Practice Management & Claims Administration

PRACTICE MANAGEMENT
& CLAIMS ADMINISTRATION
CONTACT: RONNIE HASTINGS
(646) 661-7853
GoTelecare 41 Madison Avenue, 25th Floor, New York, NY 10010

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
 State-of-the-art 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
 Awarded ‘Best Emerging BPO Company of the year 2010’
by The Economic Times
 Recognized as one of the foremost ‘emerging companies'
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 on
3rd December 2015
Key Facts Awards, Affiliations & Certifications

Our Service Offerings
 Provider Support
 Member Support
 Member Retention Program
 Clinical Help Desk
Contact Center
 Utilization Management
 Medication Therapy Management
 Hospital Re-admission Management
 Therapeutic Interchange
 Formulary Management
Clinical Services
 Enrollment Processing & Member
Fulfillment
 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

REVENUE CYCLE
MANAGEMENT

Revenue Cycle Management Services
360°
Revenue
Cycle
Management
Services
Eligibility &
Authorization
Verification
Prior
Authorization
Billing
CodingScheduling
Payment
Posting
Accounts
Receivable

Revenue Cycle Management – Service Snippets
 Inpatient/Outpatient Hospital Coding
 Physician Coding
 Patient entry demographics & insurance information
 Fee Schedule / Charge Entry
 Scrubbing all entries for correctness and completeness with appropriate billing edits;
correction of identified errors
 Submission of claims to payers, e.g. EDI or paper
 Creation and mailing of patient statements
 Posting of payments received from patient and payer
 Reconciliation of charges, payments received and adjustments made
 Denial Management (understanding denials and making corrections)
 Resubmission of claims
 A/R calls as follow-up on outstanding issues
 Closure of a claim once the balance is zero
CODING
BILLING
A/R FOLLOW-UP

Revenue Cycle Management Experience
HOSPITAL
 Accounts
Receivable
Follow - Up
 Denial
Management
 Claims
Resubmission
DME
 Order Entry
 Eligibility
Verification/
Authorization
 Follow up on Auth
Approval
 Delivery
Scheduling
 Submission of
claim
 Rejection
Management
 Payment Posting
 A/R Follow-Up
 Denial
Management
 CPAP Compliance
Tracking
O&P
 Rx Order Entry
 Patient
Demographics
and Insurance
Entry
 Product Code
entry/Rx & Dx
Entry
 Eligibility
Verification/
Authorization
 Collection of
complete Rx
 Collection of
Documents for
Auth Approval
 Submission
 Rejection/Denial
Management
 A/R Follow-Up
URGENT CARE
 Order Entry –
Patient
Information,
Ordering
Physician, Rx &
Diagnosis
 Eligibility
Verification
 Medical
Document
Collection
 Authorization
Approval
 Order Audit
Confirmation
 Submission of
Claims
 Rejection
Management
 Payment Posting
 A/R Follow-Up
 Patient Entry:
Demographics &
Insurance
 Eligibility
Verification
 Authorization
Follow-Up
 Charge Entry
 Submission of
Claims
(EDI/Paper)
 Rejection
Management
 Payment Posting
 A/R Follow-Up
 Denial
Management
PHYSICIAN
 Patient Entry:
Demographics &
Insurance
 Charge Entry
 Submission of
Claims
(EDI/Paper)
 Rejection
Management
 Payment Posting
 A/R Follow-Up
 Denial
Management
HOME HEALTH

Areas of Operation
We provide turnkey billing & coding services in the following areas:
DME / HME Prosthetics & Orthotics Urgent Care
Pathology Critical Care Radiology
Internal Medicine EKG Compounding Pharmacies
Cardiology ENT Orthopedic Surgery
Anesthesia Family Practice Specialty Clinics
Rehab Centers Pharmacy Physicians, and more…

