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?:
  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?:
  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.
 
 
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