NSS Billing Contract Between. Innovative Healthcare Solutions

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1 INNOVATIVE HEALTHCARE SOLUTIONS, LLC 213 EAST BROADWAY LOUISVILLE KY efax NSS Billing Contract Between & Innovative Healthcare Solutions This Billing Services Agreement ("Agreement") is made effective as of, between Innovative Health Care Solutions, (IHCS) of 7410 New Lagrange Rd Suite 108, Louisville, Kentucky and. In this agreement, the CLIENT seeks to utilize billing services for NEUROSTIMSTIMULATORS (NSS) provided by IHCS exclusively for its medical practice and is subject to all terms and conditions contained herein. NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties hereto agree as follows: 1. COMMENCEMENT DATE. Billing Agreement is scheduled to begin on 2. TERM. This agreement shall continue for a period of one year after Commencement Date. 3. RENEWAL. This agreement will automatically renew unless written notice is given by the canceling party at least 30 days prior to the last day of the term then in effect. 4. SERVICES. IHCS will provide billing services to NSS CLIENTs for the term of this agreement as provided in Addendum A. IHCS will bill NSS Distributor (a) in a manner consistent with applicable federal, state and local laws and regulations and (b) within the policies and procedures of third party payers that are made known by CLIENT or third parties to IHCS in writing. 5. FEES. Billing fees are included in the price of the Full Service Program and are being paid to IHCS via your NSS Distributor. 6. CLIENT RESPONSIBILITIES. All Clinical and Charge source data and insurance forms are to be completed in an accurate and timely manner by CLIENT and provided to IHCS in the format designed by IHCS. IHCS will provide CLIENT with a CLIENT s policy & procedure information sheet. See Addendum A. CLIENT must strictly adhere

2 to procedures for the submission of billing information to IHCS. CLIENT acknowledges that such compliance is a condition of precedent to any and all obligations of IHCS. DESCRIPTION OF SERVICES. Beginning on, IHCS will provide NSS Billing Services, which will include the use of a web based Practice Management Service where IHCS will maintain patient demographic information,claim submission, follow-up, reporting and prior authorizations for CLIENTs of CLIENT. PERFORMANCE OF SERVICES. The manner in which the Services are to be performed and the specific hours to be worked by IHCS shall be determined by IHCS. IHCS will work as many hours as reasonably necessary to fulfill the needs of the CLIENTs of CLIENT obligations under this Contract. TERMINATION. This Agreement can be terminated at any time on written notice for cause. For purposes of this Agreement, the term for cause is defined as a material breach of a term or condition hereof that is not corrected within forty-five (45) days of prior written notice describing the breach in reasonable detail. IHCS reserves the right to terminate for noncompliance of protocols. Protocols are attached to this agreement as Addendum A. Should IHCS request termination, IHCS will make a recommendation of another billing agency to assist with a smooth transition. Termination by CLIENT for Cause: In the event that termination by CLIENT is for cause, CLIENT shall be responsible for all unpaid amounts owed IHCS by CLIENT up to the effective date of termination and shall pay IHCS such outstanding sums on or before the last day of service requested by CLIENT and prior to IHCS's turnover of transition information and databases to CLIENT. Upon notification of termination by CLIENT for cause, IHCS shall cease performing services for CLIENT and will send to CLIENT, at CLIENT s expense, a complete printout of remaining Accounts Receivable on HCFA-1500 forms and a printout of all remaining patient balances within ten (10) business days of the effective date of termination. Termination by IHCS for Cause: Termination by CLIENT other than for Cause. If, prior to end of the term of this Agreement, IHCS terminates for cause or if CLIENT terminates other than for cause, then CLIENT shall pay IHCS the sum of any outstanding invoices due by CLIENT to IHCS. All amounts owed IHCS under this subsection shall be paid to IHCS in a single lump sum payment no later than the last day of service requested by CLIENT and prior to IHCS's turnover of transition information and database to CLIENT. Termination Procedure. In the event this Agreement expires or is terminated other than by CLIENT for cause, IHCS will: 1. Continue to perform services, at the then-current rates hereunder, for a period of ninety (90) days after the effective date of termination (the Wind Down Period ) for all of CLIENT's accounts receivable relating to CLIENT s charges for Medical Services rendered prior to the termination date (Existing Accounts Receivable);

