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REVENUE CYCLE
MANAGEMENT SERVICES
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
3© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Our Service Offerings
 Provider Support
 Member Support
 Member Retention Program
 Clinical Help Desk
Contact Center
 Utilization 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 cater to
Prosthetics & Orthotics and DME companies in Revenue Cycle Management
Physicians and Hospital in Revenue Cycle Management
Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
4© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management by GoTelecare
360°
Revenue Cycle
Management
Services
Eligibility
Verification &
Authorization
Billing
Coding
Scheduling
Payment
Posting
Account
Receivables
5© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
6© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management Experience
HOSPITAL
 Accounts
Receivables
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
7© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Revenue Cycle Management – Service Portfolio
 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
 AR calls as follow-up on outstanding issues
 Closure of a claim once the balance is zero
CODING
BILLING
A/R FOLLOW-UP
8© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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.
Sample Report
9© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
ELIGIBILITY VERIFICATION
& AUTHORIZATION
10© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Eligibility Verification & Authorization Services
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
11© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Sample SOW (Statement of Work)
Each pre-authorization service consists of three transactions. Tasks involved in carrying out this
Pre Authorization service include the following steps:
a) Authorization Initiation transaction involves the following activities:
 Calling up insurance to find the authorization filing procedure and turnaround time
 Gathering pre-authorization form and relevant medical documents from the providers
 Submission of the authorization request (fax/online) to the payer along with relevant
documentation
 Tracking of Fax receipts
b) Authorization Follow up transaction will involve following up with the payer to check the
status of the authorization as per the TAT set for each payer.
c) Acknowledgement of Authorization approval transaction will involve updating approved
authorization in the clients billing system with the start and end date for the Authorization
approval. If required by the client, scanned image of the approval will be uploaded into the
clients system.
12© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Sample Reports
0
20
40
60
80
100
120
140
4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015
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
4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015
45
25
38
44
46
20
15
26
22 21
25
10
12
22
25
AUTHORIZATION
Auth Required Auth Obtained Auth Pending
13© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
ACCOUNTS RECEIVABLES
(AR) FOLLOW-UP
14© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Reasons for AR Management
 Authorization Issues
 Referral Issues
 Medical Necessity and Medical
Records requests
 Non-Participation with Insurance
Network
 Terminated Insurance
 Coordination of Benefits
 Wrong Diagnosis
 Inclusive Procedures
 Partial Payments
 Out-of-network Claim Status and
Deductibles
 EDI Rejections
 No Status and No Claim on File
 PIP cases
15© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Steps in AR Follow-up
 A/R Analysis
 14% of all claims submitted to the payers are denied and have to be resubmitted, appealed
or written off by providers
 50% of denied claims are never re-filed
 50-70% of denied claims have higher chance of being recovered
Reducing days in A/R, claims submission and improving collection ratio with an increase
the probability of payment through timely follow-up is the responsibility of the A/R team
 Follow-up with payer
 Aggressive follow up with the insurance company's on all accounts at any stage of the aging
bucket plays an important part in A/R follow up activities.
 Closure of claim
16© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Sample SOW of AR Follow-up
Go Telecare will make outbound calls to reach out to the Payers to gather information about the
status of claims as per the list provided by Customer. Key tasks involved in carrying out this work
are detailed below.
 Planning to start calling Payers as per the list of claims based on the downloaded AR Reports
 Research details of the claims in the AR list in the Clients system
 Making outbound calls to the respective Payers for claims aged 31 days and more
 Document finding of the calls
 Preparation of claims reports with status information gathered during the call
Modifications, removal or adding tasks to this are agreed upon between client and Go Telecare
17© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Sample SOW of AR Follow-up
No remark claims:
Any claims in which absolutely no status is known for the claim.
Last remark claims:
Any claims which remain unpaid for various reasons. These claims are routinely
followed up on a monthly basis.
2 types of claims follow-ups
18© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Medical Billing & Coding
MEDICAL BILLING &
CODING SERVICES
19© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Highlights
 FREE Billing Software
 FREE EMR
 FREE Implementation
 No Hidden Cost
 97% Collection Rate
 99.9% Coding Accuracy
 Claims Submission within 24 – 48 hours max.
