Get an Impact Analysis

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Please complete the following information for us to conduct an accurate study of billing at your facility. Feel free to replace any case types you do not perform and add any case types that may not be listed.
Please do not include cases in which local anesthesia was used where anesthesia providers are not directly involved.
Please complete the following information for us to conduct an accurate study of billing at your facility. Feel free to replace any case types you do not perform and add any case types that may not be listed.
Please do not include cases in which local anesthesia was used where anesthesia providers are not directly involved.

Please complete the following information for us to conduct an accurate study of billing at your facility. Please do not include cases in which local anesthesia was used where anesthesia providers are not directly involved.

IF YOU DO NOT PERFORM CERTAIN CASES, PLEASE LEAVE BLANK.

Please complete the following PERCENTAGE information for patient classification by carrier.

  • Basic Information
  • Surgery Information
  • Patient Classification by Carrier

Your Information

First Name

Last Name

Position

Email

Phone Number

Hospital/Practice Information

Practice/Hospital Name

Address

Annual Cardiac Cases

Number of CABG OUTPATIENT Cases

Number of CABG INPATIENT Cases

Number of Valve Replacement OUTPATIENT Cases

Number of Valve Replacement INPATIENT Cases

Number of Valve Replacement OUTPATIENT Cases

Number of Pacemaker INPATIENT Cases

Ear Nose Throat (ENT)

Number of ENT OUTPATIENT Cases

Number of ENT INPATIENT Cases

Endoscopies/Gastro (Colonoscopy & EGD)

Number of Endoscopy/Gastro OUTPATIENT Cases

Number of Endoscopy/Gastro INPATIENT Cases

General Surgery (All types not listed elsewhere)

Number of General Surgery OUTPATIENT Cases

Number of General Surgery INPATIENT Cases

Neuro

Number of General Neuro OUTPATIENT Cases

Number of General Neuro INPATIENT Cases

Number of Craniotomy OUTPATIENT Cases

Number of Craniotomy INPATIENT Cases

Number of Spinal Instrumentation OUTPATIENT Cases

Number of Spinal Instrumentation INPATIENT Cases

OB/GYN

Number of C-SECTION deliveries each year

Number of Total Annual Deliveries

Number of General OB/GYN Cases (Not Delivery)

Ophthalmology (All Eyes)

Number of Ophthalmology (All Eyes) OUTPATIENT Cases

Number of Ophthalmology (All Eyes) INPATIENT Cases

Orthopedic

Number of General (Scopes, etc.) OUTPATIENT Cases

Number of General (Scopes, etc.) INPATIENT Cases

Number of Total Joint Replacement OUTPATIENT Cases

Number of Total Joint Replacement INPATIENT Cases

Oral Surgery/Peds Dental

Number of Oral Surgery/Peds Dental OUTPATIENT Cases

Number of Oral Surgery/Peds Dental INPATIENT Cases

Plastic Surgery

Number of Plastic Surgery OUTPATIENT Cases

Number of Plastic Surgery INPATIENT Cases

Podiatry

Number of Podiatry OUTPATIENT Cases

Number of Podiatry INPATIENT Cases

Urology

Number of Urology OUTPATIENT Cases

Number of Urology INPATIENT Cases

Vascular

Number of Vascular General OUTPATIENT Cases

Number of Vascular General INPATIENT Cases

Number of Vascular AAA OUTPATIENT Cases

Number of Vascular AAA INPATIENT Cases

Medicare (Please include Other Medicare Advantage Plans)

Percentage (%) of overall cases:

Medicaid (Please include Medicaid HMO products as well)

Percentage (%) of overall cases:

Blue Cross - Blue Shield - Texas

Percentage (%) of overall cases:

United (only include HMO/PPO products - NOT Medicare products)

Percentage (%) of overall cases:

Cigna (only HMO/PPO products – NOT Medicare products)

Percentage (%) of overall cases:

Aetna (only HMO/PPO products – NOT Medicare products)

Percentage (%) of overall cases:

Humana (only HMO/PPO products – NOT Medicare products

Percentage (%) of overall cases:

Other Commercial Carriers including Scott & White

Percentage (%) of overall cases:

Tricare / Champus / Military

Percentage (%) of overall cases:

Worker’s Comp

Percentage (%) of overall cases:

Private/Self Pay

Percentage (%) of overall cases:

Charity – Free Care (Indigent Program)

Percentage (%) of overall cases:

“Other” – please identify (Self – Funded Plans, etc)

Percentage (%) of overall cases:

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