Transcript Pharmacy Billing Services for Workers` Compensation / PIP Claims

CONTACT: Glenda Hill, MBA
 (775) 499-5499
Pharmacy Billing Services
for Workers’ Compensation / PIP Claims
GoTelecare 41 Madison Avenue, 25th Floor, New York, NY 10010
Company Overview
Key Facts
Awards, Affiliations & Certifications
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‘Onshore /Offshore’ KPO & BPO Services
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Serving US healthcare industry since 2007
Sun Knowledge, our contracted company, is ISO
27001:2005 and ISO 9001:2008 certified
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Robust & scalable infrastructure
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State-of-the-art technology and systems
CMMi-SVC implementation in progress under KPMG
guidance
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Highly skilled and trained staff with good
communication skills and in-depth knowledge of process
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Member of NASSCOM, the Governing Industry body for
IT/ITES in India
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Structured training, feedback and coaching
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Awarded ‘Best Emerging BPO Company of the year 2010’
by The Economic Times, India
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HIPAA-HITECH compliant
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Offices located in US & India
Recognized as one of the foremost 'Emerging companies in
Eastern India' by NASSCOM in 2011
• New York City, US – Situated in Manhattan (facility
inbuilt with all redundancies – power, infrastructure
and others)
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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
• Kolkata, India – Situated in the IT Hub of Eastern
India (facility inbuilt with all redundancies – power,
infrastructure and others)
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Awarded the prestigious “Outsourcing Service Provider of
the Year” award in the Asian Outsourcing Excellence
Awards ceremony hosted by CMO Asia on 1st August 2013
in Singapore

Awarded “Highest New Job Creator (IT/ITES)” by STPI
(Software Technology Parks of India) on 3rd December 2015
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41 Madison Avenue, 25th Floor, New York, NY 10010
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PHARMACY BILLING
BASICS
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41 Madison Avenue, 25th Floor, New York, NY 10010
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WORKERS’ COMPENSATION – OVERVIEW
What is Workers’ Compensation (WC)?
It is a form of insurance providing wage replacement and medical benefits to
employees injured in the course of employment in exchange for mandatory
relinquishment of the employee's right to sue his or her employer for the tort of
negligence.
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41 Madison Avenue, 25th Floor, New York, NY 10010
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PHARMACY COMPOUNDING – OVERVIEW
What is Pharmacy Compounding?
Pharmacy compounding is the art and science of preparing personalized medications
for patients. Compounded medications are made based on a practitioners prescription
in which individual ingredients are mixed together in the exact strength and dosage
form required by the patient.
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41 Madison Avenue, 25th Floor, New York, NY 10010
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PERSONAL INJURY PROTECTION – OVERVIEW
What is Personal Injury Protection (PIP)?
It is an extension of car insurance available in some U.S. states that covers medical
expenses and, in some cases, lost wages and other damages.
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41 Madison Avenue, 25th Floor, New York, NY 10010
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PERSONAL INJURY PROTECTION – DESCRIPTION
Understanding Personal Injury Protection
PIP is sometimes referred to as "no-fault" coverage, because the statutes enacting it
are generally known as no-fault laws, and PIP is designed to be paid without regard to
"fault," or more properly, legal liability.
Typically a PIP claim is made by the insured driver to their own insurance company.
However, there are several exceptions that allow persons who have been injured in an
accident to make a PIP claim if they do not own a vehicle.
The particular state law and policy language of the insurer should
be reviewed to see what exceptions exist in that state.
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41 Madison Avenue, 25th Floor, New York, NY 10010
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WC / PIP VS. REGULAR PHARMACY CLAIMS
WC / PIP Claims
Regular Pharmacy Claims
• Submitted to Payer and treated
similar to a physicians’ claim
• Processed through PBM on
real time basis
• Additional expense coverage
includes physical and
occupational therapy and
rehabilitation costs, psychiatric
expenses and other professional
health services.
• Covers expenses for medical,
surgical, dental and
chiropractic treatments that
are considered necessary and
reasonable such as
ambulance transportation,
hospitalization, X-rays,
nursing care, prosthetics and
funeral expenses.
PIP also offers insurance
coverage for wages lost from
work, other reasonable nonmedical or work related losses
and a death benefit.
