EZ Medical Claims Specialists

18840 Jacobs Circle,  Omaha, NE  68135-3689 

Phone/Fax: (402) 292-5432, Email address: ezmedclaim1@cox.net

Web: www.ezmedclaim.net 

 

     Please complete and then email or fax the survey below to receive a billing cost estimate. 

Questionnaire:

1) Type of health service or specialty: ________________________   Years in Business? ________

2) Name/address/phone of practice: ________________________________________________

____________________________________________________________________________

3) Phone #:___________________, Fax #: _________________, email: ________________________

4) Will billing be under a single company name, or separate names? __________________________

5) Names of providers and specify individual or group billing:_______________________________

    __________________________________________________________________________

6) Name/Phone of key contact person? ______________________________________________

7) Do you have Medicare patients sign a waiver for potentially non-covered items before services are rendered? __

8) Do you keep current “assignment of benefits” and “release of medical information” forms on file for each patient in your office files? ______   (Please update these forms yearly.)

9) Do you retain copies of the front and back of patients’ medical insurance cards? _____

10) How do you currently verify patient insurance coverage/benefits? ________________________ 

11) If not already doing so, would you like to check patient eligibility online? _________

12) What % of claims are Medicare?____  Medicaid?: ____ BCBS? _____  Commercial?: ____

    Tricare /Champus?: ____ Worker’s Comp?: ____ Other? ____ type ______________

12) Do you currently process any of your claims by paper?  Or electronically?

(  ) yes-some   (  ) yes-all  (  ) no-none                      (  ) yes-some   (  ) yes-all  (  ) no-none

13) How many insurance claims, on average, does your company process weekly?

     (  )  less than 25    (  )  25-49     (  )  50-99    (  ) 100-149   (  )  150-200   (  ) 201-300  (  ) Over 300

14) What is the average dollar value of your average claim? _________

15) Do you currently appeal resubmitted rejected claims to attempt payment?

(  )  yes-some    (  )  yes-all     (  )  no-none   

16) Do you feel some of your claims are uncollectable?   (  ) yes    (  ) no

   If so, how many and why? _____________________ __________________________

17) Do you wish to use our Collections Referral service? ___________________

18) For Patient Billing, approx. how many patients billed per month? _________________

   For payment, do you accept credit cards? ____ If so, which ones? _________________________________________________________________________

19) For Additional Services needed, see our list. Please specify any not listed you are interested in: ____________________________________________________________________________

20) What Practice Management Software do you use? ___________________________________

21) Would like a free copy of Practice Management? ___ (NOT for billing purposes, no tech support.)

22) If yes above, select method to receive backup claims data: ____   CD ROM (  ) OR Internet (  ) 

23) Method to send Invoices/Encounter Forms:  circle Priority Mail(  ), Fax(  ) use HIPAA cover sheet,  OR Electronically (  ) $50 per month,  Other (  ) _____________________ please specify

24) Are you currently dissatisfied with your billing, and if so, why?__________________________

___________________________________________________________________________

25) We want you to be satisfied. Any other information that may be helpful? __________________

___________________________________________________________________________

26) Signature: ________________________________,Date: __________________, 20______

      Print Name: _______________________________