraft Group (Global Businesses with $3B sales)
q Board Representatives and Executive Team :
Ø Chairman of the Board – Chris Sinclair (ex Chairman and CEO of the Pepsi-Cola Co )
Ø Globally experienced Multi National Executives from GE, Microsoft, Pepsi, Nike and SAP
Ø Ramesh Vangal – Chairman ScandentNetwork, Chairman Seagrams Asia Pacific, FormerChairman PepsiCola Asia Pacific and CEO PepsiCola India
Ø Kannan Ramasamy – CEO ScandentNetwork, former CEO GE Capital Indiia
About ScandentNetwork
11
Technology and information services
HealthCare
InsuranceFinancialServices
Corporate Structure
Business Process Outsourcing
• CORPORATE OVERVIEW
• India BPO Advantage
• About Scandent
• Corporate Structure
• WHY ProcessMind?
• Medical Billing & Collections Value Proposition
• Quality Management
• Infrastructure, Facilities & Data Security
• Scalability
• HIPAA AND REGULATORY COMPLIANCE
• HOW WE WORK WITH YOU
Contents
13
Medical Billing, Collections and A/R management
ProcessMind has the Superior Value Proposition to Clients
Revenue Improvement
Cost Savings
Data Analytics
Encapsulation of Intellectual Capital: practice/payorexperience, payor rules enable reduction in denials
Labor Economics: enable better follow up of denied andunderpaid claims
Risk Based Pricing: cost reduction for meeting historicalcollection rates with success fee upside
Process Re-Engineering: standardization andsimplification of provider processes
Clinical Analytics: analysis and reporting on patientsegmentation for risk sharing and clinical usage.
Performance Analytics: analysis and reporting on keyfinancial, operational and payor indices for best practiceoperations
14
Revenue Enhancement Value Tree – Medical Billing
Benefit toClient
Reduced cost inbilling and recordsmanagement
Increased patientthroughput
Increase physicianproductivity
Reduce excessworking capital costs
Reduce records storagecost
Reduce billing system costs
15
Service Offerings
EligibilityVerification
ClaimsTransmission
CUSTOMERSERVICE
AccountsReceivable
Management
CPT/ ICD-9 Coding
Demographic &Charge Entry
PaymentPosting
Patient Follow-up
Insurance Follow-up
16
Service Offerings – Contd.,
Diagnosis Coding
Procedural coding
Modifier Coding
CODING
Demo &
Charge Entry
Eligibility Verification
Incompletes
Charts Tracking
CHARGE ENTRY
Posting Denials
Posting Payments
Claims Transmission
PAYMENT POSTING
Receivable Process
Denial Analysis
Appeals Process
AR MANAGEMENT
Account Balance
Verification
Handling Statement Enquiries
Update Coverage
Information
CUSTOMER SERVICE
Insurance Follow-up
Patient Follow-up
17
Coding- Value Proposition
Current Offerings
International Classification of Diseases codes released by the WHO- ICD-9CM &ICD 10 .
Current Procedural Terminology (CPT) codes released by the AMA-Americanmedical association.
Modifier Coding and External Cause coding using the E-codes.
Compliance Edit for every report we code to minimize denials, using the updatedLMRP’s (Local Medical revenue policies).
Team
Team of 5 coders certified from American Academy for Professional Coders(AAPC)
Experience in coding different modalities like:
Interventional Radiology, Surgery, Radiology, Emergency Room, SurgicalPathology
Compliance
The team updates itself regularly onLocal Medical Revenue Policies (LMRP) of different states in the USAmerican Medical Associates (AMA) Coding guidelinesCompliance issuesOIG Alerts
18
Current Offerings - Coding
We code in compliance to the coding guidelines released by theAMA and WHO using:
• Current Procedural Terminology (CPT) codes released by theAMA-American medical association
• International Classification of Diseases codes released by theWHO- ICD-9CM & ICD 10
• Modifier Coding and External Cause coding using the E-codes
19
Compliance
We perform Compliance Edit for every report coded to minimizedenials, using the updated LMRP’s (Local Medical revenuepolicies).
