Name of Practice:
Name of Office or Practice Manager:
Office Address:
Phone Number:
E-mail Address:
1. How many claims per month?
2. How many active patients?
3. Average or Percentage of
claims that are rejected or denied for payment
per month?
%
4. Average personnel hourly
rate for all employees in the practice who
participate in the billing or statement process?
$
5. Cost of one HCFA form?
$
6. Cost of one HCFA envelope?
$
7. Percentage of active patients who receive
monthly statements?
%
8. Cost of each monthly statement?
$
9. Total hours it takes to prepare
statement?
10. Expenses include depreciation,
lease amount, and new or used hardware purchase
for doing claims and statement?
$
11. Include any cost of software
purchases related to reimbursement aspects
within the practice including backup software,
etc?
$
12. Include any cost for any
software upgrades related to reimbursement
within the practice including backup software,
etc?
$
13. Include monthly support
costs, updates, or purchases required to maintain
an active account with software/hardware vendor?
14. Average cost for printer
ribbons, cartridges, pens, pencils, paper,
etc?
$
15. Average cost of square footage
devoted to claims processing per month?
$
16. Average cost of supervisory
related expenses?
$
17. Average number of telephone
calls to patients and insurance companies
per month?
18. Average cost of a single
telephone call to patients and insurance companies
per month?
$
19. What is the number of claims
a practice can process in an hour?
20. Do you accept assignment?
Choose
One
Yes
No
21. Percentage wise, how many
claims do you process weekly of the following?
22. Total Gross Billings per
month?
$
23. Total Collections per month?
$
24. What is your present accounts
receivable total?
$
Do you have credit balances?
Choose
One
Yes
No
If yes, how much?
$
How is this reflected in the
accounts receivable total?
Aging:
25. When was the last time you
updated your superbill?
26. Briefly explain the most
difficult and time consuming aspect of your
current claims processing and billing system.
27. What would you like to see
in ways of improving your current claims processing
and billing system?