 100% HIPAA Compliance
 Custom Reporting
 Excellent References
 Real Time Audits
20© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Areas of Operation
We provide turnkey billing services in the following areas:
Urgent Care Prosthetics & Orthotics DME (Durable Medical Equipment)
Pathology Critical Care Radiology
Internal Medicine EKG Compounding Pharmacy
Cardiology ENT Orthopedic Surgery
Anesthesia Family Practice Inpatient Hospitalization
Rehab Center Pharmacy Physicians, and more…
21© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Medical Coding – Overview
Downloading Allocation
CodingQuality Check
Uploading Feedbacks & Updates
Encrypted reports are
downloaded from SFTP site
Reports are allocated to
coders according to specialty
Quality checked for LCDs,
updates and client specs.
Analysis of reports, allocation
of ICD and Service codes
Analysis of reports, allocation
of ICD and CPT codes
Client reports back with
feedbacks and updates
Medical Coding Process Flow
22© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Medical Billing Cycle
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
AR
Follow-up
23© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Billing Cycle – Details
 Order entry based on the Rx received from the Physician
• Patient demographics & insurance entry
• Provider information entry
• Product code, Rx & Dx entry
• If necessary, a telemedicine consultation can be completed to obtain a Rx to expedite the order entry process
 Eligibility verification and authorization requirement enquiry
 Patient’s appointment with Practitioner for Practitioner to assign codes
 Collection of detailed Rx from ordering Physician’s office
 Collection of documents required by Payer for authorization approval, e.g. Diabetic Verification Form, initial
evaluation, medical notes to support K level, PPR Form
 Calculation of service estimates (Patient and Payer responsibility)
 Determination that payer criteria are met before delivery of device (if criteria are not met,
the Patient needs to be contacted & informed of the additional financial liabilities)
 Generation of delivery ticket (based on which delivery is made to the Patient)
 Creation of claim after receipt of confirmation of delivery
 Submission of EDI/paper claim to Payers
 Cash Posting
 Rejection & Denial Management
 A/R follow-up
24© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Coding & Billing System
We use Kareo for coding and billing services that covers the complete billing cycle:
 SOAP notes review
 Superbill generation and coding
 Claims edit checking and correction
 Claims submission through EDI clearing house at a scheduled time
 Rejection management
 ERA/EOB posting and reconciliation
 Automatic secondary payer billing
 Denial Management
 Patient statement generation and mailing
25© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
26© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
27© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
28© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
29© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Challenges and Our Approach
 Defining KPI for rejection management
process and assigning responsibility
 Claims reconciliation and exception
report generation
 Unapplied balance
 Accumulation of backlog
 Manual posting
 Denials not posted
 Delayed correction and resubmission
 Possible loss of payment
Payment Posting
Rejection Management
Paper Claim Submission
 Proper tracking of every submission of
paper claims
 Moving to EDI based submission
whenever possible will reduce cost of
manual work and faster payment cycle
TASK DESCRIPTION CHALLENGES APPROACH
 Additional work for printing and
faxing/mailing
 Delayed filing leading to denials
 Lack of information about the actual
status
 Defining guidelines
 Review of patient payments
 Define KPI – TAT & Accuracy
 Denial posting and review
30© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Challenges and Our Approach
 Proper documentation – process
manual, guidelines & checklists
 Defining proper tracking mechanism
through various reports -Ageing, Status,
Daily, Exception
 Generate exception reports and regular
audit of every process tasks
 Defining KPIs and assigning
responsibility
 Lack of clarity of claims volume and
current status affects management
decision making process
 Impact on overall billing process
performance and improvement
 Decreased productive 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
31© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Technology, Operational & Compliance Framework
TECHNOLOGY, OPERATIONAL
& COMPLIANCE FRAMEWORK
32© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Software Development
Some of the applications which we have developed include,