The team is regularly updated on:
• Local Medical Revenue Policies (LMRP) of different states inthe US
• American Medical Association (AMA) Coding guidelines
• Compliance issues
• OIG Alerts
20
AR Analysis
• Aged AR Analysis
• Denial Analysis
• Review of duplicate payments
• Monitoring changes in plan
• Tracking billing and payment patterns
• Demographic Issues, Upcoding, Unbundling, and Physician Profiling
21
AR Analysis and Follow-up - Workflow
• Set collection targets for the month
• Develop strategies to achieve the target
• Identify and review claims that are unpaidor inappropriately paid
• Speedy and corrective action on denials
• Effective follow-up with theinsurance/patient
22
Services notcovered
Duplicate claim
Bundled /inappropriatecode
Misseddeadlines
Outright denials
Missingdocumentation
Missing referral
Missing authorization
Patient not in plan
Improper place of service
Modifier not available
Wrong payor
An analysis of denial EOBs indicate the reasons for the “outright” denials.
CAUSES
•Lost claims•Payor error (checknever sent, etc)
•Services not covered•Patient not in plan•Wrong payor•Missed deadlines•Missing pre-authorization•Missing referral•Missing documentation
•Bundled / inappropriatecode•Modifier not available
SOLUTIONS
Follow up on every claim
•Improve patient registration process•Rapid response: Create initial /appeal claims within 2 days ofservice or denial. Notify of missingpre-auths/referals immediately•Provide specific feed-back tophysicians about need for pre-authsand documentation
•Use rules engine to identify:•Appropriate codes andmodifiers•“Improper place of service
3rd Party Denials
23
• “One Blue Cross / Blue Shield plan in the Northeast now offers morethan 5000 different benefit designs, each with its own pre-certification, pre-authorization and eligibility rules”
CodeCorrect press release 11 / 14 / 2000
• United Healthcare requirements in Texas• Medical records much be attached for 258 separate codes• Medical records must be attached for certain CPT code modifiers, such
as surgery and anesthesia
• Golden Rule Insurance requirements in Texas• Medical records must be attached for 6 specific conditions, including
“maternity (except routine)” and “schlerotherapy (exceptspiderveins)”
• Medical records for all claims during the first two years of a patient’sservice
• “MedUnite claims that 50% of claims contain mistakes, 80% of which arebecause the claim lacks one of the basic pieces of data on the billing form.”
AM News, Clean claim rules …12 / 4 / 2000
Another reason for the many mistakes are the complex and ever changing rules imposed by thepayors. Learning and applying all these rules consistently is beyond normal human capacity
Claims Rejections: Payor Driven Complexity
24
20
19
4
100
2
33
3
Most of the reasons for claims rejection are simple human data entry mistakes which are impossible tosolve without the help of technology
THE REASON?Claims Rejections: Provider Driven Administrative
Source: MGMA
9
Percent 10
Incompletepatientdemographicinformation
Incomplete orinaccuratediagnosticcode
Invalidaddress
Patientnotcoveredunderinsurance plan
HFCAForm1500containstoomanycodes
Filingclaimswithzerototals
IncompleteMedicare /Medicaidsubscribercodes
OtherTotal
25
Metrics SamplePareto Analysis for Error distribution
CE-Error Distribution Chart-Jul-2003
177
144
6256
48
34
20 19 167
30.4
55.1
65.7
75.3
83.5
89.492.8
96.198.8 100.0
0
20
40
60
80
100
120
140
160
180
200
P10 P6 P1 P7 P8 P5 P2 P3 P4 P9
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Occurrence Cumulative
26
Revenue Collection Process
Superbill andencounter formare deliveredfromreceptionist
Claim is createdand electronicclaims are tested,then redone
Claim isreviewedby payor
EOB isgeneratedand returned
If claim is paid,updatedatabase,adjustreimbursement
2. Handoff chartcharge capture toclaims creation &submission
1. Handoff caredelivery staff toback office
3. Handoffprovider topayor
4. Handoffpayor topaymentpostings
5. Handoffpaymentposting tocollections
Charge sheetsare separated
intoacceptableand wrong*
Claims aremanually keyed
Request foradditionalinformation
Claims submitted
•80% electronic
•20% manual
EOB isexaminedagainst payorcontract
If claim isrejected,enter intosystem
New claim isgeneratedandsubmitted
Key Issues:
Incorrect / problemclaims not discovereduntil at payor
Limited learning, e.g.,same mistake morethan once
2 month delay infollowing up ondenials
System inability totrack and escalate
*identified opportunistically by experienced charge entry personnel
27
Follow up-Underpaid & Denied Claims
Nu
mb
er
of
cla
ims
Claims size
63864
16827
2191 915 552
7301
0
10000
20000
30000
40000
50000
60000
70000
< $100 $101 - $200 $201 - $300 $301 - $400 $400 - $500 $501 +
29%37%
2% 3%5%
23%
< $100
> $501
$201 -$300
$101 -$200
$301 -$400
$401 -$500
Total Charges = $2.7mm
§ Given average collection rates of 40%, total collections on these claims is smalland unlikely to be followed up on if denied or underpaid.
