Contact Information

Your Name (required):

Your Email (required):

Practice Name:

Type of practice:

Specialty:

Contact person:

Phone number:

Best time to call:
 AM  PM

Mailing Address:

City:

State:

Zip code:

Practice Data

Number of providers in practice:

Top 3 insurance carriers:

Are claims processed electronically?:
 Yes  No  Medicare only

Claims processing:

In-house:

If In-house, staff hours per week:

Billing company:

Cost of billing:

In House, monthly:

Billing company, monthly:

Insurance Data

Number of claims per month:

Electronic claims:

Paper claims:

Average value per claim:

Personnel Rate/Hour:

Minutes to complete form:

Error rate:

Reimbursement turnaround time:
 15-30 days  31-60 days  61-90 days  91 or more days

What percent of claims are unpaid due to billing errors?:
 5%  10%  15%  20% or more

What percent of claims are uncollectible?:
 5%  10%  15%  20% or more

What is the approximate amount of A/R?:

How many days outstanding?:

For you, what is the most important issue regarding your claims processing?:

Esinan Meical Billing Services will never release your information to 3rd parties. This information is gathered only to respond to your request for a quote.