 GoTelecare - A full fledged Telehealth application for providers, hospitals and patients with integrated EMR,
practice management system and video conferencing system
 Integration of DICOM server, DCM4CHE with EMR software
 mHealth – Remote patient monitoring and health data collection through medical devices and QUALCOMM
cloud services
 PDP Manager – To manage Medicare Part D processes
 Medication Therapy Management (MTMpro) application
Our technology development team works with Java (Enterprise Edition) and technology components include,
 Web application technologies like servlets, JSP, JSTL, JSF, JSON, web sockets, applets
 Open source frameworks like Struts, Spring, Hibernate
 Enterprise technologies like dependency injection, messaging services, transaction management services,
persistence management services, annotations, javamail, java enterprise beans, interceptors, connector
architecture
 Web service technologies like RESTful web services, enterprise web services, JAX -WS, JAX- RPC
 Database servers like MS SQL server, Oracle, MySQL
33© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
IT Infrastructure
 Service continuity supported by BCP and disaster management mechanisms
 100% redundancy in all IT assets, providing high-availability and reliability
 12 Mbps leased line internet connectivity provided by two ISPs in load sharing and automatic
failover configuration
 Data protection and security provided by Fortigate® 310B firewall combined with other physical
and logical access controls
 Voice telephony infrastructure built using E1 lines provided by two IPLC
providers
 Avaya PBX with IVR, ACD and CTI functionalities and 100% call recording
& reporting features
 Data center with 13 IBM x3650 rack servers with rack mounted UPS
 Polycom VSX 7000A video conference system for remote training
and client communication
 24/7/365 IT-Infrastructure support personnel for user support, using ticket management system
 120 KVA on-line UPS power backup systems and additional backup provided by 180 KVA power
generator
34© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Operational Framework
TRANSITION
 Project scoping
& planning
 Knowledge
transfer –
Process training
and assessment
 Process
documentation
 Solution
customization
 Infrastructure
set up
 Pilot/Transition
period
TRAINING
 Training Need
Identification
 Customized
training program
as per client’s
requirement
 Pre-process &
process training
 Voice & accent
and cultural
training
 Refresher
training
PRODUCTION
 Project
management
approach
 Exception
handling and
reporting
 Effective
coaching &
monitoring
practices
 Periodic review
and evaluation
 Service level
management
and reporting
QUALITY
 Regular audit for
process and
deliverables
 Identify and
analyze errors
to take
corrective
measures
 Flowcharting
and root cause
analysis for
process
improvement
measures
 Management
reporting of
quality
assurance
activities
 Capacity
planning
 Forecasting,
staffing &
scheduling
 Real time
reporting
 Billing and
revenue
management
MIS / WFM
 Ensure 100%
adherence to
federal / data
protection laws
 Governance &
compliance
audits
 Organization
preparedness
for client & third
party audits
 HIPAA
compliance
CONTROL &
COMPLIANCE
PROJECT MANAGEMENT & OVERSIGHT
IT INFRASTRUCTURE– TOOLS & TECHNOLOGY
35© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Governance Model
GoTelecare
Governance
Structure
Steering Committee
Program Management Office
Project Delivery Team
 Executive sponsorship
 Management oversight
 Ensure business goals and
engagement goals alignment
 Ensure tangible results and
demonstrable value
 Continuously educate & report
executive leadership on the
critical success factors of
engagement
 Plan and implement change;
define, establish performance,
metrics aligned to goal
 Review project scope, timeline
and budget and monitor project
progress
 Communication, status reporting
& escalation to steering committee
 Manage cross team
dependencies
 Identify, initiate & institutionalize
process improvements
 Oversee knowledge repository
building
 Project Management
 Scope Management
 Knowledge
Management
 Change Management
 Ensure successful
engagement startup
 Quality Management
 Resource Management
 Communication &
Status Reporting
 Issue Management
 Monitor & measure
knowledge transfer
process
 Incorporate industry
best practices
36© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Quality Assurance & Control
Our Quality Control & Assurance processes help us meet our client’s expectations and SLA target. We
use Quality Assurance program to set production and quality goals. Our daily quality audit activities
ensure that we evaluate our agents’ work on all relevant criteria.