28
AR Follow-up – Insurance & Patient
• Accounts Receivables Follow-up- Follow-up with insurance companies on Pending & Denied
claims
- Follow-up with hospitals for additional information
- Follow-up with EDI for electronic claims transmission
- Follow-up with provider office for provider enrollment issues
- Eligibility Verification
• Patient Follow-up- Soft collections
- Setting patients on budget plan
- Accept payment by phone
29
Customer Service
• Customer service (Inbound Contact Center)
- Handling statement enquiries
- General account verification from patients, insurance co’s,
provider’s office, Hospital & Attorney’s office
- Update insurance coverage information
- Accept payment by phone
30
• Full analysis is practiced on denials to understand rejection and denial patterns inorder to develop client experiential based technical rules that are then incorporatedinto the Claims Scrubbing Engine (e.g., all codes X for Payor Y require a letter ofmedical necessity).
• Full analysis and follow-up is practiced on all payor specific rules updates todevelop technical rules for the Scrubbing Engine.
•All learnings are captured and systematically shared across an individual practice,
•The Scandent billing advantage is the ability to allocate a significant amount of laborresources to claims creation and follow-up. All claims receive follow-up phone callsand review to insurance companies regardless of face value.
• All secondary claims are submitted. Scandent follows up on all third party as wellas patient funds owed which are traditionally a large component of write off revenuefor any group practice.
• All payment postings are compared against payor contracts for validity. If theamount is not as per the fee schedule, collections processes will be initiated tocollect the leftover amount, regardless of the missing dollar size. This amount wouldotherwise have been written off by most payments posting departments due to theinability of their software systems to track to this minute a level
• The billing system is AS400 based with the capability for system wide proactiveescalation, denials tracking and extensive management reporting
Experiential and Payor Specific Rules Database
Payor Fee Schedule Payment Measurement
100% Claims Follow-up
Intelligent BillingSystems
Billing & Collections Value Proposition
31
Training
• Various levels of training
• Basic Level – includes induction training 40 hrs
• Software driven
• Training on updates (continuous process)
• Mock call sessions (AR Follow-up & Customer service)
• Other trainings
• Accent Enhancement & Neutralization training for CSR’s
• Cross functional training
• We use various tools like CBT, Handouts & SupportingSoftware's
32
Current Project Stats30# of physician groups handled
$1,800,000.00Average collection
4.5 / 5.0Customer Satisfaction Index
Chart production
CodingCharge Entry
Tracking IncompletesPayment posting
AR Analysis & Follow-up,Collections
Customer service
Functions handled
$4,200,000.00Average value of charges
22000Total # of charts entered
280# of Physicians
33
Specialties Handled
• Radiology
• Interventional Radiology
• Surgery
• Emergency medicine
• Surgical Pathology
• Pathology
• Anesthesiology
• Otology
• Neurology
• Physical therapy
• Internal medicine
We handle various specialties for 30 hospitals and physician groups acrossUSA, which include
34
The Teamq The team has total experience of over 4 years in servicing the
providers network of US
q The team has worked on diverse medical billing software likeMedisoft, Medic+, Medic manager and Kredo
q The team members have certification from Brain Bench for medicalbilling and collections & HIPAA
q Certified coders from American Academy for Professional Coders(AAPC)
q Physicians with coding expertise
q Experience in handling diverse specialties
q Call center executives in the AR Follow-up and Customer Service teamare professional and well qualified
q Follow-up team trained on American Accent & Culture
q The team is process oriented and have obtained training in qualitystandards such as ISO, COPC & CMM
35
Benefits
• Accelerated Cash flow
• Coding recommendations for maximized reimbursement
• Provide highest level of Quality Services
• More effective use of highly trained staff
• 24/7 account management
• Proactive follow-up
36
ProcessMind – Team Strength
MeetHIPAA
Guidelines
ContinualTraining
ProcessKnowledge
Healthcare Experience
Strengths
37
Achievements
• Migrated the project in a short span of time i.e., 25 days
• Excellent quality maintained across all functions i.e., over 99%
• Implemented paper-free processing methodology
• Identified and solved pending issues which contributed to the
increase in collections
• Improved Customer Satisfaction Index from 3.0 to 4.5 on a
scale of 5.0 in a span of six months
• CORPORATE OVERVIEW
• India BPO Advantage
• About Scandent
• Corporate Structure-IR/PM/SN
• WHY SCANDENT?
