Free Practice Analysis
Before you schedule a demo please tell us about your practice so we can show you appropriate pricing and have a C & C Medical Administration consultant contact you to build a customized solution. This form takes less than 10 minutes.
What type of solution are you looking for?
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Please Select
EHR
Electronic File Management
Medical Billing Services
Practice Management System
Revenue Cycle Management
How many locations does your practice have?
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Please Select
1
2
3 - 4
4 +
Does your practice currently use an EHR?
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Please Select
YES
NO
If Yes, What EHR do you currently use?
Are there any aspects of the system you are unhappy with?, If yes please explain
How much do you pay for EHR every month?
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How do you currently process claims in your office?
*
Please Select
UTSOURCE
IN-HOUSE
IF OUTSOURCE billing:
What company do you use?
Do you have access to their system?
Please Select
YES
NO
How much do they charge? % of collections
IF IN HOUSE billing:
What billing system is being used?
Is it integrated with your practice management system?
Please Select
YES
NO
What are your monthly clearinghouse + billing system + software support fees?
How many hours each week are spent by your staff members on billing and collection related activities?
Please Select
5 - 10
12 - 20
22+
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What is your approximate patient payor base distribution? (all should add up to 100%)
Commercial
*
%
Medicare
*
%
Medicaid
*
%
Self Pay
*
%
Worker's comp/PI (if any)
*
%
Number of Providers in your practice
*
Please Select
1
2 - 3
4 - 10
11 -15
Any Nurse Practitioner or Physician Assistant?
*
Please Select
YES
NO
How would you describe your practice?
*
Please Select
Primary care
Dental
Hospital
Physical therapy/ chiropractic
Specialty
What's your specialty?
*
Please Select
Allergy and Immunology
Anesthesiology
Cardiology
Critical Care
Dermatology
Diabetes and Endocrinology
Emergency Medicine
Family Medicine
Gastroenterology
Hospice and palliative care
Infectious Diseases
Internal Medicine
Nephrology
Nurse Practitioner
Neurology
Ob/Gyn
Ophthalmology
Oncology
Osteopathic Medicine
Orthopedics
Otolaryngology
Pathology
Pain Management
Pediatrics
Pediatric anesthesiology
Pediatric dermatology
Physical Medicine and Rehabilitation
Podiatry
Psychiatry
Public Health and Preventative Medicine
Pulmonology
Radiology
Rheumatology
Sports Medicine
Surgery, General
Urgent Care
Urology
Other
If other, please specify specialty
On average, practices suffer a 30% or more claim rejection, denial, or non-payment rate. Would you say you are about average?
*
Please Select
0 - 5%
6 - 14%
15%
20%
25%
30% +
Average number of patients seen per day?
*
Please Select
1 - 5
6 - 15
16 - 25
30+
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How many insurance claims are you filing per month?
*
Any surgeries?... If yes How many?
*
How much on average is collected per month (total revenue)?
*
Please Select
$5,000 - $15,000
$20,000 - $35,000
$40,000 - $60,000
$65,000 - $85,000
$90,000 - $110,000
$120,000 +
How much is in insurance A/R (total due from insurance companies)?
*
Please Select
$20,000 - $35,000
$40,000 - $60,000
$65,000 - $85,000
$90,000 - $110,000
$120,000 +
Do you have a patient portal?
*
Please Select
YES
NO
Do your patients have ability to request appointments online?
*
Please Select
YES
NO
How is your current process for confirming patient appointments?
*
Please Select
Automated
Manual
Call Insurance
How is your current process for verifying insurance eligibility prior to NEW patient visits?
*
Please Select
Automated
Manual
Call insurance
How is your current process for re-verifying insurance eligibility prior to established patient visits?
*
Please Select
Automated
Manual
Call insurance
How long does insurance carriers take to pay claims to your practice? (A/R days average)
*
Please Select
7 - 14
15 - 30
31 - 60
61 - 90
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Patient Eligibility
What Form is your billing completed on?
*
Please Select
CMS-1500
UB-04
ADA Form
Do you have a disaster recovery solution in place for your patient charts?
*
Please Select
YES
NO
Do you have any file cabinets in your practice or stored in a different place?
*
Please Select
YES
NO
Are there any areas of your practice that you would like to enhance performance / efficiency?
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What is your zip code?
*
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Practice Name
*
Practice Owner
*
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Email
*
Practice Website
*
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Let’s finish up! Who do we have the pleasure of working with on this Practice Analysis request?
First Name
*
Last Name
*
Job Title
*
Phone Number
*
Please Schedule a Demo
*
SUBMIT
DateTime
Your Time Zone
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