RCM Gateway Inc

Key Facts About us

 ‘Onshore /Offshore’ Medical Billing Services RCM Gateway Inc established out of the
 Serving US healthcare industry since 2018 desires to create a quality, service-oriented
 Robust & scalable infrastructure billing and Practice Management Company.
Since its inception, RCM Gateway has
 State-of-the-art technology and systems
maintained a commitment to quality,
 Highly skilled and trained staff with good accountability, compliance, and personal
communication skills and in-depth service to each of its clients. Our Executive
Management Team is actively involved in
knowledge of process
providing client services.
 Structured training, feedback and
coaching
 HIPAA-HITECH compliant
 State-of-the-art office inbuilt with all
redundancies – power, infrastructure
and others

A-151, Prince Road, Sarovar Portico Lane, A

Jaipur-302021 INDIA
Private & Confidential Web: www.rcmgatway.com 1

Email: operations@rcmgatway.com
Phone # 99291 11325
 RCM Gateway Inc

Administrative Services Contact Center

 Medical Coding & Billing  Provider Support

 Claims Administration  Member Support
 Enrollment Processing & Member  Member Retention Program
Fulfillment  Clinical Help Desk
 Credentialing
 Premium billing and collections

Analytics IT Services

 Claims /Drug Utilization  Telemedicine Services

Analysis  Remote Patient Monitoring
 PDE Analysis
 Application Development & Support
 RAF Analysis
 Technical Support
 Payment Reconciliation
 Technical Documentation

We provide services to
Providers – Physicians, Hospitals, DME, Laboratories, Home Health Care and Pharmacies

Private & Confidential 2

 SERVICE AREAS
PRACTICE BILLING &
PAYER SERVICES
MANAGEMENT COLLECTIONS

Scheduling Coding Credentialing

Eligibility &
Utilization
Authorization Charge Posting
Verification Management

Customer
Prior Authorization Claims Submission
Service

Customer Care Payment Posting

Denial Management

Accounts Receivable

Private & Confidential 3

 SERVICE AREAS

We provide revenue our services in the following areas:

Nursing Homes Prosthetics & Orthotics Urgent Care

Durable Medical Equipment Dentistry Skilled Nursing Facilities
Wound Care Pain Management Pharmacies
Cardiology Specialty Clinics Orthopedic Surgery
Physical Therapy Family Practice Radiology
Rehab Centers Dermatology Diabetics
Healthcare Facilities and more…

Private & Confidential 4

 SERVICE HIGHLIGHTS
 Up to 97% collection rate
 Instant reduction of billing cost by 70%
 FREE medical billing software, EMR & setup*
 Real-time eligibility checks & fast authorization
 100% HIPAA-HITECH compliance
 Claim status analysis using Rapid Automation Technology®
 Turnaround time less than 48 hours max.
 Low service fees with no hidden cost
 Zero lockup service contract that can be cancelled anytime
 Real-time audits and custom reporting

Private & Confidential

 HIPAA COMPLIANCE SUMMARY

SL. COMPLIANCE ASPECT HIGHLIGHTS

1 Physical Access Authorized access only | Bio-metric access | Proximity card system | Photo ID cards | Access log review
2 General Security 24 hour security personnel | Logging of visitor details | Physical register retained for 10 years
3 Monitoring CCTV monitoring (with recording) of production area | Daily review of recording
Signing confidentiality agreement before accessing sensitive areas | Accompanied by security personnel/employee during
4 Vendor Access all times

5 Mobile Phones All employees (except managers) are required to deposit mobile phones in the locker box before entering facility
6 Personal Baggage No backpacks or other bags allowed | All baggage to be deposited in locker box before entering facility
Network & Unique user IDs created using Microsoft Active Directory | Access to storage devices, shared drives, USB/mass
7 Application Usage storage devices, printers – controlled by Domain Group Policy | No wireless access points

Unified Threat Management System | Internet traffic regulation using multiple filters | Network Address Translation (NAT) |
8 Firewall Intrusion Prevention Systems (IPS) | Port-mapping for traffic between Virtual LANs | Default setting to deny all traffic

VPN (Virtual Site-to-site IPSec VPN tunnels | Authorized access via client-to-site VPN connections | Access authorization
9 Private Network) controlled by Active Directory's authentication service

Redundancy Fully redundant network stack | Two ISP links configured in active-active mode | Power backup supplied by 130 KVA UPS
10 Management and 750 KVA generator | 22 KVA UPS backup for server and network systems

Virus & Malware Central anti-malware system | Automatic updates | Extra protection by gateway firewall |
11 Protection Centralized OS patch management system (using Microsoft's WSUS server)

12 Other Measures Fire extinguishers at key areas | Half-yearly fire drills

Private & Confidential 6

 REVENUE CYCLE
MANAGEMENT

Private & Confidential 7

REVENUE CYCLE MANAGEMENT – KEY PROCESSES

Eligibility &
Authorization
Verification
Patient
Reporting Information
Entry

Denial
Coding
Management 360°
Revenue Cycle
Management
Services

Accounts
Charge Entry
Receivable

Payment Claim
Posting Submission

Private & Confidential 8

 IMPORTANT TASKS
 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
A/R FOLLOW-UP
Private & Confidential 9
 MEDICAL BILLING CYCLE
Rx Order Entry
Patient
Demographics
A/R Follow-up
and Insurance
Entry