The highest quality is ensured by carrying out rigorous quality assurance and control activities such as,
 Periodic process review
 Process audit
 Testing deliverables and root cause analysis
 Process improvement / re-engineering
 Incorporating customer feedback
 Internal quality audit of client deliverables & review reporting
 Weekly/monthly monitoring of productivity reports
37© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
38© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Compliance – Key Facts
 Well defined policies to cover compliance aspects
 Written procedures covering compliance aspects
 Proactive compliance reporting and issue escalation
 Action list for changes in rules and regulations by regulatory authorities
 Compliance evaluation framework
 Periodical training on compliance issues and update
 Periodic audit and review mechanism to address potential compliance risks
 Implementation of data privacy and security standards like HIPAA-HITECH and ISO 27001
 Incident reporting for data security violation
 Compliance awareness among the employees and reward on compliance reporting
 Compliance violation by employees leads to employee retraining and reassessment
GoTelecare has defined and established a process and system to avoid compliance risks while carrying
out operations and encourage employees to proactively report compliance issues to the higher
management.
39© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Compliance Escalation Structure
Service Delivery
Service Delivery Mgr
(Service Delivery POC)
Head of Operations
(1st Level Escalation
POC)
Operations
CEO & MD
(Final Escalation POC)
Executive Board
Board of Directors
Compliance
Compliance Mgr
(Compliance Escalation
POC)
Head of Compliance
Compliance
Team Lead
Process Team Lead
(Service Delivery POC)
Technology
Technology Mgr
Quality
Quality Mgr
HR/Training
HR/Training Mgr
Compliance
Issue
Trigger Point
 Process Team Leader will inform
Service Delivery Manager and
Compliance Manager immediately
after occurrence of the event
 Compliance Manager/ Service Delivery
Manager will assign the severity of the
compliance issue
Compliance Escalation Path
Severe Compliance Escalation Path
40© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Data Security and End-User Privacy
 Information security management system is aligned with ISO 27001:2013 standard
 Implementation of policies and procedures with respect to PHI comply with HIPAA-HITECH regulations
 Data replication between 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
41© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Why GoTelecare?
WHY US?
42© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
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
97%
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!
* Only $10 /hr for a
full time biller | Just 4% of
collections for AR services |
Only .85 cents /claim for
eligibility verification &
authorization.
Clients enjoy
Extra Savings with
 FREE Billing Software
 FREE EMR
 FREE Implementation
 No Hidden Cost !
43© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
GoTelecare vs. Other Staffing Agencies
44© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Why Us?
 Very Little Risk
• Proven track record in providing healthcare BPO/KPO services
• Highly experienced in providing services to both payers and providers
• Experienced in working with various software platforms
• Quick and efficient resource for special projects requiring technical and process expertise
 Significant Upside Potential
• Great understanding of the Healthcare Industry. Operation scale-up with a short notice
• Extremely competitive rates, greater productivity, improved quality, increased member
and provider satisfaction
 Proven Process Performance
• Low denial rate  increase in revenue collection
• Verification & authorization accuracy > 99.9%; TAT: 24 hours
• High accuracy in Eligibility Data Maintenance (in sync with CMS)
 Clear Communication and Quick Response at All Times
 ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection
45© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
The Real Question
But really, why us?
Because we do Six Sigma quality work, validated
by excellent client references, at the lowest
prices in the market!
We are so confident of the quality of our
services that we challenge you to find
another company which can deliver
better quality services at a cheaper rate!
46© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Our 4 Pillars of Strength
Highest
Quality
Excellent
References
Unique
Profile
Cheapest
Rates
Consistently delivering the best
quality, with the highest levels of
accuracy, efficiency & expertise
Glowing testimonials from every
client and not a single customer
churn in our 8 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
47© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
What are Our Clients Saying
"The professionalism I have experienced with GoTelecare’s
employees has made them very easy to work with and has
improved our operation processes. Any time I have a
question, they are literally just a phone call or e-mail away.
I love the accessibility!”
- CFO of a major US healthcare company
“I am starting to see an upswing with Medicare and
United cash flow”
- CEO of a leading US healthcare organization
“Your productivity is very
impressive for your first month.
Almost everyone has an
average of close to 40 accounts
per day. We have gone over a
few things with you and each
time we talk, I am impressed
with how quickly changes and
improvements are put in place.
I will continue to share
feedback as I get it on
additional improvements that
can be made and appreciate
your attentiveness and
questions that you bring to our
daily meetings.