3 2. CLIENT expressly agrees to cooperate and assist IHCS with its performance during the Wind Down Period and will timely report, or cause to be reported, all payments applicable to the existing Accounts Receivable for which IHCS is responsible. 3. At the end of the Wind Down Period, IHCS will discontinue performing services as to CLIENT s existing Accounts Receivable 4. Deliver to CLIENT, at CLIENT's expense, after and conditional upon full payment to IHCS of all fees, whether disputed or not, owed to IHCS by CLIENT under this Agreement, a complete printout of remaining Accounts Receivable on HCFA-1500 forms and a printout of all remaining patient balances. CLIENT may receive copies of all of CLIENT s EOBs in IHCS s possession by providing IHCS with at least five (5) business days prior written notice. A backup copy of CLIENT s information stored on IHCS s hard drive system can be made available to CLIENT by IHCS per written request. 5. Except for the forgoing or for such other matters as the parties may agree to in writing, after the effective date of termination, IHCS shall have no further obligations to provide Services to CLIENT under this Agreement. CLIENT may negotiate with IHCS for additional transitional services or for the provision of additional data, including CLIENT data, to be provided by IHCS after the date of termination at CLIENT s additional expense. CLIENT RECORDS. Each party shall maintain its own records. IHCS may elect to scan and store copies of CLIENT records (EOBs, patient registration forms, medical notes, and correspondence) that are less than twelve (12) months in age. Upon written notice from CLIENT, IHCS will transmit to CLIENT all CLIENT records that have been in IHCS s possession for at least twelve (12) months via regular U.S. mail at CLIENT s sole expense. IHCS will destroy all CLIENT records that have been in the possession of IHCS for at least twelve (12) months via shredding or incineration upon written notice from CLIENT. In such event, IHCS will provide written certification of the destruction of the CLIENT records to CLIENT. Notwithstanding the foregoing, IHCS shall have the right, in its sole discretion, to destroy or otherwise dispose of all copies of CLIENT records remaining in IHCS s possession for at least eighteen (18) months. OUTSOURCING. At IHCS s discretion, and subject to the privacy and security provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended, IHCS may utilize outside resources, domestic or otherwise in the performance of its duties and responsibilities as set forth by this Agreement. SURVIVAL. The terms, conditions, obligations and covenants of this Agreement shall survive its execution by the parties hereto and the execution of contracts hereafter entered into between the parties except to the extent that such transactions and contracts may be inconsistent with the Agreement. RELATIONSHIP OF PARTIES. It is understood by the parties that IHCS is a Service Provider with respect to CLIENT, and not an employee of the CLIENT. CLIENT will not provide fringe benefits, including health insurance benefits, paid vacation, or any other employee benefit, for the benefit of IHCS.