ELIGIBILITY &
AUTHORIZATION
VERIFICATION

 Full Range of Verification Services
 Fast 24-hour Turnaround Time
 Above 99.9% Accuracy
 Detailed Documentation
 100% HIPAA Compliance
 Experience with National and Private Carriers
Insurance Claim Eligibility Verification – Highlights

Insurance Claim Eligibility Verification
Eligibility check covers the following:
 Policy active for date of service
 DME coverage
 Copay / Coinsurance / OOP
 Rx & Dx entry
(with appropriate timeframe)
 Provider status (INN / OON)
 CSI check
 Authorization requirement
 Obtaining authorization
 Patient responsibility

Insurance Claim Authorization Verification
 Diligent follow-up till resolution and closure
 Uniform importance given to every account irrespective of size, age or claim value
 Fast completion of authorization process
 Periodic follow-ups to maintain authorization validity

Highlights
 360o operations support in medical benefit coverage
 Quick authorization process
 Detailed documentation
 100% HIPAA-HITECH compliance
 Experience in working with both Payers and Providers
 Highly accurate eligibility data maintenance (in sync with CMS)
 Excellent references from more than 7 years of successful operation

PRIOR AUTHORIZATION
SERVICES

Prior Authorization – Highlights
• Full Range Service Authorization Request Follow-up Approval
• 100% HIPAA-HITECH Compliance
• Low prices with no hidden cost
• Highly streamlined, fast and accurate service
• DME
• Hospitalization
• Outpatient Surgery requiring general anesthesia
• Skilled Nursing
• Organ, Bone Marrow, Stem Cell Transplants and other similar procedures
• Inpatient rehabilitation – Treatment for alcohol or drug abuse
• Other conditions
We cater to

Sample Reports
0
20
40
60
80
100
120
140
96
83
94
98
96
29
11
6
31
32
125
94
100
129
128
41
32
26
30
28
ELIGIBILITY VERIFICATION
Number of New Patient Patient Brought Forward
Primary Checked Secondary Checked (if applicable)
0
5
10
15
20
25
30
35
40
45
50
45
25
38
44
46
20
15
26
22 21
25
10
12
22
25
AUTHORIZATION
Auth Required Auth Obtained Auth Pending

MEDICAL CODING
SERVICES

Coding Services – Overview
Service Offerings
Medical Coding
• Place of Service Based Coding – Inpatient, Outpatient Coding
• Provider Specialty Based Coding– E/M, Cardiology, Orthopedics, Physical Medicine etc.
GoTelecare handles medical coding - promptly, perfectly and professionally –
using Kareo® or other billing systems as preferred by the client.
• Review medical notes and clinical documents
• Assign ICD-10 codes for the diagnosis identified by the physician and Procedure codes (CPT/ ICD 10 PCS)
• Assign modifiers as applicable
• Code review and quality assurance
• Communication with Physician’s office for additional medical documentation and clarification
Key Tasks

Coding – Key Facts
• Our coders deliver error-free charge sheets within agreed TAT provided by the
client
• We monitor, analyze and improve coding
documentation to avoid denials and
guarantee reimbursements
• We carefully determine the codes according
to the clinical information provided by the
Healthcare Provider/Professionals and report
back accordingly
• Our coders have undergone extensive medical coding training and are well aware
of updated coding guidelines
• All our coders are ICD-10 certified (CPC)

Coding – Sample Production Report
Weekly Chart Review Summary Mon Tue Wed Thu Fri
No. of charts to be reviewed/pending brought forward 42 124 110 91 62
No. of charts received 142 48 52 40 51
No. of charts reviewed 65 68 74 70 67
No. of charts with insufficient information to code 34 14 23 20 17
No. of calls made to physicians office to get information 25 18 22 16 12
No. of charts succesfully coded 60 62 71 69 62
No. of charts coding pending/ carried forward 124 110 91 62 51