- Manager (Revenue Cycle) of a
reputed US healthcare company
48© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010
Contact
41 Madison Avenue, 25th Floor,
New York, NY 10010
(866) 636-6264
rh@GoTelecare.com
Ronnie Hastings

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GoTelecare Revenue Cycle Management Services

  • 1. REVENUE CYCLE MANAGEMENT SERVICES CONTACT: RONNIE HASTINGS (646) 661-7853 GoTelecare 41 Madison Avenue, 25th Floor, New York, NY 10010
  • 2. 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
  • 3. 3© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Our Service Offerings  Provider Support  Member Support  Member Retention Program  Clinical Help Desk Contact Center  Utilization 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 cater to Prosthetics & Orthotics and DME companies in Revenue Cycle Management Physicians and Hospital in Revenue Cycle Management Commercial Plans, MA Plans, Medicaid HMOs, MAPD/PDPs, IPAs, MSOs, TPAs, PBMs and RBMs
  • 4. 4© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Revenue Cycle Management by GoTelecare 360° Revenue Cycle Management Services Eligibility Verification & Authorization Billing Coding Scheduling Payment Posting Account Receivables
  • 5. 5© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 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
  • 6. 6© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Revenue Cycle Management Experience HOSPITAL  Accounts Receivables 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
  • 7. 7© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Revenue Cycle Management – Service Portfolio  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  AR calls as follow-up on outstanding issues  Closure of a claim once the balance is zero CODING BILLING A/R FOLLOW-UP
  • 8. 8© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 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. Sample Report
  • 9. 9© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 ELIGIBILITY VERIFICATION & AUTHORIZATION
  • 10. 10© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Eligibility Verification & Authorization Services 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
  • 11. 11© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Sample SOW (Statement of Work) Each pre-authorization service consists of three transactions. Tasks involved in carrying out this Pre Authorization service include the following steps: a) Authorization Initiation transaction involves the following activities:  Calling up insurance to find the authorization filing procedure and turnaround time  Gathering pre-authorization form and relevant medical documents from the providers  Submission of the authorization request (fax/online) to the payer along with relevant documentation  Tracking of Fax receipts b) Authorization Follow up transaction will involve following up with the payer to check the status of the authorization as per the TAT set for each payer. c) Acknowledgement of Authorization approval transaction will involve updating approved authorization in the clients billing system with the start and end date for the Authorization approval. If required by the client, scanned image of the approval will be uploaded into the clients system.
  • 12. 12© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Sample Reports 0 20 40 60 80 100 120 140 4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015 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 4/6/2015 4/7/2015 4/8/2015 4/9/2015 4/10/2015 45 25 38 44 46 20 15 26 22 21 25 10 12 22 25 AUTHORIZATION Auth Required Auth Obtained Auth Pending
  • 13. 13© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 ACCOUNTS RECEIVABLES (AR) FOLLOW-UP
  • 14. 14© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Reasons for AR Management  Authorization Issues  Referral Issues  Medical Necessity and Medical Records requests  Non-Participation with Insurance Network  Terminated Insurance  Coordination of Benefits  Wrong Diagnosis  Inclusive Procedures  Partial Payments  Out-of-network Claim Status and Deductibles  EDI Rejections  No Status and No Claim on File  PIP cases
  • 15. 15© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Steps in AR Follow-up  A/R Analysis  14% of all claims submitted to the payers are denied and have to be resubmitted, appealed or written off by providers  50% of denied claims are never re-filed  50-70% of denied claims have higher chance of being recovered Reducing days in A/R, claims submission and improving collection ratio with an increase the probability of payment through timely follow-up is the responsibility of the A/R team  Follow-up with payer  Aggressive follow up with the insurance company's on all accounts at any stage of the aging bucket plays an important part in A/R follow up activities.  Closure of claim
  • 16. 16© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Sample SOW of AR Follow-up Go Telecare will make outbound calls to reach out to the Payers to gather information about the status of claims as per the list provided by Customer. Key tasks involved in carrying out this work are detailed below.  Planning to start calling Payers as per the list of claims based on the downloaded AR Reports  Research details of the claims in the AR list in the Clients system  Making outbound calls to the respective Payers for claims aged 31 days and more  Document finding of the calls  Preparation of claims reports with status information gathered during the call Modifications, removal or adding tasks to this are agreed upon between client and Go Telecare
  • 17. 17© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Sample SOW of AR Follow-up No remark claims: Any claims in which absolutely no status is known for the claim. Last remark claims: Any claims which remain unpaid for various reasons. These claims are routinely followed up on a monthly basis. 2 types of claims follow-ups
