| PRACTICE NAME__________________________________________________________________ PRACTICE SPECIALTY_____________________________________________________________ PHYSICIAN'S NAME________________________________________________________________ PRACTICE'S PHONE NUMBER(include area code)________________________________________ OFFICE MANAGER'S NAME_________________________________________________________ PRACTICE MAILING ADDRESS_______________________________________________________ APPROX. HOW MANY ACTIVE PATIENTS DOES YOUR OFFICE HAVE_______________________ APPROX. HOW MANY PATIENTS ARE SEEN PER DAY___________PER WEEK__________ AVERAGE NUMBER OF CLAIMS PER MONTH___________________________________________ AVERAGE DOLLAR VALUE OF EACH CLAIM____________________________________________ WHAT IS THE BIGGEST PROBLEM YOUR PRACTICE IS CURRETLY EXPERIENCING___________ ________________________________________________________________________________ DO YOU EXPERIENCE REJECTED CLAIMS?__YES__NO IF YES, WHAT % OF ALL CLAIMS ARE REJECTED?____0-15% ____15-20% ____20-25% ____25-30% ____MORE DO YOU CURRENTLY HAVE A BACKLOG OF CLAIMS? _______YES _______NO HOW DOES YOUR OFFICE PROCESS CLAIMS? _______MANUAL _______ELECTRONIC _____OTHER(please explains)_______________________________________________________ NUMBER OF EMPLOYEES WORKING ON CLAIMS & ACCOUNTS RECEIVABLE________________ HOURLY WAGE OF EMPLOYEES PROCESSING CLAIMS _____$5-$6/hr _____$7-$8/hr _____$9-$10/hr _____$11-$12/hr _____More than $13/hr HOURS SPENT PER DAY ON ACCEPTED CLAIMS PER EMPLOYEE_________________________ HOURS SPENT PER DAY ON REJECTED CLAIMS PER EMPLOYEE__________________________ DO YOU USE AN OUTSIDE SERVICE TO PROCESS CLAIMS? ______YES ______NO IF SO, ARE YOU SATISFIED WITH THIS SERVICES? _______ YES ______NO DO YOU FIND FILING INSURANCE CLAIMS TIME CONSUMING? ______YES ______NO WOULD YOU LIKE TO REDUCE THE TURN AROUND TIME FOR REIMBURSEMENT?____YES ____NO WOULD YOU CONSIDER AN OUTSIDE BILLING SERVICE? ____YES ____NO IF NO (Please elaborate)____________________________________________________________ SURVEY COMPLETED BY______________________________TITLE________________________ |
| Free Cost Analysis |
| Please Complete the following no-obligation analysis to see how much $$$$ we can save your practice. If you have any questions regarding this form please call us at (610)366-1228. All replies will be held in strictest confidence. |
| Del Re's Medical Billing Services 998-6 South Krocks Road Allentown, PA 18106 (610)366-1228 (610)366-9277 Fax |
| Simply, Print this page, complete it and fax to (610)366-9277 |