Optional Information

1. Name:  Not required 

2. E-Mail address: Not required

3. Age:  Under 20 20-30 31-40 41-50 51-60 Over 60

4. Gender: Female Male

Geographical Data

1. The State in which you work

2. If other than the USA, the Country in which you work

Personal Information

1. Billing Location: Hospital Medical Records Single Specialty Group Solo Practice Multi Specialty Group Ambulatory Surgery Hospital Out Patient Billing Service Insurance Carrier     
    Other Location:

2. Years in the medical field:       
    Years of billing/coding experience:

3. Highest Level of Education: HS Diploma Career College Associates Degree Bachelor's Degree Master's Degree     Other:

4. Certification (i.e.: CMBS, CPC or other)
         Billing        Certificate year

        Coding        Certificate year    

5. Association Memberships:

6. How many hours a week do you work?

General Billing

1. Do you use a superbill or encounter form?                                                        Unsure Yes No
        a) Is your superbill updated annually?                                                           Unsure Yes No

2. Do you have current coding manuals in your office?                                          Unsure Yes No

3. Do you use Practice Management Software?                                                    Unsure Yes No

4. Do you use coding software?                                                                           Unsure Yes No

5. Do you update patient insurance information annually?                                      Unsure Yes No

6. Do you verify patient's insurance prior to the patient seeing the doctor?             Unsure Yes No

7. When do you collect patient co-pays?    Before patient is seen After patient is seen Bill patient for their co-pays

8. Do you obtain Medicare patient's signatures annually?                                      Unsure Yes No

9. How do you bill insurance carriers?       Electronically Paper Claims Both Electronic and Paper

10. What percentage of your billing goes electronically?%

11. Do you use a clearinghouse?               Yes No         Which?  

12. Do you submit any claims direct to the carrier?                                                Unsure Yes No

13. Who codes you claims?    Doctor Biller Certified Coder Outside Agency RN      Other:

14. Do you use HCPCS codes?                                                                            Unsure Yes No

15. Do you use Modifiers?                                                                                    Unsure Yes No

16. Do you continue your billing and coding education regularly?    Weekly Monthly Yearly

Claim Payment Cycle

1. How do you generate claims?    Individually by patient Batch bill daily Batch bill weekly

2. How many days, on average, does it take to begin the claim cycle (days from patient visit to billing insurance)?        0-3 4-7 8-15 16-30

3. How many days, on average, to close the claim cycle (days before payment in received)? 0-30 31-36 61-90 91-120 121-180  

4. How many days from receipt of insurance payment does it take your office to bill patient for the patient responsible portion?     1-7 8-14 15-21 22-30 More than 30  

Collection Statistics

1. How much do you bill out each month?    Under $10K $10K-25K $26K-50K Over $50K

2. How much by percentage remains uncollected each month? %

3. Do you review each EOB as it is received by your office and verify that the amount paid for each procedure is the contractually agreed upon fee?                                                  Unsure Yes No

4. Have you ever appealed a denied claim?                                                        Unsure Yes No
        a) Have you appeals been overturned?                                                       Unsure Yes No

5. How many levels of appeals have you ever gone though? (please check)    
        a) Review              Telephone Written
        b) Hearing             Telephone On-the-record Personal Appearance
        c) Administrative Law Judge   
        d) Final Appeals    Appeals Council Judicial Review  

Provider Office

If you work at a provider office/clinic/hospital/carrier, please answer the following:

1. Number of staff:        Billing     Coding

2. Do you use a billing service?    Yes No

3 Dose your employer offer Benefits?    Medical Insurance Family Coverage Life Insurance Retirement (401K) Education Allowance Overtime Pay

4. Are you required to pay a percentage of any Benefits?    Unsure Yes No

5. Your annual Income?    $15-25 thousand $26-35 thousand $36-45 thousand $46-50 thousand over $60 thousand

6. Do you receive a bonus or production incentive?    Unsure Yes No
        a) Do you have a collection base before your bonus starts?    Unsure Yes No

7. How often is your performance reviewed for salary increases?    6 Month Annual   

8. How many paid vacation days do you receive a year?     

9. Does your Practice have a compliance plan in force?    Unsure Yes No

Billing Center

If you work at a billing center, please answer the following:

1. Are you a billing center:    none Owner Employee

2. Number of providers' you bill for:  

3. How do you charge your provider?  Flat fee $/claim      Percentage %

4.How long have you been in business? years

5. Do you have any out of state accounts?    Unsure Yes No

6. Do you specialize in one type of provider?    Unsure Yes No     Type

7. Your Annual Income  $ 

8. Do you have a compliance plan in force?    Unsure Yes No

Consultant

If you are a consultant, please answer the following:

1. How much do you charge for chart reviews?
        Per chart    none $10 or less $11-20 $21-30 more than $30
        Per hour    none $25 or less $26-50 $51-100 more than $100

2. Average number of charts audited daily?    none 0-15 16-30 31-45 46-60 61-75 76-90 over90

Thank you for your assistance!  

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