2007 Benchmark Survey
Return Deadline - November 12, 2007
Date _________________________________Section One: General Information
Geographic location (select one)
Eastern: (Connecticut, Delaware, District of Columbia, Maine, Massachusetts, Rhode Island, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Vermont, Virginia, West Virginia)
Midwest: (Illinois, Indiana, Iowa, Michigan, Minnesota, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin)
Southern:(Alabama, Arkansas, Florida, Georgia, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas)
Western:(Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming)
Organization of practice (select one)
Independent, physician ownership Hospital/health system ownership
Other (please specify) __________________________________________________________
Type of pain practice (select one)
Dedicated pain specialty practice only
Pain practice as part of anesthesiology practice Pain practice as part of spine/orthopedic practice
Pain practice as part of other specialty practice (please specify specialty) __________________ Other (please specify) __________________________________________________________
Do the physicians have ownership in an ambulatory surgery center?
Yes No
Does your pain specialty practice have more than one location?
Yes No
If yes, how many locations? _______________
What ancillary services are provided at your pain practice? (check all that apply)
Clinical laboratory services
General radiography (x-ray) CT MRI Psychology/psychiatry services
Section Two: Staff Information
A. Physicians and Non-Physician Provider Staff
Physicians
Physician Specialty
Number (FTE)
% of time devoted to pain
Hrs/week for clinic appointments
Hrs/week for procedures/surgery
Pain Anesthesiology
Neurology
Neurosurgery
Orthopedic
Family medicine and/or internal medicine Physiatry (PM & R) Psychiatry
Other (please specify)
Total physicians:
Comments: ______________________________________________________________________ ________________________________________________________________________________
Non-Physician Providers (NPP)
NPP specialty
Number (FTE)
% of time devoted to pain
Hrs/week for clinic appointments
Nurse practitioner Physician assistant
Psychologist Physical therapist
Other (please specify)
Total NPP:
Comments: ______________________________________________________________________ ________________________________________________________________________________
B. Support Staff
Please list the total number of FTEs (full-time equivalents) for each position listed below
Staff FTEs
Administrative (business manager, office assistant, administrative secretary) Billing, charge entry, collections, accounts receivable
Accounting, budget, finance, accounts payable Information systems staff
Facility staff (cleaning, maintenance, security)
Total business operations support staff
Receptionist, appointment schedulers Medical secretaries, transcriptionists Medical records
Other front desk support staff
Total front desk support staff
Registered Nurses (RNs)
Licensed Practical Nurses (LPNs) Medical Assistants (MAs),
Patient assistants, nurse’s aides, other clinical support staff
Total clinical support staff
Laboratory staff (technologists, assistants, secretaries) Radiology/x-ray (technologists, assistants, secretaries) Other ancillary support staff (physical therapy aides, etc)
Total ancillary support staff Total Support Staff
Comments: ______________________________________________________________________ ________________________________________________________________________________
C. Outsourced Services
Please check those services not performed by employed and contracted staff but are outsourced to other companies for a fee.
Outsourced Service
Please check all that apply
Accounting, budget, finance
Accounts payable (payment of bills)
Transcription Billing (including charge entry, billing functions, collections
and accounts receivable management) Facility maintenance, cleaning and security Other – please specify
Section Three: Billing Systems and Electronic Health Record (EHR)
Does your practice have its own billing software and hardware (billing system)?Yes No
Is billing done within the practice? Yes
No Billing service:
If an outside billing service is used, what percent of collections is paid for billing services? _______ Does your practice currently use an EHR system (or document imaging and storage system)?
Yes No
Is your practice considering converting to an EHR some time in the future? Yes
No
Section Four: Billing and Payer Information
A. Accounts Receivable
Provide information on your practice’s days in accounts receivable (do not include accounts that have been sent to collection agencies)
Category Dollar amount Percent of Total
Current to 30 days $ %
31 to 60 days $ %
61 to 90 days $ %
91 to 120 days $ %
Over 120 days $ %
Total $ 100%
Comments: ______________________________________________________________________ ________________________________________________________________________________
B. Payer Mix
Estimate the percent (%) of your practice’s total gross charges and net revenue (collections) by type of payer. (If you prefer, you can provide charges and revenue in dollars.)
Payer
Gross Charges % or $
Net Revenue % or $
Medicare – fee for service
Medicare – managed care fee for service (HMO, PPO & other)
Medicare – capitation (HMO capitation) Medicaid – fee for service
Medicaid – managed care fee for service (HMO, PPO & other)
Medicaid – capitation (HMO capitation) Commercial – fee for service
Commercial – managed care fee for service (HMO, PPO & other)
Commercial – capitation (HMO capitation) Workers’ compensation
Charity care and professional courtesy
Self-pay Other payers
Total 100% or $ 100% or $
Section Five: Charges, Revenue and Productivity
Fiscal year: For the purposes of reporting for this survey, what time period is being used? Beginning month _________ year _________
Ending month _________ year _________
A. Charges, Collections and Contractual Adjustments
Total gross fee-for-service charges? (total billed charges) $_________(annual) Total contractual adjustments? $__________________(annual)
Bad debt write-offs? $_________________(annual)
Total collections? (net revenue) $___________________(annual) (this number should equal total gross charges, minus contractual adjustments and minus bad debt write-offs)
B. Encounters (visits) and Procedures
Total annual ambulatory encounters? (E & M clinic visits) _______________________ New patient encounters_________ Established patient encounters ______________ Total annual hospital encounters? (E & M inpatient consults) _______________________ Please report the number of procedures for each of the following categories done at each location.
Procedure Office ASC
Hospital
Outpatient Department
Hospital
OR/ Surgery Injections and Blocks(epidural, trigger points, facets, etc.)
Destruction RF, Cryo, Chemical (Botox, etc.) Discograms
Pump implants
Neurostimulator implants Other procedures
Total Procedures
Please list the number of imaging guided procedures performed (codes 72275 through 72300)
Please list the number of imaging guided procedures performed (codes 76000 through 77003)
Comments: ______________________________________________________________________ ________________________________________________________________________________
Section Six: Comments
Please include any comments or clarifying information in the space below:
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Please return no later than November 12, 2007 By mail to:
ASIPP
c/o PRACTICE Advantage
Or by fax to: 763-514-9992 4000 Lexington Avenue, X195 St. Paul, MN 55126-2983