  • 18. 18© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Medical Billing & Coding MEDICAL BILLING & CODING SERVICES
  • 19. 19© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Highlights  FREE Billing Software  FREE EMR  FREE Implementation  No Hidden Cost  97% Collection Rate  99.9% Coding Accuracy  Claims Submission within 24 – 48 hours max.  100% HIPAA Compliance  Custom Reporting  Excellent References  Real Time Audits
  • 20. 20© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Areas of Operation We provide turnkey billing services in the following areas: Urgent Care Prosthetics & Orthotics DME (Durable Medical Equipment) Pathology Critical Care Radiology Internal Medicine EKG Compounding Pharmacy Cardiology ENT Orthopedic Surgery Anesthesia Family Practice Inpatient Hospitalization Rehab Center Pharmacy Physicians, and more…
  • 21. 21© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Medical Coding – Overview Downloading Allocation CodingQuality Check Uploading Feedbacks & Updates Encrypted reports are downloaded from SFTP site Reports are allocated to coders according to specialty Quality checked for LCDs, updates and client specs. Analysis of reports, allocation of ICD and Service codes Analysis of reports, allocation of ICD and CPT codes Client reports back with feedbacks and updates Medical Coding Process Flow
  • 22. 22© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Medical Billing Cycle 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 AR Follow-up
  • 23. 23© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Billing Cycle – Details  Order entry based on the Rx received from the Physician • Patient demographics & insurance entry • Provider information entry • Product code, Rx & Dx entry • If necessary, a telemedicine consultation can be completed to obtain a Rx to expedite the order entry process  Eligibility verification and authorization requirement enquiry  Patient’s appointment with Practitioner for Practitioner to assign codes  Collection of detailed Rx from ordering Physician’s office  Collection of documents required by Payer for authorization approval, e.g. Diabetic Verification Form, initial evaluation, medical notes to support K level, PPR Form  Calculation of service estimates (Patient and Payer responsibility)  Determination that payer criteria are met before delivery of device (if criteria are not met, the Patient needs to be contacted & informed of the additional financial liabilities)  Generation of delivery ticket (based on which delivery is made to the Patient)  Creation of claim after receipt of confirmation of delivery  Submission of EDI/paper claim to Payers  Cash Posting  Rejection & Denial Management  A/R follow-up
  • 24. 24© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Coding & Billing System We use Kareo for coding and billing services that covers the complete billing cycle:  SOAP notes review  Superbill generation and coding  Claims edit checking and correction  Claims submission through EDI clearing house at a scheduled time  Rejection management  ERA/EOB posting and reconciliation  Automatic secondary payer billing  Denial Management  Patient statement generation and mailing
  • 25. 25© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 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
  • 26. 26© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 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
  • 27. 27© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 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
  • 28. 28© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 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
  • 29. 29© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Challenges and Our Approach  Defining KPI for rejection management process and assigning responsibility  Claims reconciliation and exception report generation  Unapplied balance  Accumulation of backlog  Manual posting  Denials not posted  Delayed correction and resubmission  Possible loss of payment Payment Posting Rejection Management Paper Claim Submission  Proper tracking of every submission of paper claims  Moving to EDI based submission whenever possible will reduce cost of manual work and faster payment cycle TASK DESCRIPTION CHALLENGES APPROACH  Additional work for printing and faxing/mailing  Delayed filing leading to denials  Lack of information about the actual status  Defining guidelines  Review of patient payments  Define KPI – TAT & Accuracy  Denial posting and review
  • 30. 30© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Challenges and Our Approach  Proper documentation – process manual, guidelines & checklists  Defining proper tracking mechanism through various reports -Ageing, Status, Daily, Exception  Generate exception reports and regular audit of every process tasks  Defining KPIs and assigning responsibility  Lack of clarity of claims volume and current status affects management decision making process  Impact on overall billing process performance and improvement  Decreased productive 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
  • 31. 31© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Technology, Operational & Compliance Framework TECHNOLOGY, OPERATIONAL & COMPLIANCE FRAMEWORK
