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Name of Practice Owner
Name of Practice
Address
City
State
Postal / Zip Codey
Phone
PRACTICE INFORMATION
How long has this practice been operating?
Number Of Locations?
Please list each location:
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How many patient visits per week?
Monthly INSURANCE Collections/site?
Total insurance collections per month?
Amount of insurance services billed per month (per site)
Total monthly insurance services ($) for group
Explain your current billing procedures
How are charges billed? Do you bill some services under the DC and others under the MD? If so, please detail
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Are you currently sending claims electronically?
Are the majority of your payments sent electronically?
Name of Practice Management Software
Name of Clearinghouse
How are charges entered?
How often are claims being sent to insurance companies?
How are rejections handled?
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How is the aging worked? Who is responsible for follow up on aging?
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What are your most common denials or rejections from insurance companies?
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Is there a specific issue with your claims at this time?( a procedure that continues to be denied)
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Are each of your provider’s set up with Medicare to bill claims?
For each Provider, please list insurance companies that provider is participating/credentialed with. Does your office participate with Blue Cross, United Healthcare, Medicare, Humana.
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Do you have any pending credentialing issues at this time?
SERVICES
Please list each provider and credentials/specialty
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Please explain how the Medical Services are rendered to the patients, ie, a mid level practitioner that has a collaborating agreement with an md? OR MD providing services?
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What Medical services are you currently providing to your patients?(injections, allergy tests, ultrasound, etc..)
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What Medical services do you want to implement?
Do you have a DMERC supplier number to file DME to Medicare?
What DME are you currently providing to your patients, commercial insurance and Medicare?
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What is your greatest concern?
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What do you need assistance with?
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