• Medical Billing & Collections Value Proposition
• Quality Management
• Infrastructure, Facilities & Data Security
• Scalability
• HIPAA AND REGULATORY COMPLIANCE
• HOW WE WORK WITH YOU
Contents
• CORPORATE OVERVIEW
• India BPO Advantage
• About Scandent
• Corporate Structure-IR/PM/SN
• WHY SCANDENT?
• Medical Billing & Collections Value Proposition
• Quality Management
• Infrastructure, Facilities & Data Security
• Scalability
• HIPAA AND REGULATORY COMPLIANCE
• HOW WE WORK WITH YOU
Contents
40
Billing Solution
•Testsagainstproprietaryrules engine
•Biller retrievesinfo from recordsdb•Creates claim
•Updates rules engine•Resubmits claim or appeal
EOBsent
•Checks againstpayor contract•Posts
The combination of specialized human knowledge andtechnology commonly achieves 98% clean claims withcollections of 80% of expected value on first pass throughwith significant revenue growth, and reduced DSOs for thecustomers
Defectiveclaims
Aggressivelyfollows up onevery claim
Cleanclaims
Topayor
Denials / inforequests
Claim paid
•Cash to customer
•Front office clinicoperations collectscharges entry fromphysician(electronic orpaper)
41
ProcessMind basic value proposition is to addressmajor issues in the healthcare administrative backoffice without altering physician workflow eitherduring implementation or ongoing operations
… Value Proposition
• We work with our clients to remain as workflow compliant as possiblewith medical and administrative staff operating workflows
•We understand the dramatic cost pressures our clients face every daydue to the rapidly evolving healthcare marketplace and therefore havestructured our pricing to include little to no start up investment costs
•Scandent delivers high impact solutions emphasizing cash flow,management control and client satisfaction through cutting edgetechnology and operational optimization
•Most of all, what differentiates Scandent is our commitment to resultsthrough the complete alignment of our team’s incentives with yours bytaking substantial performance based revenue risk
Low start upinvestment
Risk BasedPricing
High ImpactSolutions
WorkflowCompliance
42
Cost Savings
55
15
30
14
20
20
0
20
40
60
80
100
%
In-house outsourced
Employee Technology & Communication Other costsSource : McKinsey & Co., Edweiss
43
Performance AnalyticsProcessMind dedicates a practice analyst to provide the in depth key indicator reporting and comparativeanalysis critical for best practice management
• Physician Financials: Tracking by individual physician and across allphysicians of charges, collections, denials, DSOs, patient mix, topprocedure codes• Snapshot daily, monthly, quarterly financial reports, cash flow tracking,current, charges, future expected• Shortfall and write-off rationale reporting• Aged accounts receivables reporting
• Service analysis measurement by physician of number of patients perday, average charges per patient, average bundle of services per patient• Service analysis measurement across practice with comparables overtime• Patient volume by facility by financial class• Compliance alerts
• Tracking of net cash expected for each month’s charges, collections,DSOs, % of re-filed claims by insurance company
• Maximum procedure payment by insurance company across thepractice
Key Financial Metrics
Key Operational Metrics
Payor Contract Management
• CORPORATE OVERVIEW
• India BPO Advantage
• About Scandent
• Corporate Structure-IR/PM/SN
• WHY SCANDENT?