  • 32. 32© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Software Development Some of the applications which we have developed include,  GoTelecare - A full fledged Telehealth application for providers, hospitals and patients with integrated EMR, practice management system and video conferencing system  Integration of DICOM server, DCM4CHE with EMR software  mHealth – Remote patient monitoring and health data collection through medical devices and QUALCOMM cloud services  PDP Manager – To manage Medicare Part D processes  Medication Therapy Management (MTMpro) application Our technology development team works with Java (Enterprise Edition) and technology components include,  Web application technologies like servlets, JSP, JSTL, JSF, JSON, web sockets, applets  Open source frameworks like Struts, Spring, Hibernate  Enterprise technologies like dependency injection, messaging services, transaction management services, persistence management services, annotations, javamail, java enterprise beans, interceptors, connector architecture  Web service technologies like RESTful web services, enterprise web services, JAX -WS, JAX- RPC  Database servers like MS SQL server, Oracle, MySQL
  • 33. 33© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 IT Infrastructure  Service continuity supported by BCP and disaster management mechanisms  100% redundancy in all IT assets, providing high-availability and reliability  12 Mbps leased line internet connectivity provided by two ISPs in load sharing and automatic failover configuration  Data protection and security provided by Fortigate® 310B firewall combined with other physical and logical access controls  Voice telephony infrastructure built using E1 lines provided by two IPLC providers  Avaya PBX with IVR, ACD and CTI functionalities and 100% call recording & reporting features  Data center with 13 IBM x3650 rack servers with rack mounted UPS  Polycom VSX 7000A video conference system for remote training and client communication  24/7/365 IT-Infrastructure support personnel for user support, using ticket management system  120 KVA on-line UPS power backup systems and additional backup provided by 180 KVA power generator
  • 34. 34© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Operational Framework TRANSITION  Project scoping & planning  Knowledge transfer – Process training and assessment  Process documentation  Solution customization  Infrastructure set up  Pilot/Transition period TRAINING  Training Need Identification  Customized training program as per client’s requirement  Pre-process & process training  Voice & accent and cultural training  Refresher training PRODUCTION  Project management approach  Exception handling and reporting  Effective coaching & monitoring practices  Periodic review and evaluation  Service level management and reporting QUALITY  Regular audit for process and deliverables  Identify and analyze errors to take corrective measures  Flowcharting and root cause analysis for process improvement measures  Management reporting of quality assurance activities  Capacity planning  Forecasting, staffing & scheduling  Real time reporting  Billing and revenue management MIS / WFM  Ensure 100% adherence to federal / data protection laws  Governance & compliance audits  Organization preparedness for client & third party audits  HIPAA compliance CONTROL & COMPLIANCE PROJECT MANAGEMENT & OVERSIGHT IT INFRASTRUCTURE– TOOLS & TECHNOLOGY
  • 35. 35© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Governance Model GoTelecare Governance Structure Steering Committee Program Management Office Project Delivery Team  Executive sponsorship  Management oversight  Ensure business goals and engagement goals alignment  Ensure tangible results and demonstrable value  Continuously educate & report executive leadership on the critical success factors of engagement  Plan and implement change; define, establish performance, metrics aligned to goal  Review project scope, timeline and budget and monitor project progress  Communication, status reporting & escalation to steering committee  Manage cross team dependencies  Identify, initiate & institutionalize process improvements  Oversee knowledge repository building  Project Management  Scope Management  Knowledge Management  Change Management  Ensure successful engagement startup  Quality Management  Resource Management  Communication & Status Reporting  Issue Management  Monitor & measure knowledge transfer process  Incorporate industry best practices
  • 36. 36© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Quality Assurance & Control Our Quality Control & Assurance processes help us meet our client’s expectations and SLA target. We use Quality Assurance program to set production and quality goals. Our daily quality audit activities ensure that we evaluate our agents’ work on all relevant criteria. The highest quality is ensured by carrying out rigorous quality assurance and control activities such as,  Periodic process review  Process audit  Testing deliverables and root cause analysis  Process improvement / re-engineering  Incorporating customer feedback  Internal quality audit of client deliverables & review reporting  Weekly/monthly monitoring of productivity reports
  • 37. 37© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 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
  • 38. 38© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Compliance – Key Facts  Well defined policies to cover compliance aspects  Written procedures covering compliance aspects  Proactive compliance reporting and issue escalation  Action list for changes in rules and regulations by regulatory authorities  Compliance evaluation framework  Periodical training on compliance issues and update  Periodic audit and review mechanism to address potential compliance risks  Implementation of data privacy and security standards like HIPAA-HITECH and ISO 27001  Incident reporting for data security violation  Compliance awareness among the employees and reward on compliance reporting  Compliance violation by employees leads to employee retraining and reassessment GoTelecare has defined and established a process and system to avoid compliance risks while carrying out operations and encourage employees to proactively report compliance issues to the higher management.
