Reimbursement Analysis Survey

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Doctor's Name:
Phone Number:
Home Phone:
E-mail address:
Address:
City:
State - Zip:



1) Please list your monthly average for the following statistics over the last 3 or 6 months:
Office Visits:
New Patients:
Total Services Rendered:
Total Collections:



2) What do you perceive as your number one reimbursement challenge at this time?




3) Describe your patient financial plans:




4) What is your current accounts receivable? How much is due from patients?




5) How many phone calls are made to insurance companies for follow up in an average week?




6) What is the demographic breakdown of your patients by percentage?
Commerical insurance patients:	%
Cash (no third party reimbursement) patients:	%
Personal Injury patients:	%
Worker's Compensation patients:	%
Medicare patients	%
Other patients ( describe):	%




7) What percentage of your monthly collections is collected from patients vs. third party payers?




8) What is the least favorite third party payer you deal with and why?




9) What services do you typically render in an established patient visit? Describe the service and how you code it:




10) How do you rate your documentation on a scale of 1-10 ? Why ?




11) What are your current short term goals with respect to your reimbursement?




12) Approximately how many visits per condition are paid to you from Medicare?




13) How did you hear about us?





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