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41 Madison Avenue, 25th Floor, New York, NY 10010
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WORKERS’ COMPENSATION – OVERVIEW
Mandatory requirements for WC / PIP claims submissions
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Employee Claim Form (C-3)
Doctor's Initial Report (C-4)
Prescription
List of ingredients (in case of compound drug)
LMN (Letter of Medical Necessity) *
Medical notes *
Patient consent *
* to be furnished upon request by payer/ adjuster
© GoTelecare 2016-17| All Rights Reserved
41 Madison Avenue, 25th Floor, New York, NY 10010
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WC / PIP CLAIMS – ADDITIONAL REQUIREMENTS
Additional information required for WC / PIP claims submissions
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Date of accident/injury
Employers details
Carrier/payer details
WC/PIP case number
Patient’s accident/injury details/diagnosis
Compound drug description, quantity dispensed, days’ supply, etc.
Compound drug ingredient details including NDC, cost, units/%, etc.
Prescriber details – Name NPI/Other license, etc.
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41 Madison Avenue, 25th Floor, New York, NY 10010
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WC / PIP PAYERS – EXAMPLES
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41 Madison Avenue, 25th Floor, New York, NY 10010
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MEDICAL
BILLING
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REVENUE CYCLE MANAGEMENT – OVERVIEW
Billing
Payment
Posting
Coding
Revenue Cycle
Management
Components
Account
Receivables
Scheduling
Eligibility
Verification &
Authorization
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SERVICE PORTFOLIO
 Inpatient/Outpatient Hospital Coding
 Physician Coding
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
BILLING
 Denial Management, e.g. 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
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A/R FOLLOW-UP
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HIGHLIGHTS
 Above 95% Collection Rate
 Claims Submission TAT 24 – 48 hours max.
 Error-free Patient Entry
 Over 99.9% Coding Accuracy
 Real Time Audits
 Proactive Follow-up on Rejections
 Denial Management
 Methodical and Proactive AR Follow-up
 100% HIPAA Compliance
 Custom Reporting
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41 Madison Avenue, 25th Floor, New York, NY 10010
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AREAS OF OPERATION
We provide billing services in the following areas:
Urgent Care
Orthotics & Prosthetics
DME (Durable Medical Equipment)
Pathology
Critical Care
Radiology
Orthopedic Surgery
EKG
Inpatient Hospitalization
Cardiology
ENT
Ambulatory Surgery Center
Anesthesia
Family Practice
Internal Medicine
Rehab Center
Pharmacy
Physician, and more…
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41 Madison Avenue, 25th Floor, New York, NY 10010
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MEDICAL BILLING CYCLE
Encounter
(SOAP)
notes
review
AR
Follow-up
Superbill
generation
and code
review
Denial
Management
Claims edit
checking
and
correction
Automatic
secondary
payer billing
ERA/EOB posting
and reconciliation
Rejection
management
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EDI claims
submission
through
clearing
house
41 Madison Avenue, 25th Floor, New York, NY 10010
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WORKING WITH WORKERS’
COMPENSATION CLAIMS
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THE GOTELECARE EDGE
Contacting WC/ PIP Payers, in itself, is a challenge.
Moreover, making the Payer, or the Payer assigned adjuster, to agree that a drug was essentially
required by the patient, is a tough job.
Sun Knowledge’s trained and highly-skilled billing and AR follow up personnel can help pharmacies
submit these claims to the correct Payer(s) and follow up with them to realize the maximum
payment fast!
When claims need
to be chased,
we know
whom to ask,
when to ask
and
how to ask!
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41 Madison Avenue, 25th Floor, New York, NY 10010
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THE GOTELECARE EDGE
We have a 100% paperless approach to WC/PIP claims handling.
Paperless solutions are easy, convenient and environmentally friendly. They
also help in increasing accuracy & efficiency, while radically reducing time
& cost required in working with insurance claims.
© GoTelecare 2016-17| All Rights Reserved
41 Madison Avenue, 25th Floor, New York, NY 10010
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THE GOTELECARE EDGE
At a cost of just 4% of collections, we have the lowest prices in the market.
We also have very attractive custom pricing options.
Other companies charge approx. 12 – 15% for similar services. With us, you can
always be sure of the highest quality services at the lowest possible rates… the
first time, and always!
