How does your practice/office process claims? Paper Electronic Both

How many claims do you submit to the insurance companies
per month? 0-250 250-500 500-750 750-1000 over 1000

What is the average dollar amount of each claim?

What is the average cost per claim? $ 0 - 5 $ 5 - 10 $10 - 15 over $15

How long on the average does it take you to receive payment on the
insurance claims that you processed? 7 - 14 days 15 - 30 days 1 - 2 months 3 months over 3 months

How many people in your office are processing insurance claims?

What is their hourly rate?

How many hours per week do they spend processing insurance claims?

What percentage of claims are rejected? 0 - 10% 10 - 20% 20 - 30% 30 - 40% 40 - 50% over 50%

Have you ever contacted a billing service?

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Physician / Practice Information

Practice's Name: 

Main Physician's Name: 

Contact Person or Office Manager's Name:  

Specialty:  

Number of Physicians: 1 2 3 4 or more

Medical Office Building:

Address:

Suite:     

City:      

State:    

Zip:       

Phone:  

Email:   

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