• Medical Billing & Collections Value Proposition
• Quality Management
• Infrastructure, Facilities & Data Security
• Scalability
• HIPAA AND REGULATORY COMPLIANCE
• HOW WE WORK WITH YOU
Contents
QPresentation on Quality
46
Purpose
to appraise about• our customer care programs• our quality services
47
Total Quality
Quality checkDefect controlQuality improvement
ProcessDefect preventionInternal quality auditProcess Improvement
Quality assurance Quality control
Process Quality Product/service Quality
48
Our principles
• Quality is• accuracy• on-time delivery• performance• process compliance
• Customer satisfaction• Information security- compliance• Managed event• Improvement• Consistent, reliable service
49
Quality
Quality
Quality Control Quality Assurance
MetricsKnowledge
50
Quality
Quality
Quality Control Quality Assurance
MetricsKnowledge
51
Documentation structure
Quality Policy
Quality Manual
Processes
Guidelines
Forms
Checklists
Templates
Master List
Log Register
52
What our group does?
• Represents customer• Do everything a customer would do
• Set benchmark• In house and international
• Develop processes• Process consultancy
• Represents management• Report the quality health of projects
53
Quality policy
“ProcessMind, a process driven organization,will achieve customer satisfaction by
complying to standards and requirements,ensuring delivery of cost effective productsand services. We maintain an environmentthat encourages continual improvement of
processes”
54
Our Goals
55
End to end process
• Seamless transitionThrough
• Project transition• Process definition• Process mapping• Process training• Process documentation• Operations• Deliveries
56
Identify The Prospective Customer
Go/ No-Go
Proposal
TerminateEngagement
Security AndDisaster Recovery Plan
Pilot Training India Team Setup Technology Track
Define Security Requirements& Disaster Recovery Plan
Deploy Pilot Team ForTraining
Recruit First Team InIndia
Visit Of Systems Team ToEach Other’s Sites
Design Security Infrastructure Pilot Team TrainingProcess Live Cases
Induction Training Design Systems AndConnectivity Solutions
Implement security infrastructureand DRP
Pilot team returns to India leavingbehind one coordinator
Pilot team conductsOperations training
Implement systems andconnectivity solutions
Contract
Project Initiation
Project Management Plan
Feasibility Study And Core Team OnsiteAnalysis
Live Processing
Project Closure
57
Internal quality audits
• Process compliance verification across thecompany• Projects• Support departments• As per standard ISO 10011
• Trained independent group• Identification of non conformances• Detection of process lapses and
improvement
58
Change management
• Change management process
• Any changes are controlled• Changes are reviewed before acceptance
• Changes are communicated across the group
• Changes are monitored additionally for maturity
• Changes are always through documentation• Change Control Board
• A set of people who review the changes required and approve
• Change Log• Changes are always logged for history
• Changes are tracked
• Change audits• Quality audits include change status
• Change management tool – VSS
59
Quality control
Service Quality
Quality Control Quality Assurance
MetricsKnowledge
60
Quality checks• On-line quality checks (verifications)
• Demographics entry (registration, changes)• Charge entry• Claims filing• Cash posting• AR analysis and follow up
• Independent check personnel
• A QC per 10-12 CSRs
• Sampling criteria based on severity and status•• Rework before delivery
• Metrics collection
61
Quality organization
Project Manager
Quality coordinator
Quality rep
Quality manager
TC
CSR/IA
TL
62
Quality roles
• Quality rep• On line QC• Reporting defects• Re checks• Case clearance
• QC• Quality supervision• Metrics collection• Process consultancy• Reviews with PM and
Quality
• TC & TLs• Defect removal• Periodic team reviews• Preventive actions
• PM• Defect elimination• Project reviews• Preventive actions
63
Reviews
• Team reviews
• Project reviews
• Management reviews
• Client reviews
64
Feedback
• Customer feedback
• Customer complaints
• Customer satisfaction survey
65
Metrics
Quality
Quality Control Quality Assurance
MetricsKnowledge
66
Metrics
• Organization specific
• Mandatory for all projects
• SLA specific
• Project specific
67
P-Q metrics
• Production
• Productivity
• Efficiency
• Volume
• Trend
• Level
• Backlog
• Amount collected (cc)
• Yield rate (cc)
• Abandonment (cc)
• Quality
• First time pass yield
• Accuracy
• Time (cycle and on)
• Verification effort
• Trend
• Level
• Call quality (voice)
• Compliance to law
68
Dash board concept
• Dashboard a tool for driving• Monitoring available to managers
69
Quality improvement
• Metrics collection across projects
• Analysis
• Identification of areas of improvement
• Improvement
• Plan
• Team assignment
• Implementation
• Process change
70
Knowledge
Quality
Quality Control Quality Assurance
MetricsKnowledge
71
Knowledge
• No process, control or metrics can work withoutknowledge
• The important function in quality management
• Creation of knowledge bank
• Knowledge is shared across the organization
• Program wise
• Company wise
• Quality wise
• Information is shared in the drives under programs
72
Processes
73
Processes
74
Total quality
Quality
Quality Control Quality Assurance
MetricsKnowledge
75
ProcessQuality
Metrics
Improvement
• CORPORATE OVERVIEW
• India BPO Advantage
• About Scandent
• Corporate Structure-IR/PM/SN
• WHY SCANDENT?
