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Billing Solutions Questionaire

* Name of Doctor/Clinic
* Email:
* Preferred Contact Method?
* Position of Person taking Survey:
Owner/Not a Practitioner
Spouse/Partner of Owner
Associate Doctor/Practitioner
Office Manager/Administrator
Staff Member

About Your Practice

What is your medical/professional specialty?
What are the primary services you perform at your clinic?

(example: routine office visits, chiropractic care, dental care, outpatient mental health counseling, physical therapy, minor surgeries, etc)

Do you provide Ancillary Services (Nutrition/Weight Loss, Acupuncture, Massage Therapy, Cosmetic Dermatology, etc)?
Are you a Solo Practice
If No, how many other healthcare providers are there in your clinic? (do not include LVN, CNA, CA, Massage Therapists, PTA?s or other healthcare professionals who do not have a rendering NPI)
Please provide credentials of each Health Care Practitioner in your clinic (MD, DC, DO, PT, etc)
Are they employees or independent contractors?
How long have you been in practice?
How long have you been at your current practice location?
Do you have any pending credentialing issues?

Please give a an estimate of the following statistics, on the AVERAGE (* Items mandatory)

* Monthly Patient Visits:
Monthly New Patients
* Monthly Services Billed/Rendered:
* Monthly Collections:
* Estimated Accounts Receivable (AR) $
Estimated AR Under 90 days $
Estimated AR between 90-180 days $
Estimated AR between 181-365 days $
Estimated AR over 365 days
* Estimated Percentage of Patients with insurance
Estimated Percentage of Patients who are uninsured (pay cash)
Are your insurance patients mostly:
Commercial (Blue Cross/AETNA/CIGNA/United Healthcare, etc)
Personal Injury/Work Comp
Even mixture of Medicare/Medicaid and Commercial
Medicare Status:
Medicaid Status:
Commercial Insurance: Please choose the statement that most closely describes your status as a commercial insurance provider
I am in-network with most managed care plans
I am out-of-network with most managed care plans
I am in network with about half the managed care plans and out of network with about half.
I do not bill insurance at all for any of my patients. My patients file their own insurance and pay me cash
How many Staff Members do you employ?
How many are Part Time:
How many are Full Time:
How many are PRN:
Do you have High Turnover?
* How would you rate your Front Desk Collections:
* How would you rate your Insurance Collections:
* Is your billing department in-house?

If NO, you may skip the questions about Practice Management Software

What Practice Management Software do you use?
How long have you used this program?
Do you have the most up to date version?
Does your software have EMR Capabilities?
If YES, do you use the EMR portion of your software?
Is your software Meaningful Use Certified?
Is your software HIPAA Certified?
Is your software ready for the use of the new CMS1500 form and ICD10?
Are you happy with your software?
Are you thinking of changing software?
If YES, have you been actively shopping/searching for new software?
Are you happy with the performance of your billing department or billing service?
Urgent needs/concerns
* If you need to make a change in your billing department, and are considering Gold Star Medical, how soon would you need our services?
* f you are not thinking of making a change to your billing department, would you be interested in economical consulting support for your billing CA?
* Do you have other needs, such as assistance with front desk CA support, staff training, and/or practice consulting?
If Yes, describe
Additional Comments
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