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AER CONSULTING
PRACTICE ASSESSMENT QUESTIONNAIRE
NAME OP PRACTICE: _____________________________________________ Attach Doctors’ CVs
ADDRESS:_______________________________ PH:_________ FAX:________
OFFICE HOURS:___________________________________________________
BUILDING: Owner_____ Leased________ Other__________________________ Attach Copy of Lease
SERVICES: OP
SURGERY___ In HOUSE LAB_____ DME:______ Attach
Productivity Rept.
IN
HOUSE X-RAY_____ OTHER_________________________________
2 yrs by CPT Codes
LICENSURE: Occupational_____ Medicare______ Medicaid______ Other_______
ACCOUNTANT:___________________________________________________
Name
Address Phone/Fax Numbers
ATTORNEY______________________________________________________
Name
Address Phone/Fax
Numbers
BANK__________________________________________________________
Name
Contact Phone/Fax Numbers
PERSONNEL: Doctors_______
Nurses______ MA’s______ Manager________
Technicians:_______
Lab_________ X-Ray________
Office___________
Other_____________
Total
Staff:________________________ (Full Time/Part Time)
Attach List of Staff /w Name, DOE, Salary, Hours
worked/week
YEAR-TO-DATE LAST YEAR
STATISTICS: Number
of Patients seen_______________ _________________ Attach
monthly Breakdown
Patient
Mix: Private Pay _________
| HMO _________ |
Attach
List
|
PPO ______________________________________________________________
Contracts
__________________________________________________________
Medicare
___________________________________________________________
Medicaid ___________________________________________________________
Other __________________________________________________
Referral Sources Attach Tracking Rpt.
Average Number of New Patients per Month _______________ _________________
Number of Active Patients _______________ _________________ Attach Report
Monthly Charges (average) _______________ _________________ Attach System Summary Attach Fee Schedule
Monthly Collections (Average) _______________ _________________ Attach System Summary
Insurance Forms Processed/month _______________ _________________ Attach Ins.Aging Sumry.
AR: % patients insurance verified prior to visit _________________________
% patients co-pay collected at time of visit_____________________________
% patients dedoctibles collected at visit_______________________________
Managed Care
Participation: # of Plans _______________________________
Attach list of Plans &
copies of contracts
| Collection system in use___________________________________________ Attach |
|
Aging
Report
|
Do you use a
billing service Yes No
If yes,
NAME ____________________________
Date of
contract___________________________ Attach
Agreement
Monthly Erpenses
____________ _____________ Attach 3 years of Financial
Statements
Staff
Salaries _______________ ______________
Operating
Expenses ___________ _____________
| Loans Outstanding |
List
Amount/Source
|
List any Government
or Aging Audits during Last 3 Years__________________________
__________________________________________________________
Attach Reports
COMPUTER SYSTEM:
Hardware________________________
Software________________________
Electronic Billing
Y N
Appointments
Y N
Word Processing
Y N
Medical
Records Y N
Collection
System Y N
ORGANIZATION: PA______ Solo_______ Corporation_______
Mission Statement
Y N
Goals/Objectives
Y N
Organizational
Chart Y N
Personnel
Manual Y N
Procedure
Manual Y N
Job Descriptions
Y N
All above must be attached
New Employees
Oriented Y N
Continuing
Training Y N
MARKETING:
Advertising
Y N
YP Newsltrs Media
Fairs Other___________________
Patient Satisfaction
Ones. Y N ATTACH
Focus
Groups Y N
Practice
Brochnre Y N ATTACH
Patient
Info Brochure Y N ATTACH
Logo Y
N
Newsletter
Y N ATTACH
Seminars/Speakers
Burean Y N
Tracking
Systems Y N
Referrals Other________________
INSURANCE :
General Liability
Y N Limits_____________________
Professional
Liability Y N Limits__________________
Automobile
Y N Limits_____________________
Umbrella
Y N Limits_____________________
Workers Corp
Y N
Comprehensive
Ins. Y N Fire,burglary,,.
Fidelity
Bond (employee) Y N Amonnt-$____________
Multi-peril
Package Y N Covers all except WC.?
Health
Insurance Y N Type______________________
Disability
Insurance Y N Who______________________
Overhead
Insurance Y N Who______________________
Key person
Insurance Y N Amount__________________
Other__________________________________________
PROBLEMS: __________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
FUTURE GROWTH:
_____________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
OTHER COMMENTS:
____________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_____________________________________________________________
PRACTICE ASSESSMENT QUESTIONNAIRE
LIST OF ATTACHMENTS
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Doctors' Cvs |
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Copy of Building Lease |
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Productivity Report - 2 years (current and previous year) |
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List of Staff with Name, Date of Employment, Salary, Hours worked per week |
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Monthly Breakdown of number of patients seen Current Year and Previous Year |
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List of Patient Mix by Payor |
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Referral Tracking Report - 2 years |
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Active Patient Report |
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System Summary - Current and Previous Year |
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Current Fee Schedule |
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Insurance Aging Summary - Current |
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List of Managed Care Plans and copies of contracts |
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Current Aging Report (AR) |
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Copy of Encounter Form (Charge slip) |
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Sample copies of current insurance rejections |
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Billing Service Agreement - if applicable |
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Financial Statements - 3 years (current and previous 2 years) |
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Loans outstanding information |
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Government Audits - if applicable |
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Mission Statement & Goals and Objectives |
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Organizational Chart |
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Job Descriptions |
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Personnel and Procedure Manuals |
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Marketing Materials, e.g., patient satisfaction questionnaires, brochrues, newsletters letterhead, business cards, logo, etc. |
Please
check material and check off to confirm attachments.
AER
Consulting,Inc.has the expertise to assist you.
Call today to discuss your needs.
|
Phone:
(813) 831-5761 …
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Fax: (813) 832-5293 |
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E-Mail:
aerconsulting.aer@verizon.net
|
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P. O. Box 320245, Tampa, Florida 33679-2245