Sample Coding Report
CPT Codes Billed Report
CPT codes Code description Units Billed Charges Payments Collection %
99212
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND
MANAGEMENT OF AN ESTABLISHED PATIENT
158 $$$$ $$$$ 68.18%
99218
INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND
MANAGEMENT OF A PATIENT
162 $$$$ $$$$ 76.00%
99225
SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND
192 $$$$ $$$$ 70.00%
99233
SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND
161 $$$$ $$$$ 88.57%
99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES OR LESS 254 $$$$ $$$$ 60.00%
99252
INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH
REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED
HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND
STRAIGHTFORWARD MEDICAL DECISION MAKING
168 $$$$ $$$$ 60.00%
99281
EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT
OF A PATIENT
126 $$$$ $$$$ 93.75%

MEDICAL BILLING
SERVICES

Medical Billing Cycle Services
Encounter
(SOAP)
notes
review
Superbill
generation
and code
review
Claims edit
checking
and
correction
EDI claims
submission
through
clearing
house
Rejection
management
ERA/EOB posting
and reconciliation
Automatic
secondary
payer billing
Denial
Management
A/R
Follow-up

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

Billing & Coding Services - Highlights
 FREE Billing Software
 FREE EMR
 FREE Implementation
 No Hidden Cost
 Up to 95% Collection Rate
 99.9% Coding Accuracy
 Claims Submission within 24 – 48 hours max.
 100% HIPAA-HITECH Compliance
 Custom Reporting
 Excellent References
 Real Time Audits

OTHER PRACTICE
MANAGEMENT SERVICES

Payment/Denial Posting Process
Payment posting is crucial to the billing process. Due to the sensitivity of this process,
accurate and efficient payment posting process is indispensable.
Our billers are known to be highly efficient and analytical in the payment posting process.
Payment Entry Process
Select Patient Account
Select EncounterSelect Encounter
If not found
Refer Client SpecifiesDenial
Denial Code
Hold Transfer BalanceTransfer BalanceWrite-off
Post Payment
Payment

Productivity Efficiency Tracking
Employee
Name
Note Count Days Worked
Hours
Worked
Notes Per
Hour
Max Note
Time
Avg. Note
Time
John Smith 977 23 203.55 4.8 1:29:52 0:07:15
Jane Doe 1025 23 214.97 4.77 0:55:14 0:04:56
Rick Williams 913 21 207.07 4.06 1:27:08 0:07:14
Robert Frost 870 21 187.35 4.64 0:42:54 0:04:05
Dan Chesser 910 23 216.47 4.2 3:50:55 0:06:18
Derek Malia 823 23 210.37 3.91 7:01:30 0:04:37
Our clients depend on transparency.
We provide our clients with the ability to maintain detailed tracking for
increased productivity and efficiency.
A Sample Report

Denial Management
Auth Related
14%
Coding Error
5%
OON Issue
8%
COB Issues
10%Patient info missing
6%
Exceeds Timely Filing
8%
Duplicate Claim
5%
Service Not Covered
6%
Primary Paid Max
7%
Pre-Existing Condition
5%
Others
26%
Distribution of Denied Claims

Challenges and Our Approach
 Assignment of adequate staff
 Completion of secondary verification
 Rigorous audit
 Time consuming with limited staff
 Documentation collection requires
continuous follow-up
 Increased TAT
 Time consuming with limited staff
 Secondary verification not carried out
Checking Authorization
Requirement and
Obtaining Authorization
Eligibility Verification
Patient Demographics /
Insurance / Charge Entry
 Transaction audit to minimize errors;
reduces denial due to missing patient
information
TASK DESCRIPTION CHALLENGES APPROACH
 Missing information / Key-in errors
 Increased denial rate
 Increased TAT
 Assignment of adequate staff
 Systematic and regular follow-up with
physicians’ offices & payers to collect
documentation and obtain authorization
 Proper tracking mechanism