  • 39. 39© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Compliance Escalation Structure Service Delivery Service Delivery Mgr (Service Delivery POC) Head of Operations (1st Level Escalation POC) Operations CEO & MD (Final Escalation POC) Executive Board Board of Directors Compliance Compliance Mgr (Compliance Escalation POC) Head of Compliance Compliance Team Lead Process Team Lead (Service Delivery POC) Technology Technology Mgr Quality Quality Mgr HR/Training HR/Training Mgr Compliance Issue Trigger Point  Process Team Leader will inform Service Delivery Manager and Compliance Manager immediately after occurrence of the event  Compliance Manager/ Service Delivery Manager will assign the severity of the compliance issue Compliance Escalation Path Severe Compliance Escalation Path
  • 40. 40© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Data Security and End-User Privacy  Information security management system is aligned with ISO 27001:2013 standard  Implementation of policies and procedures with respect to PHI comply with HIPAA-HITECH regulations  Data replication between 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
  • 41. 41© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Why GoTelecare? WHY US?
  • 42. 42© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 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 97% 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! * Only $10 /hr for a full time biller | Just 4% of collections for AR services | Only .85 cents /claim for eligibility verification & authorization. Clients enjoy Extra Savings with  FREE Billing Software  FREE EMR  FREE Implementation  No Hidden Cost !
  • 43. 43© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 GoTelecare vs. Other Staffing Agencies
  • 44. 44© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Why Us?  Very Little Risk • Proven track record in providing healthcare BPO/KPO services • Highly experienced in providing services to both payers and providers • Experienced in working with various software platforms • Quick and efficient resource for special projects requiring technical and process expertise  Significant Upside Potential • Great understanding of the Healthcare Industry. Operation scale-up with a short notice • Extremely competitive rates, greater productivity, improved quality, increased member and provider satisfaction  Proven Process Performance • Low denial rate  increase in revenue collection • Verification & authorization accuracy > 99.9%; TAT: 24 hours • High accuracy in Eligibility Data Maintenance (in sync with CMS)  Clear Communication and Quick Response at All Times  ISO 27001:2013 & HIPAA Compliance for End-user Data Privacy and Protection
  • 45. 45© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 The Real Question But really, why us? Because we do Six Sigma quality work, validated by excellent client references, at the lowest prices in the market! We are so confident of the quality of our services that we challenge you to find another company which can deliver better quality services at a cheaper rate!
  • 46. 46© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Our 4 Pillars of Strength Highest Quality Excellent References Unique Profile Cheapest Rates Consistently delivering the best quality, with the highest levels of accuracy, efficiency & expertise Glowing testimonials from every client and not a single customer churn in our 8 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
  • 47. 47© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 What are Our Clients Saying "The professionalism I have experienced with GoTelecare’s employees has made them very easy to work with and has improved our operation processes. Any time I have a question, they are literally just a phone call or e-mail away. I love the accessibility!” - CFO of a major US healthcare company “I am starting to see an upswing with Medicare and United cash flow” - CEO of a leading US healthcare organization “Your productivity is very impressive for your first month. Almost everyone has an average of close to 40 accounts per day. We have gone over a few things with you and each time we talk, I am impressed with how quickly changes and improvements are put in place. I will continue to share feedback as I get it on additional improvements that can be made and appreciate your attentiveness and questions that you bring to our daily meetings. - Manager (Revenue Cycle) of a reputed US healthcare company
  • 48. 48© GoTelecare 2016-17| All Rights Reserved 41 Madison Avenue, 25th Floor, New York, NY 10010 Contact 41 Madison Avenue, 25th Floor, New York, NY 10010 (866) 636-6264 rh@GoTelecare.com Ronnie Hastings