• Medical Billing & Collections Value Proposition
• Quality Management
• Infrastructure, Facilities & Data Security
• Scalability
• HIPAA AND REGULATORY COMPLIANCE
• HOW WE WORK WITH YOU
Contents
77
The campus
• Centrally air conditioned independentmodular office to seat 700 employees ina single shift 1000 KVA state power
• State power backed up through diesel generators
• All computing and communication equipments poweredthrough UPS running in parallel redundancy mode
• In-house cafeteria, vehicle parking and other facilities
• Fully equipped auditorium with audio and videoconferencing
• Fully equipped training rooms for in-house training
• State of art access control system
• Security managed by Group 4 security
78
The campus
• 256k Internet link
• Two dedicated international lease lines through redundant routes
• Additional building with 400 seats capacity can be added in 6-8months in the same campus
• State of art communication equipment• CCTV provision
79
Redundancy
Satellite
TAT
TPATPA
Bangalore
New Jersey
80
Physical Connectivity
ProcessMind
Indianapolis
FrameRelay
Clients
Newport FinancialCenter
New Jersey
USA END
ProcessMindIndia
Koramangala
Bangalore
ProcessMind IndiaChennai
ProcessMind India
STPI
Bangalore
Fiber (Atlantic)
Fiber (Pacific)
E1 Fiber
E1 Fiber
Satellite
INDIA END
E1 Fiber
81
Physical Connectivity
Clients
Newport Financial Center
New Jersey
USA END
ProcessMindKoramangala
Bangalore
ProcessMindChennai
ProcessMind STPIBangalore
Fiber (Atlantic)
Fiber (Pacific)
E1 Fiber
E1 Fiber
Satellite
E1 PRI for Homeusers connectivity
Home User
SatelliteLink
ProcessMindIndianapolis
INDIA END
INTERNET
Frame relay
PSTN
PSTN
82
Features of our Voice and Data Network
• New technology standard for voice
• Centralized call processing deployment model
• Single Administrator to maintain voice and data network
• Digital IP phones
• Location Independent
• Extension Mobility assists in disaster recovery by allowing
employees to take calls at home or anywhere on the network
83
Physical security
• Access control• All entry and exit doors controlled by access
control system• Access to server room and other sensitive areas restricted
• Visitors• All visitors are required to declare personal belongings such as
cell phones, pagers, lap tops, CDs, floppies etc. at the security• Employees need to authorize and escort any visitors inside the
office
• CCTV
• Burglar & Intruder alarm system
• Emergency Rescue Team (ERT)
84
Data security
• Internet & e-mail security• Can be used for official purpose
only• Built-in system to monitor usage
• Restrictions• All employees are forbidden from carrying any
magnetic media inside the office• No desktops have floppy and CD drives• Desktops will have bio-metric login devices• Scanned images – no papers required
• Access• All logins are secure logins with audit trail
85
Disaster Recovery Management Plan
• All electronic data is backed up in two sets
• One set of back-up tapes in the fire proof safe at office
• Second set of back-up tapes is stored off site
• An incubation facility, outskirts of the city is ready withstandby servers, data links etc. so that critical work can startwithout loosing any time
• Vendors who can hire out PCs and other equipmentsat short notice have been identified
86
Disaster Recovery Management Plan
• Employees with home PCs will be asked to work from home incase of emergency
• Key employees are provided with high-speed net connection athome
• Critical operations will be shifted over to the unaffected units
• In case of civil disturbance, employees will be asked to report tothe nearest work place and operate
n CORPORATE OVERVIEW
Ø India BPO Advantage
Ø About Scandent
Ø Corporate Structure-IR/PM/SN
n WHY SCANDENT?
