RMS Prospective Client Information

1
Please take a few moments to complete the following survey regarding the practice /
facility. Your answers to these questions will allow us to identify your needs and enable us to provide an accurate and competitive quotation on professional fees and scheduling for a site visit. If you need more room for some responses, please feel free to attach an additional sheet of paper.
2
Practice Name* This field is required.
3
Specialty* This field is required.
4
Number of Billing Providers* This field is required.
5
Year practice was established?* This field is required.
6
How many practice sites are there?* This field is required.
7
How many sites would you like us to visit as part of the consultation?* This field is required.
8
As the result of this consultation, what issues/areas do you want to be demonstrably different? Admin / Physician response (required):* This field is required.
Yes
No
Coding & Billing
Accounts Receivables Management (Improve cash receipts)
Staff Training
Staff Turnover
Patient Payment Agreement Maintenance
Patient Education (Assist the patient in understanding why balances are owed)
Verification of Insurance Processes
Financial Records Maintenance ( Scanning of financial information for claims)
Coding & Billing
Accounts Receivables Management (Improve cash receipts)
Staff Training
Staff Turnover
Patient Payment Agreement Maintenance
Patient Education (Assist the patient in understanding why balances are owed)
Verification of Insurance Processes
Financial Records Maintenance ( Scanning of financial information for claims)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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9
Additional issues / concerns:* This field is required.N/A , If none.
10
Clinical Personnel Roster / NPI* This field is required.
11
Identify the most significant strategic challenges you face.* This field is required.
12
Identify any major changes the practice / facility has undergone in the past two years. (Such as mergers, additional or retiring physicians/partners, addition of a new service line, etc.)* This field is required.
13
What additional changes do you anticipate in the future?* This field is required.
14
Do you use a billing service or in-house billing?* This field is required.
Yes
No
15
Software* This field is required.
16
Are you satisfied with the system?* This field is required.
Yes
No
17
Why?* This field is required.
18
Are you using an Electronic Medical Record?* This field is required.
Yes
No
19
EMR Software:* This field is required.
20
What is the practice / facility average patient volume?* This field is required.
Volume
Weekly
Monthly
Weekly
Monthly
Volume
Volume
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21
What is practice / facility year-to-date?* This field is required.
$/%
Gross Charges
Net Collections
Annual Revenue 1 (one) year prior
Annual Revenue 2 (two) year prior
Current Insurance Accounts Receivables
Current Patient Accounts Receivables
What % of the AR are over 90 days old?
Gross Charges
Net Collections
Annual Revenue 1 (one) year prior
Annual Revenue 2 (two) year prior
Current Insurance Accounts Receivables
Current Patient Accounts Receivables
What % of the AR are over 90 days old?
$/%
$/%
$/%
$/%
$/%
$/%
$/%
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22
Are you satisfied with the practice / facility collection ratio?* This field is required.
Yes
No
23
Who are your top 10 carrier?* This field is required.
Should be Empty: