Medical Billing Services Questionnaire

Contact Name*

Legal Provider Name & Address

Zip Code*
Main Contact Phone*
Number of Patient Visits (aka Encounters) per Month*
Type of Organization*
Monthly Receipts*
Current Month Receipts*
12 Month Rolling Average*

Types of Payments Insurance Commonly Accepted:

Check all that apply
How much Out of Network Billing (OON) do you process monthly $$$ of claims?

Please enter a specific numerical value, or tool will not work (eg. 0, 1, 10, 100)

Number of Providers / MDs*
Number of mid-level providers (ie. non-MDs)*
Number of Offices*
Primary State in which your Practice Operates*

Medical Billing Services:

Please select the specific billing service model you are most interested in: Please check one or more

General Questions

  • 1.What EHR/PM software solution they are using?
  • 2.What Billing Software?
  • 3.Are you currently outsourcing to a billing company?
  • 4.What areas do you need help within your billing Department?
     -Augmentation of Staff : Please explain
      -Add remote resources for one or more areas: Please Explain
  • 5.Why are you considering a change or addition to your current RCM/billing solution? Please explain
  • 6.What is your biggest concern with your current process? Please explain 
  • 7.Do you currently bill in house?

    If Yes : Please explain your current staffing level and areas of concern.