4 SUPPORT SERVICES. CLIENT will not provide support services, including office space and secretarial services, for the benefit of CLIENT. WORK PRODUCT OWNERSHIP. Any copyrightable works, ideas, discoveries, inventions, patents, products, or other information (collectively, the "Work Product") developed in whole or in part by IHCS in connection with the Services shall be the exclusive property of CLIENT. Upon request, IHCS shall sign all documents necessary to confirm or perfect the exclusive ownership of CLIENT to the Work Product. EMPLOYEES. IHCS's employees, if any, who perform services for CLIENT under this Contract shall also be bound by the provisions of this Contract. At the request of the CLIENT, IHCS shall provide adequate evidence that such persons are IHCS employees. ASSIGNMENT. IHCS's obligations under this Contract may not be assigned or transferred to any other person, firm, or corporation without the prior written consent of CLIENT. CONFIDENTIALITY. IHCS will not at any time or in any manner, either directly or indirectly, use for the personal benefit of IHCS, or divulge, disclose, or communicate in any manner any information that is proprietary to CLIENT. IHCS will protect such information and treat it as strictly confidential. This provision shall continue to be effective after the termination of this Contract. Upon termination of this Contract, IHCS will return to CLIENT all records, notes, documentation and other items that were used, created, or controlled by IHCS during the term of this Contract. INDEMNITY. CLIENT shall indemnify, defend and hold harmless IHCS, its officers, directors, employees, agents, and shareholders against and in respect of any and all claims, settlements, demands, losses, costs, expenses, obligations, liabilities, damages, recoveries, and deficiencies, including interest, penalties and reasonable attorney s fees and disbursements (including, but not limited to any attorney s fees and disbursements incident to any appeals), that IHCS (it s owners, officers, directors, employees and agents) may incur or suffer which arise, result from, or relate to either (i) any breach of or failure by CLIENT to perform any of its duties and/or responsibilities described in this Agreement or in any schedule, certificate, exhibit or other instrument furnished or to be furnished by CLIENT under this Agreement, or (ii) any action (or failure to act) of CLIENT, including, without limitation, collection efforts and activities by CLIENT or third parties, noncompliance with any local, federal and state statutes, rules and regulations and all private carrier rules and regulations governing health insurance payments. CLIENT shall promptly notify IHCS of the existence of any claim, demand or other matter to which CLIENT s indemnification obligations would apply, and shall give IHCS a reasonable opportunity to defend the same at CLIENT s expense and with counsel of IHCS s selection; provided that IHCS shall at all times also have the right to fully participate in the defense at its expense. If CLIENT shall within five (5) days after such otice fail to initiate such a defense, IHCS shall have the right, but not the obligation, to undertake the defense of, and to compromise or settle the claim or other matter on behalf, for the account, and the risk of CLIENT. IHCS will indemnify and hold harmless CLIENT against any damages or liabilities incurred by CLIENT,

5 it s employees or contractors arising out of the failure of IHCS knowing or willful violation of applicable laws and regulations. COMPLIANCE. CLIENT and IHCS each agree to establish and maintain a Medicare Compliance Program. IHCS agrees to provide CLIENT with a specific compliance outline and additional educational materials provided by distributor. Upon request, IHCS will perform a biannual random chart audit of twenty (20) patient encounters for each provider in CLIENT s practice. EXCLUSIVE RELATIONSHIP. CLIENT grants IHCS the exclusive right to serve as the billing service for all of CLIENT s patient NSS billings during the term of this Agreement and each renewal hereof. No other service or in-house billing service shall be used by CLIENT, in whole or in part, during the term of this Agreement. IHCS reasonable suspicion of a violation of this provision shall entitle IHCS to a full accounting, at CLIENT s expense, by an accountant of IHCS s choice, of all CLIENT s financial records to determine the amount and source of monies collected by CLIENT during the period in question. IHCS shall be entitled to receive any deficiency in payment by CLIENT to IHCS revealed by such accounting, plus interest at the rate of twelve percent (12%) per annum (or any lower rate to the extent permitted by law) from the date of actual collection. NOTICES. All notices required or permitted under this Contract shall be in writing and shall be deemed delivered when delivered in person or deposited in the United States mail, postage prepaid, in the addresses detailed in the beginning of the Contract. ENTIRE CONTRACT. This Agreement sets forth all of the representations, obligations, responsibilities and understandings of the parties. No prior Agreements or representations, either written or oral, shall be binding upon either party unless included in this Agreement. No modification or change hereto shall be valid or binding unless in writing and executed by the parties to this Agreement. AMENDMENT. This Contract may be modified or amended if the amendment is made in writing and is signed by both parties. SEVERABILITY. If any provision of this Contract shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If a court finds that any provision of this Contract is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited. COUNTERPARTS. This agreement may be executed in several counterparts, each of which shall be an original, and all of which shall be constitute one and the same instrument. WAIVER OF CONTRACTUAL RIGHT. The failure of either party to enforce any provision of this Contract shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict compliance with every provision of this Contract.

