Questionaire

Tell Us About Your Practice

Thank you for scheduling a consultation with Billing Partners of Carolina! This short questionnaire will help us learn more about your practice, current billing process, and the level of support you may need before we meet. Estimates and ranges are perfectly fine—we’ll review the details together during your consultation.

Your responses will also help us evaluate the factors that may affect pricing, including practice size, claim volume, collections, payer mix, billing complexity, accounts receivable, and the scope of services you may need.

Please do not include patient names, account numbers, dates of birth, or other protected health information in this form.

About Your Practice

Practice Name

Your name and role within the practice

What type of practice or specialty do you operate?

How many providers are currently billing under the practice?

How many of those providers are actively seeing patients and submitting claims?

Approximately how many insurance claims does your practice submit each month?

What are your average monthly insurance collections within the last 3-6 months?

Does your practice have multiple locations, tax identification numbers, or billing entities?

No

Yes

Not sure

Your Current Billing

How is your billing currently handled?

Which billing services are you currently handling internally or receiving from another company?

Select all that apply

Which EHR or practice management system do you use?

Which clearinghouse do you use, if applicable?

Which insurance payers make up the largest portion of your practice?

Select all that apply

Does your practice bill for any services or arrangements that may require additional billing review or follow-up?

Select all that apply

Your Billing Needs

What are the biggest billing challenges you’re experiencing right now?

Approximately how much outstanding insurance A/R does your practice currently have?

Approximately what percentage or amount of your insurance A/R is more than 90 days old?

Do you have a significant amount of insurance A/R over 120 days old?

No

Some

Yes

Not sure

Are there specific older unpaid claims or balances you would like us to discuss working?

Yes

No

Not sure

If yes, please give us a general idea of the volume, age, payer, or type of claims involved. Please do not include patient information.

Are there any known billing issues that may require additional investigation or cleanup?

Select all that apply

What would you most like to improve about your current billing process?

Are you primarily looking for ongoing billing support, a one-time cleanup project, or both?

Ongoing billing support

One-time A/R or billing cleanup

Both

Not sure

When would you ideally like billing support to begin?

Working Together

Who would be our primary contact for billing questions, documentation requests, and other items that need your practice’s attention?

Who is responsible for providing timely access to records, documentation, payer information, and system credentials if needed?

How involved would you like your practice to be in day-to-day billing activities?

We prefer the billing company to manage most activities

We would like regular review and approval

We prefer to remain closely involved

Not sure

Are there any practice policies, staffing limitations, system limitations, or other factors that could affect billing workflow or turnaround time?

Is there anything else about your practice or billing needs you’d like us to know before we meet?

Thank you! We’ll review your responses before your consultation so we can spend our time together getting to know your practice, answering your questions, and determining whether Billing Partners of Carolina is the right fit for your needs. Your responses will also help us discuss the appropriate service scope and develop pricing that reflects the size, complexity, and level of support your practice requires.