Ø Medical Billing & Collections Value Proposition
Ø Quality Management
Ø Infrastructure, Facilities & Data Security
Ø Scalability
n HIPAA AND REGULATORY COMPLIANCE
n HOW WE WORK WITH YOU
Contents
88
Scalability
• Management Team
• Capital
• Process Management
• Resources of a Corporate
• Communication
n CORPORATE OVERVIEW
Ø India BPO Advantage
Ø About Scandent
Ø Corporate Structure-IR/PM/SN
n WHY SCANDENT?
Ø Medical Billing & Collections Value Proposition
Ø Quality Management
Ø Infrastructure, Facilities & Data Security
Ø Scalability
n HIPAA AND REGULATORY COMPLIANCE
n HOW WE WORK WITH YOU
Contents
90
Health Insurance Portabilityand Accountability Act
(HIPAA)
91
Briefing Objectives
• Provide an overview to the key elements of HIPAA
• Outline key principles to achieve timely HIPAAcompliance
• Discuss key elements of our HIPAA compliancestrategy
92
Why was HIPAA enacted ?
• Assure portability of Health Insurance
• Decrease healthcare fraud and abuse
• Improve efficiency and effectiveness of healthcare
• Enforce standards
• Guarantee security and privacy of Health Information
93
Who is affected?
• Health care providers• Employers• Public Health Authorities• Insurers• Clearinghouses• Billing Agencies• Vendors & Business Associates (Outsourcing Agencies like MBCs, Claim
Processing Units, Call Centres etc.)• TPAs
94
95
HIPAA – Titles
• Title 1 - Guarantees access, portability and insurability of healthinsurance.
• Title 2 – Preventing Health Care Fraud & Abuse• Fraud & Abuse Control• Administrative Simplification• Medical Liability Reform
• Title 3 – Tax related health provisions for Medical Savings Account.
• Title 4 – Application and enforcement of group health planrequirements.
• Title 5 – revenue offset provisions.
96
Title II – Administrative Simplification
GOALS:
- Guarantee security and privacy of health information
- Enforce standards for health information andtransactions
- Reduce the cost of healthcare by standardising theway the industry communicated information
97
Proposed Standards
• Electronic Transaction Standards
• Standard Code sets
• Unique Health Identifier
• Security Standards
• Privacy
98
Electronic Transaction Standard
EDI standards accepted by HIPAA
- Claims/Encounter, Eligibility verification,enrollment and related transactions: ANSI X12N
- Pharmacy transactions : NCPDPTelecommunication Claim Version 5.1 or NCPDPBatch Standard Version 1.0
99
Standard Code Sets
Code set standards defined
• ICD-9-CM volumes 1,2 and 3
• Physician CPT-4 which are HCPCS level 1
• HCPCS level-2
• NDC for prescription drugs
• CDT-2 for dental services
100
Unique Health identifier
• National Provider Identifier
• Employer Identifier
• National Health Plan ID
• Patient Identifier
101
Security Standards
• To protect confidentiality and availability of healthcareinformation• Administrative procedures• Physical Safeguards• Technical Security mechanisms & services
• Electronic Signature Standard
102
Administrative procedures
• Purpose is to guard data integrity, confidentiality andavailability.
• Are documented formal procedures for selecting andexecuting information security measures.
• Also addresses staff responsibilities for protectingdata
103
Physical safeguards
• To protect physical computer systems, buildings andequipments from fire, and other environmentalhazards as well as intrusions
104
Technical Security Mechanism &Services
• Processes used to prevent unauthorized access todata transmitted over a communications network
• Processes used to protect, control and monitorinformation access.
105
Electronic Signature Standards
“Electronic Signature” means an electronic sound,symbol, or process attached to or logically associatedwith an electronic acquisition or contract record andexecuted or adopted by an authorized person withthe intent to sign the acquisition or contract record.