 Defining KPI for rejection management
process and assigning responsibility
 Claims reconciliation and exception
report generation
 Unapplied balance
 Accumulation of backlog
 Manual posting
 Denials not posted
 Delayed correction and resubmission
 Possible loss of payment
Payment Posting
Rejection Management
Paper Claim Submission
 Proper tracking of every submission of
paper claims
 Moving to EDI based submission
whenever possible will reduce cost of
manual work and faster payment cycle
 Additional work for printing and
faxing/mailing
 Delayed filing leading to denials
 Lack of information about the actual
status
 Defining guidelines
 Review of patient payments
 Define KPI – TAT & Accuracy
 Denial posting and review

 Proper documentation – process
manual, guidelines & checklists
 Defining proper tracking mechanism
through various reports -Ageing, Status,
Daily, Exception
 Generate exception reports and regular
audit of every process tasks
 Defining KPIs and assigning
responsibility
 Lack of clarity of claims volume and
current status affects management
decision making process
 Impact on overall billing process
performance and improvement
 Decreased productive efficiency
Process Administration
and Reporting
AR Follow-up &
Denial Management
 Regular analysis, follow-up and review
 Transaction audit
 Accumulation of backlog
 Denials not posted
 Claims reconciliation issue

Client Benefits
Significant decrease in operational expenses
 We charge as low as $10 per hour per employee!
 Our clients save on other associated costs for employees including Health Insurance Premiums, Payroll Costs,
Medicare Tax, Human Resources, Employee Attrition, additional Real Estate and Infrastructure Costs
 We guarantee > 50% operational savings effective immediately; e.g. one of our clients reported a $2.1 million
operational savings in Y1 alone!
Heightened collection and increased Accounts Receivables
 30% of DME Rx are incomplete when first received. We excel in completing the Rx claim quickly.
Cyclical Data Reporting
 Data reporting interval customized to meet the needs of the customer
 Productivity Efficiency Tracking allows for quantifying the team workload
Demonstrated experience handling DME claims
 Medicare, Medicaid and Commercial Plans  Fee for Service and Capitated Plans

TECHNOLOGY, OPERATIONAL
& COMPLIANCE FRAMEWORK

IT Infrastructure
 Service continuity supported by BCP and disaster management mechanisms
 100% redundancy in all IT assets, providing high-availability and reliability
 12 Mbps leased line internet connectivity provided by two ISPs in load sharing and automatic
failover configuration
 Data protection and security provided by Fortigate® 310B firewall combined with other physical
and logical access controls
 Voice telephony infrastructure built using E1 lines provided by two IPLC
providers
 Avaya PBX with IVR, ACD and CTI functionalities and 100% call recording
& reporting features
 Data center with 13 IBM x3650 rack servers with rack mounted UPS
 Polycom VSX 7000A video conference system for remote training
and client communication
 24/7/365 IT-Infrastructure support personnel for user support, using ticket management system
 120 KVA on-line UPS power backup systems and additional backup provided by 180 KVA power
generator

Operational Framework
TRANSITION
 Project scoping
& planning
 Knowledge
transfer –
Process training
and assessment
 Process
documentation
 Solution
customization
 Infrastructure
set up
 Pilot/Transition
period
TRAINING
 Training Need
Identification
 Customized
training program
as per client’s
requirement
 Pre-process &
process training
 Voice & accent
and cultural
training
 Refresher
training
PRODUCTION
 Project
management
approach
 Exception
handling and
reporting
 Effective
coaching &
monitoring
practices
 Periodic review
and evaluation
 Service level
management
and reporting
QUALITY
 Regular audit for
process and
deliverables
 Identify and
analyze errors
to take
corrective
measures
 Flowcharting
and root cause
analysis for
process
improvement
measures
 Management
reporting of
quality
assurance
activities
 Capacity
planning
 Forecasting,
staffing &
scheduling
 Real time
reporting
 Billing and
revenue
management
MIS / WFM
 Ensure 100%
adherence to
federal / data
protection laws
 Governance &
compliance
audits
 Organization
preparedness
for client & third
party audits
 HIPAA
compliance
CONTROL &
COMPLIANCE
PROJECT MANAGEMENT & OVERSIGHT
IT INFRASTRUCTURE– TOOLS & TECHNOLOGY

