Questionnaire Please fill out the Medical Practice Analysis Questionnaire and submit for a complimentary consultation and evaluation. * indicates required fields    *Practice Name:   *Practice Type/Specialty:   *Name/Title:   *Office Manager/Practice Manager's Name:   *Mailing Address/Phone Number:   Top 3 challenges affecting practice profitability?:  Billing Insurance  Insurance Denials  Time Constraints  Regulation Changes  Follow-up On Denials  Re-Billing On Denials  Pre-Authorizations  Employee Retention   Are you a:  Solo Practice  Owner + Associate  Partner (2)  Group (3+)   Approx. how many active patients do you have?:   Approx. how many patients are seen per day?:   How many managed care plans currently enrolled in?: 0-2 3-5 6-10 11+   Does your office outsource its billing?:  Yes  No   If so, which company do you use?:   If not, do you file claims electronically?:  Yes  No   If so, to whom?: Medicare only All carriers who accept them   Average number of claims billed per month?:   Average dollar value of each claim?:   What is your current Account Receivables?:   Accounts Receivable (% or $) over 60 days?:   Accounts Receivable (% or $) over 90 days?:   Accounts Receivable (% or $) over 180 days?:   What % of the claims you submit are rejected?:   Do you currently have a backlog of claims?:  Yes  No   Specific employee following up rejected claims?:  Yes  No   Hours spent per day on rejected claims?:   Are you satisfied with this service?:  Yes  No   Do you participate in PPO's?:  Yes  No   HMO's?:  Yes  No   Estimate the average % discount of your fees?:   Would you like to reduce your turn around time?:  Yes  No   Additional Comments: This questionnaire is privileged and confidential and used for evaluation and consultation purposes by Preferred Medical Solutions. PMS is HIPAA compliant and a business associate under HIPAA regulations.

Site Map