(http://www.epa.gov/oam/ptod/ppn00-02.pdf)
Contd..
106
Electronic Signature Standards contd..
• The following three implementation features must beimplemented:
• Message integrity
• Non repudiation
• User authentication
107
Privacy
Privacy regulation addresses the following:
• Consumer control
• Accountability
• Public responsibility
• Boundaries
• Security
108
Key steps to achieve compliance..
• Step 1- Education and Awareness
• Step 2- Assessment and Planning
• Step 3- Compliance
• Step 4- Assurance
• Step 5- Periodic follow-up Audit & Assessment
109
HIPAA Compliance Timetable
2000 2001 2002 2003
Education and Awareness
Assessment
Compliance
Assurance
Follow-up Audit and Assessment
110
Compliance steps
Human Resource and general
Information System
Operations
1114.8.3.3 Digital Signatures4.8.3.4 Non-repudiation
Electronic Signatures- Digital Signatures5
4.4.3 Responding to security incidents and malfunctions4.6.5 Network Management4.6.7 Exchanges of Information & Software4.7.4 Network Access Control4.7.5 Operating System Access Control
Electronic Transmission- Communication & NetworkControls4
4.4 Personnel Security4.5 Physical & Environmental Security4.6.6 Media Handling & Security
Physical Data Security- Physical Access Control- Media- Secure workstation use &availability3
4.7 Access Control4.8 System Development & Maintenance
Technical Security- Access Control- Audit Control- Authorization Control- Entity authentication2
3.6 Records4.1 Security Policy4.2 Security Organization4.4 Personnel Security4.5 Physical & Environmental Security4.6 Communications & Operations management
Administrative Security- Contingency Plan- Information Access Control- Security Management Process1
ISO17799HIPAASl. No
Comparison of proposed HIPAA security requirementswith ISO17799
112
HR and General
• Designated a Chief Privacy Officer and ComplianceOfficer
• Assign responsibility for tracking progress ofregulations
• GAP analysis of existing policies compared toproposed standards
• Outline employee responsibilities for protecting theconfidentiality of health information in the employeehandbook.
113
Information Systems
• Familiarity with Information Security Standards andStandards Development Organizations
• Identify existing organizational structures to aiddevelopment and implementation of an informationsecurity program
• Familiarize the organization and employees withnew and emerging information security technologies
n CORPORATE OVERVIEW
Ø India BPO Advantage
Ø About Scandent
Ø Corporate Structure-IR/PM/SN
n WHY SCANDENT?
Ø Medical Billing & Collections Value Proposition
Ø Quality Management
Ø Infrastructure, Facilities & Data Security
Ø Scalability
n HIPAA AND REGULATORY COMPLIANCE
n HOW WE WORK WITH YOU
Contents
115
How We Work With You
• What to Expect- Process & Methodologies
• Account Management- Communication and Levels ofInteraction
• Reporting and Access
• Exchange of Information/ Change Management
• Escalation
116
Identify The Prospective Customer
Go/ No-Go
Proposal
TerminateEngagement
Security AndDisaster Recovery Plan
Pilot Training India Team Setup Technology Track
Define Security Requirements& Disaster Recovery Plan
Deploy Pilot Team ForTraining
Recruit First Team InIndia
Visit Of Systems Team ToEach Other’s Sites
Design Security Infrastructure Pilot Team TrainingProcess Live Cases
Induction Training Design Systems AndConnectivity Solutions
Implement security infrastructureand DRP
Pilot team returns to India leavingbehind one coordinator
Pilot team conductsOperations training
Implement systems andconnectivity solutions
Contract
Project Initiation
Project Management Plan
Feasibility Study And Core Team OnsiteAnalysis
Live Processing
Project Closure
Process
117
Account Management: Communication &Levels of Interaction
Onsite support group
Project Manager
Processor
Team Leader
Team Coordinator
Customer
Account Manager
3-Tier Process
• CorporateAccountManager
• OperationsManager
• 24/7-helpdesk andweb reporting
118
How We Work With You
• What to Expect- Process & Methodologies• Account Management- Communication and Levels of
Interaction• Reporting and Access• Exchange of Information/ Change Management• Escalation
119
Thank you
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