© GoTelecare 2016-17| All Rights Reserved
41 Madison Avenue, 25th Floor, New York, NY 10010
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CHALLENGES AND OUR APPROACH
TASK DESCRIPTION
Patient Demographics /
Insurance / Charge Entry
Eligibility Verification
CHALLENGES
APPROACH
 Missing information / Key-in errors
 Transaction audit to minimize errors;
reduces denial due to missing patient
information
 Increased denial rate
 Increased TAT
 Time consuming with limited staff
 Assignment of adequate staff
 Secondary verification not carried out
 Completion of secondary verification
 Rigorous audit
Checking Authorization
Requirement and
Obtaining Authorization
 Time consuming with limited staff
 Assignment of adequate staff
 Documentation collection requires
continuous follow-up
 Systematic and regular follow-up with
physicians’ offices & payers to collect
documentation and obtain authorization
 Increased TAT
 Proper tracking mechanism
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41 Madison Avenue, 25th Floor, New York, NY 10010
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CHALLENGES AND OUR APPROACH
TASK DESCRIPTION
Paper Claim Submission
CHALLENGES
APPROACH
 Additional work for printing and
faxing/mailing
 Proper tracking of every submission of
paper claims
 Delayed filing leading to denials
 Moving to EDI based submission
whenever possible will reduce cost of
manual work and faster payment cycle
 Lack of information about the actual
status
 Delayed correction and resubmission
Rejection Management
Payment Posting
 Possible loss of payment
 Defining KPI for rejection management
process and assigning responsibility
 Claims reconciliation and exception
report generation
 Unapplied balance
 Defining guidelines
 Accumulation of backlog
 Review of patient payments
 Manual posting
 Define KPI – TAT & Accuracy
 Denials not posted
 Denial posting and review
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41 Madison Avenue, 25th Floor, New York, NY 10010
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CHALLENGES AND OUR APPROACH
TASK DESCRIPTION
AR Follow-up &
Denial Management
CHALLENGES
APPROACH
 Accumulation of backlog
 Regular analysis, follow-up and review
 Denials not posted
 Transaction audit
 Claims reconciliation issue
 Lack of clarity of claims volume and
current status affects management
decision making process
Process Administration
and Reporting
 Impact on overall billing process
performance and improvement
 Decreased productive efficiency
 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
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41 Madison Avenue, 25th Floor, New York, NY 10010
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REASONS TO
CHOOSE US
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41 Madison Avenue, 25th Floor, New York, NY 10010
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ADVANTAGE GOTELECARE
1
2
3
4
5
Over 8 Years
of Experience
in Working as
Vendors for
Major Health
Insurance
Companies
Across US
Consistent
Performance
in Delivering
97%
Collection
Rate to
Clients
The Only
Medical Billing
Company with
Its Own Stateof-the-Art
Telemedicine
Platform
The Lowest
Prices* in the
Market!
Deep
Knowledge of
both the
Payer and the
Provider Side
of the US
Healthcare
Spectrum
Already
Recovered
over millions
in Account
Receivables
and
counting…
The Best
References
in Every
Segment
of US
Healthcare
Knowledge &
Business
Process
Outsourcing
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41 Madison Avenue, 25th Floor, New York, NY 10010
* Only $10 / hour
for a billing expert
working
exclusively on the
client account
OR
just 4% of total
collections realized
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A SIMPLE ANSWER
But really, why us?
Because we do Six Sigma quality work, validated
by excellent client references, at the lowest
prices in the market!
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41 Madison Avenue, 25th Floor, New York, NY 10010
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OUR 4 PILLARS OF STRENGTH
Glowing testimonials from every
client and not a single customer
churn in our 8 years of operation
Consistently delivering the best
quality, with the highest levels of
accuracy, efficiency & expertise
Huge experience in working for
both Payers and Providers and
the only billing company with its
own Telemedicine platform
© GoTelecare 2016-17| All Rights Reserved
Highest
Quality
Excellent
References
Unique
Profile
Cheapest
Rates
The lowest rates in the market,
with custom pricing options to
delight clients of all sizes
41 Madison Avenue, 25th Floor, New York, NY 10010
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SUMMARY OF BENEFITS
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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
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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
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Low denial rate  increase in revenue collection
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Verification & authorization accuracy > 99.9%; TAT: 24 hours
•
High accuracy in Eligibility Data Maintenance (in sync with CMS)
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Clear Communication and Quick Response at All Times
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ISO 27001:2005 & HIPAA Compliance for End-user Data Privacy and Protection
© GoTelecare 2016-17| All Rights Reserved
41 Madison Avenue, 25th Floor, New York, NY 10010
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TESTIMONIALS
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 major US healthcare company
My firm has evaluated an outsourcing transaction with GoTelecare. They
provide superior service at a very attractive rate and have demonstrated to us
their commitment to this partnership. Their expertise across various process
areas in the PDP/MAPD domain and unique cost structure puts them in an
incredible position to work with plans throughout the healthcare industry
Chairman & CEO of a leading US healthcare company
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41 Madison Avenue, 25th Floor, New York, NY 10010
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CONTACT US
Glenda Hill, MBA
(775) 499-5499
[email protected]
© GoTelecare 2016-17| All Rights Reserved
41 Madison Avenue, 25th Floor, New York, NY 10010
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