Rejection/Denial Product Code /

Management Rx & Dx Entry

Eligibility
Submission Verification/
Authorization

Collection of
Collection of
documents for
complete Rx
Auth Approval

BILLING Private & Confidential 10

 MEDICAL BILLING CYCLE
 Order entry based on the Rx received from the Physician
• Patient demographics & insurance entry
• Provider information entry
• Product code entry
• Rx & Dx entry (with appropriate timeframe)
• If necessary, a telemedicine consultation can be completed to obtain a Rx to expedite the order entry process
 Eligibility verification and authorization requirement enquiry
 Collection of documents required by payer for auth approval, e.g. face-to-face consultation notes, and obtaining
authorization from Payer
 Determination that Payer criteria is met before delivery of equipment, e.g. some products have time/frequency/
annual cost limitations f (if criteria is not met, the Patient is contacted and informed of the financial
responsibility)
 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

BILLING Private & Confidential 11

 MEDICAL CODING OVERVIEW
Service Offerings
• Place of Service Based Coding – Inpatient, Outpatient Coding
• Provider Specialty Based Coding– E/M, Cardiology, Orthopedics, Physical Medicine etc.

Key Tas•ksReview 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

CODING Private & Confidential 12

 MEDICAL CODING – PROCESS
Medical Coding Process Flow

Downloading Allocation
Encrypted reports are Reports are allocated to
downloaded from SFTP site coders according to specialty

Quality Check Coding

Quality checked for LCDs, Analysis of reports, allocation
updates and client specs. of ICD and Service codes

Uploading Feedbacks & Updates

Analysis of reports, allocation Client reports back with
of ICD and CPT codes feedbacks and updates

CODING Private & Confidential 13

 MEDICAL CODING – HIGHLIGHTS
• 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 Private & Confidential 14

 ELIGIBILITY & AUTHORIZATION VERIFICATION

ELIGIBILITY VERIFICATION
• Full range of verification services
• Fast 24-hour turnaround time
• 96 – 99.9% accuracy
• Detailed documentation
• 100% HIPAA compliance
• Experience with national and private carriers

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
VERIFICATION 15

Private & Confidential

 SAMPLE REPORTS
ELIGIBILITY VERIFICATION AUTHORIZATION VERIFICATION
140

129
50

128
125

45 46
44
45
120
38
100
40

98
96

96
94

94

100
35
83

80 30
25 25 26 25
25 22 22
60 20 21
20
41

40 15
32

32
31

30
29

28
15 12
26

10
20 10
11

5
0
4/6/2023 4/8/2023 4/9/2023 4/10/2023 0
4/7/2023 4/6/2023 4/7/2023 4/8/2023 4/9/2023 4/10/2023
Patient Brought Forward
Number of New Patient Auth Required Auth Obtained Auth Pending
Secondary Checked (if
Primary Checked applicable)

VERIFICATIO Private & Confidential 16

 PRIOR AUTHORIZATION
• Full Range Service (Authorization Request Follow-up Approval)

• 99.9% accuracy

• 100% HIPAA-HITECH Compliance

• Low prices with no hidden cost

• Highly streamlined, fast and accurate service

• Physical Therapy
• Nursing Homes
• Specialty Clinics
We cater to • Skilled Nursing Facilities (SNF)
• Diabetes
• Outpatient Surgery requiring general anesthesia
• Inpatient rehabilitation – Treatment for alcohol or drug abuse
PRIOR
AUTHORIZATION Private & Confidential
• Many other conditions… 17
 ACCOUNTS RECEIVABLE
Our A/R follow-up service is designed to increase the Revenue Collection
for our clients.

The process begins after the Provider creates and sends Health
Insurance Claims
(Electronic/Paper claims or Manual HCFA forms) to various Insurance
Companies.

Depending on the transmission type and length of time since submission,

we begin our follow-ups.

ACCOUNTS
RECEIVABLE Private & Confidential 18
 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

 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

Reducing days in A/R, claims submission and improving

collection ratio with an increase in the probability of payment
through timely follow-up is the responsibility of the A/R team

ACCOUNTS
RECEIVABLE Private & Confidential 19
 DENIAL MANAGEMENT

2 Categories of Denial Management

Claim Correction and Resubmission

1 These are the claims which are corrected, modified, and resubmitted as a corrected
claim to Insurance companies.

For such claims, every effort is made to resolve the denial to avoid billing the patient.

Patients' Responsibility
2 These are claims which cannot be further worked upon and the final bill is sent to the
patient for payment collection.

The reasons for sending the patient a bill generally include In-Network deductibles and
non-covered benefits as per the insurance plan. Patients receive a statement with a
clear explanation for the balance due.