Quality Assurance & Control
Our Quality Control & Assurance processes help us meet our client’s expectations and SLA target. We
use Quality Assurance program to set production and quality goals. Our daily quality audit activities
ensure that we evaluate our agents’ work on all relevant criteria.
The highest quality is ensured by carrying out rigorous quality assurance and control activities such as,
 Periodic process review
 Process audit
 Testing deliverables and root cause analysis
 Process improvement / re-engineering
 Incorporating customer feedback
 Internal quality audit of client deliverables & review reporting
 Weekly/monthly monitoring of productivity reports

Training Methodology
• Process training and
refreshers
• Availability of training
documents in
‘Knowledge Net’ portal
• V&A, Soft skills training
• Post-training assessment
• Training feedback
• Review of training
program
• Preparation of training
Modules
• Preparation of training
Plan in ‘Knowledge Net’
training module
• Regular process test and
appraisals
• Work in-sync with
Operations & QA
Training Need
Identification
Training
Program
Planning
Conduct
Training
Training
Evaluation

Compliance – Key Facts
 Well-defined policies to cover compliance aspects
 Written procedures covering compliance aspects
 Proactive compliance reporting and issue escalation
 Action list for changes in rules and regulations by regulatory authorities
 Compliance evaluation framework
 Periodical training on compliance issues and update
 Periodic audit and review mechanism to address potential compliance risks
 Implementation of data privacy and security standards like HIPAA-HITECH and ISO 27001
 Incident reporting for data security violation
 Compliance awareness among the employees and reward on compliance reporting
 Compliance violation by employees leads to employee retraining and reassessment
GoTelecare has defined and established a process and system to avoid compliance risks while carrying
out operations and encourage employees to proactively report compliance issues to the higher
management.

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 Sun Knowledge’s servers in NY and India via site-to-site IPsec VPN tunnels helps strong
business continuity management
 Daily off-site backup process to mitigate data loss risk in case of disaster
 Implementation of physical access control system in office premises restricts access to sensitive areas housing
application and database
 Physical and logical segregation of internal network into VLAN segments to control and protect data storage and
transmission between business/process units
 Implementation of perimeter security devices, like firewall and segregation of sensitive information systems
 Access to all information systems through two levels of authorization
 Implementation of two levels of end point malware protection network and system level anti-malware systems
 Use of secure e-mail system for e-mails with sensitive PHI information
 Implementation of access restrictions to prevent unauthorized deletion or movement of data using external
storage devices like optical discs, pen drives, etc.
 Security incident monitoring, reporting and resolution system
 Periodic employee awareness training on data privacy & protection and HIPAA regulations

WHY US?

Advantage GoTelecare
1
Over 7 Years
of Experience
in Working as
Vendors for
Major Health
Insurance
Companies
Across US
Deep
Knowledge of
both the
Payer and the
Provider Side
of the US
Healthcare
Spectrum
2
Consistent
Performance
in Delivering
up to 95%
Collection
Rate to
Clients
Already
Recovered
over millions
in Account
Receivables
and
counting…
3
The Only
Medical Billing
Company with
Its Own State-
of-the-Art
Telemedicine
Platform
4
The Best
References
in Every
Segment
of US
Healthcare
Knowledge &
Business
Process
Outsourcing
5
The Lowest Prices
in the Market!

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

GoTelecare vs. Other Staffing Agencies

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

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

Contact
41 Madison Avenue, 25th Floor,
New York, NY 10010
(646) 661-7853
Ronnie.Hastings@GoTelecare.com
Ronnie Hastings

Practice Management & Claims Administration

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