Get an Impact Analysis
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.
Your Information
First Name
Last Name
Position
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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