6 APPLICABLE LAW. This Contract shall be governed by the laws of the State of Kentucky. SIGNATURES. This Contract shall be signed by Physician and on behalf of IHCS by Robin Campbell. By: CLIENT (PHYSICIAN) Print Name By: Robin Campbell Owner, Innovative Healthcare Solutions

7 FSP Billing and Precertification Overview Prior Authorization Protocols 1. IHCS will initiate all prior authorizations (PA) for the NSS Device. 2. For each patient referred by your office IHCS is to be provided the required information in order to facilitate the authorization and billing of the device. Please fax this information to: A. Please fill out the NSS Device Pre-Certification form. B. Our office needs a copy of the patient s insurance card(s), front and back, in order to verify coverage and eligibility. C. Patient demographics: we need the demographics for billing. D. Office Note: for each patient, we need the provider s note ordering the NSS device. 3. Work Comp: if a patient is covered by work comp, IHCS will contact the adjuster and verify the claim and coverage. The adjuster must authorize each device the physician orders for treatment. In order to increase the likelihood of coverage for work comp patients, we must have all required information and the Office Note in order to call the adjuster. If the adjuster requires additional information we will contact your office to obtain this documentation. 4. Once the PA has been initiated, we will provide a status update within 72hrs. As soon as we determine eligibility and coverage we will contact your office with the PA information. 5. IHCS requires dictation for all patient PA. We are unable to contact an insurance company without the dictation due to the requirements of the insurers. Therefore, all orders sent to our office will be on hold waiting on the dictation. 6. It is IHCS policy that any requested documentation that IHCS does not receive within five business days will result in that patient being removed from the FSP program. 7. Should IHCS receive either a denial or a request for additional information IHCS will work with your office to provide the information needed for the insurance company to reach a decision or aid in an appeal of a denial of service. The request we most often have is for additional information, up to and including a letter from the physician s office to answer their questions regarding patient treatment and medical necessity. We ask that you answer our requests for information within seventy two (72) hours. 8. Should you have any questions or concerns about any prior authorization for your patient please send an to We will respond within 24hrs.

8 Billing Protocols IHCS provides personalized attention to all clients. As a client, you will receive constant communication from our team. In order to build a successful partnership, we require that our clients be compliant with all requests within seventy two (72) hours. It is imperative that we receive all requests for information as it is needed by the insurance company in order to render a decision. Please review the following billing protocols. 1. New Client Information sheet: this form is submitted to IHCS by the sales team. 2. NSS Encounter Forms: Please forward all NSS encounter forms at the end of each business day. We bill for services as soon as we have the information in order to expedite payment to your office. 3. Procedure Note: your office note for the procedure is needed for our software and for billing. All documents we receive from your office are uploaded into our software system. 4. We will submit claims for service within twenty-four hours of receiving your encounter form. 5. Work Comp: in order to submit a claim to work comp, IHCS must have the encounter form and the office note. Work comp insurance companies will not consider a claim without documentation. 6. Explanation of Benefits: IHCS requires clients to EOBs within twenty-four hours for the billing of the NSS device. We update records daily and for our reports to be accurate we need EOBs to enter payment information. 7. Client Billing: in order to track revenue and payments, some offices may bill for the NSS device in their billing software. It is IMPERATIVE that, as a client for whom we are billing, all such claims are placed in a HOLD status so the claims are not generated. While participating in the FSP our clients are precluded from billing for the NSS devices. This will result in duplicate billing and confusion. Reporting Accounts Receivable Report, Bi-Weekly: IHCS will send an accounts receivable report biweekly. This report will help clients keep track of their progress. Accounts Receivable Report, End of Month: IHCS will send a monthly A/R summary by the 3 rd of every month, after the month-end calculations have been completed.

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