ACCOUNTS
RECEIVABLE Private & Confidential 20
 DISTRIBUTION OF
DENIED CLAIMS
Distribution of Denied Claims

10%
24%
17% Auth Related
Coding Correction Required
11% OON Issue
3% Others
35% Patient info missing
Timely Filing

ACCOUNTS
RECEIVABLE Private & Confidential 21
 AR AGING REPORT SAMPLE
RCM Gateway Inc AR AGING REPORT FOR Client X Inc. - 07/06/2023 through 07/12/2023
>120 Days 91 – 120 Days 61 – 90 Days 31 – 60 Days
PAYER
Claims Completed Remaining Claims Completed Remaining Claims Completed Remaining Claims Completed Remaining

AARP HEALTH CARE

26 23 3 17 16 1 44 41 3 37 32 5
OPTIONS

AMERICAN TRANSIT
12 11 1 6 5 1 15 15 0 10 10 0
INSURANCE COMPANY

BCBS 28 24 4 16 13 3 41 37 4 32 30 2

MAGNACARE 13 12 1 9 9 0 23 22 1 11 10 1
HIP_PALLADIAN
6 6 0 12 9 3 12 10 2 15 15
HEALTH
MANAGED PHYSICAL 0
NETWORK
STATE FARM 12 10 2 8 7 1 10 10 0 10 8 2
INSURANCE
7 6 1 4 4 0 5 5 0 4 4
TOUCHSTONE HEALTH 0
5 5 0 8 6 2 6 4 2 16 12 4
UNITED HEALTHCARE 31 28 3 23 20 3 49 43 6 41 39 2

ACCOUNTS
RECEIVABLE Private & Confidential 22
RCM Gateway Inc

 Increased revenue – reduced collection time (95% + collection rate)

 Reduction in accounts receivable by 30% within 1 month

 Expert handling of accounts receivable by highly experienced staff with demonstrated expertise

 Claim submission within 48 hours of receipt of billing input

 Provider can focus more on core services

 Adherence to CMS billing requirements

 Proper records maintenance and visibility through reporting

Private & Confidential 23

 CHALLENGES & RESPONSES

Private & Confidential 24

 CHALLENGES & OUR APPROACH
TASK DESCRIPTION CHALLENGES APPROACH

 Missing information / Key-in errors  Transaction audit to minimize errors;

reduces denial due to missing
Patient Demographics /  Increased denial rate
patient information
Insurance / Charge Entry
 Increased TAT

 Time consuming with limited staff  Assignment of adequate staff

 Secondary verification not carried out  Completion of secondary verification
Eligibility Verification
 Rigorous audit

 Time consuming with limited staff  Assignment of adequate staff

Checking Authorization  Documentation collection requires  Systematic and regular follow-up with
Requirement and continuous follow-up physicians’ offices & payors to collect
Obtaining Authorization documentation and obtain authorization
 Increased TAT
 Proper tracking mechanism

Private & Confidential 25

 CHALLENGES & OUR APPROACH
TASK DESCRIPTION CHALLENGES APPROACH

 Additional work for printing and  Proper tracking of every submission of

faxing/mailing paper claims
Paper Claim Submission  Delayed filing leading to denials  Moving to EDI based submission
whenever possible will reduce cost of
 Lack of information about the actual
manual work and faster payment cycle
status

 Delayed correction and resubmission  Defining KPI for rejection management

process and assigning
 Possible loss of payment
Rejection Management responsibility
 Claims reconciliation and exception
report generation
 Unapplied balance  Defining guidelines
 Accumulation of backlog  Review of patient payments
Payment Posting
 Manual posting  Define KPI – TAT & Accuracy
 Denials not posted  Denial posting and review

Private & Confidential 26

 CHALLENGES & OUR APPROACH
TASK DESCRIPTION CHALLENGES APPROACH

 Accumulation of backlog  Regular analysis, follow-up and review

AR Follow-up &  Denials not posted  Transaction audit
Denial Management
 Claims reconciliation issue

 Lack of clarity of claims volume and  Proper documentation – process

current status affects manual, guidelines &
management decision checklists
making process
 Defining proper tracking mechanism
Process Administration  Impact on overall billing process through various reports -Ageing, Status,
and Reporting performance and Daily, Exception
improvement
 Generate exception reports and regular
 Decreased productive efficiency audit of every process tasks
 Defining KPIs and assigning
responsibility

Private & Confidential 27

 SUMMARY OF BENEFITS
 Very Little Risk
• Proven track record in providing healthcare BPO/KPO services
• Experienced in providing services to both payers and providers
• Experienced working with various software platforms
• Quick and efficient resource for special projects requiring technical and process expertise
 Significant Upside Potential
• Great understanding of the Healthcare Industry. Operation scale-up with a short notice
• Extremely competitive rates, greater productivity, improved quality, increased member and provider
satisfaction
 Proven Process Performance
• Low denial rate  reduced collection time  increase in revenue collection
• Billing & Coding Accuracy > 99.9%; TAT: 24 – 48 hours
• Adherence to CMS billing requirements
 Clear Communication and Quick Response at All Times

28
Company Workflow
Founder

CEO CFO

Operation
Client Manager IT Manager
Manager
RCM

Assistant Assistant
Manager EV Manager AR/
Denial

Sr Executive
Sr Ex EV AR/ Denial

Executive AR/
Executive EV
Denial
29