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Free Analysis
Name:
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First
Last
Title:
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Practice Name:
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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-
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Email
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SERVICES OF INTEREST: (Check all that apply)
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Billing Service
A/R Reduction
Provider Credentialing
Consulting
New Practice Set-Up
BILLING SERVICE/AR REDUCTION
Number Of Providers:
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Number of Office Locations:
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Charges:
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Collections:
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PRACTICE PAYOR MIX (fill in %):
Medicare %:
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Medicaid %:
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HMO %:
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Commercial %:
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BCBS %:
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Workers Comp %:
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No-Fault %:
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No Insurance/Cash %:
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PARTICIPATING PROVIDER WITH (Check all that apply):
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Medicare
Medicaid
BCBS
HMOs
Worker's Compensation
Average # of Patients treated per day:
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Average Charge per Treatment:
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Average # of Claims sent per Month:
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Average # of Procedure Codes per claim:
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Average # of Statements mailed per Month:
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Average Current Charges per Month:
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Average Current Collections per month:
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# of Current backlog of Claims (45days)
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Current A/R Balance:
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How are charges and payments currently being posted?:
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Billing Service
Internal Practice Software
via EMR
via Internet
Manual Process
Name Of Software Used:
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Name Of EMR Used:
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Would you be interested in implementing an EMR in your practice?
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Yes
No
Other
Why are you considering a billing service?
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Cannot find qualified staff/key individual left
Do not want to invest in software/hardware/upgrades
Present staff/service not sufficent
Know outsourcing is wise decision
Other
Comment
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PROVIDER CREDENTIALING
:
Please list the Insurances/HMOs that you are interested in:
Untitled
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Untitled
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CONSULTING
:
Please describe your consulting project
:
Comment
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How did you hear about PCMG?:
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Questions/Comments:
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