Request edit access Qualifying Questionnaire
Billing Questionnaire
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Email *
Your Name *
Your Title *
Company Name *
Company Address *
Primary Contact (Name, Email, Phone) *
Current EMR/Billing System *
Number of Locations *
Number of PT’s *
Number of PTA’s *
Avg. Visits per Week *
Years in Business *
Who handles your billing now? *
If a 3rd party handles your billing what percentage are you paying them? If you do your own billing answer N/A for this question. *
If your billing is outsourced how often do you speak to your billing company? *
Please list your Top 5 Payers with the percentage of your accounts receivable they each represent. *
Will you require any institutional claims billing? *
What percentage of your patients are out-of-network?
Average Monthly Charges? *
Average Monthly Payments? *
Average Payment Per Visit? *
What percentage of your A/R is > 60 Days? *
What is your "First Pass Rate"? (the percentage of claims which are accepted for processing by payers on the first transmission) *
How many visits have you lost due to missing authorizations in the last quarter? *
What percentage of your A/R has an Attorney involved? (Liens) *
What percentage of your A/R is Work Comp? *
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