Calculators
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Downloadable Forms
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For Patients
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For Internal use
Calculators
2007 Physicians Practice Fee Schedule Survey Results
Get the full results of our latest reimbursement and charge schedule survey or read our analysis of the results.
Accounts Receivable Key Indicators
How good are your key accounts receivable processes? Do you even know what to measure? Find out how you are doing by entering key data from your practice and comparing your key measurements to industry benchmarks.
Calculate EMR ROI
Thinking about buying an EMR, but not sure how it will pay off? Try this ROI calculator, supplied by A4 Health Systems. It will show you where you can expect to cut costs, regardless of what system you buy.
Denial Benchmarks
Compare your denial rate from Medicare to national averages for your specialty by total amount denied, number of services denied, or percent of services denied. Data from the Centers for Medicare and Medicaid Services.
Denials Tracking Worksheet
Manage your denials from insurance companies by tracking them in this worksheet. Track the denials according to the functional area to identify opportunities for improvement. By tracking and monitoring denials, you can fix the problem and prevent denials in the first place.
E & M Coding Benchmarks
Compare your E&M coding patterns with national norms from Medicare (2005). It's a fast way to see if you are out of whack. Translate Medicare's data for your specialty into percentiles for easier comparison.
Measure the Financial Health of Your Practice
Here are the fourteen key measurements you need to make -- about once a quarter -- to measure your practice's financial health. We've made it easy for you. Just enter some information; we'll do the math.
Overhead Calculator and Benchmarking Tool
We'll help you accurately measure your overhead costs -- and compare them to national benchmarks.
Productivity by RVU
Measure physician productivity by relative value units (RVUs) -- one of the most reliable ways to do it. This spreadsheet does the necessary calculations for you.
Recruitment ProForma
Crazy busy but not sure if you can afford to hire another physician? Just fill in the blanks on this site. It'll do the analysis for you.
Staffing Benchmarks
The best performing practices in the country tend to have more staff than practices doing less well. Why? More support staff means physicians can focus on seeing patients -- and bringing in money. Find out how your staff per physician ratio compares to national benchmarks.
What Causes Low Collections?
Follow our flowchart to find ways to improve your collections. A great companion to our Accounts Receivable Key Indicators calculator. If your results there are lower than you like, this flowchart will help you improve.
Downloadable Forms
We know you can never find the time to create useful, nice-looking forms. Use ours. Download these forms and use
and change them as you see fit.
For Patients
Advance Beneficiary Notice
Use this form if you think Medicare will not cover a service you are about to perform on a patient covered by Medicare. If the patient still wants the treatment, their signature shows they know they may be responsible for payment. Please note that a separate form must be signed for each service for each date of service, and that the patient has the option to refuse the service. Because of the specificity required, this process (and form) is best managed by the clinical team, instead of the front office.
This form was created by the Center for Medicare and Medicaid Services (formerly the Health Care Financing Administration) for your use. For more information, visit http://www.hcfa.gov/medlearn/refabn.htm.
Advance Beneficiary Notice - Lab Work
This is similar to the general notice above, but is specifically for laboratory work. Again, this form comes directly from the Center for Medicare and Medicaid Services. Access its Web site for more information.
Assignment of Benefits
Assignment of Benefits -- Spanish
Closing Practice -- Letter to Patients
If you are closing your practice, you need to let patients know and advise them to find another physician. Here is a letter you can use to get the job done.
Collections Letter 1
This is the first in a series of letters to use for patient collections.
Collections Letter 1 -- Spanish
Collections Letter 2
Collections Letter 2 -- Spanish
Collections Letter 3
Collections Letter 3 -- Spanish
Consent to Treat
Consent to Treat -- Spanish
Financial Policy
Let new patients know about your policies from the get go. Follow these guidelines.
HIPAA: Authorization for Use of Protected Health Information
The Health Insurance Portability and Accountability Act requires authorization from patients for the release of protected health information for uses other than treatment, payment or health care operations. Here's a sample form for this purpose. Provided by Rachel Glitz, Paul Smith, and Becky Williams of Davis Wright Tremaine, LLP.
HIPAA: Notice of Privacy Practices
Straight from the HIPAA regulation, here is an outline to follow as you create your Notice of Privacy Practices.
Insurance Waiver
If you can't verify a patient's insurance, their signature on this form shows they know they are responsible for payment.
Insurance Waiver -- Spanish
Medication Chart
Instead of having patients carry all their medications to every visit, ask them to bring in this simple chart. It's a more efficient way to check for counterindications. You can even give patients a digital copy by saving it to a disk or e-mailing a copy. That makes it easy for patients to update it.
Patient Dismissal Letter
Use this letter if a patient consistently refuses to pay for services rendered, and you are forced to dismiss the patient from your practice.
Patient Information Form
Patient Information Form -- Spanish
Patient Satisfaction Survey
An easy way to find out what patients think of your practice -- and where you need to improve.
Patient Satisfaction Survey -- Spanish
Payment Coupons
Take a page from your mortgage company. Instead of sending self-pay patients on a payment plan statements every month, give them coupons. The coupons remind them what they owe. They simply need to mail one in, with a check, each month.
Records Release Form
Records Release Form -- Spanish
Referral Waiver
Specialists, use this waiver if a patient forgot his referral. It says that the patient agrees to pay for services rendered that are not covered by his managed care company.
Referral Waiver -- Spanish
For Internal Use
Appeal Letter for Claims Denied as Duplications
Medicare denies claims for 26 percent of all services submitted. More distressing -- 40 percent of those services are never resubmitted for payment by providers. Talk about missed opportunities!
Customize this form letter -- and the ones below -- to appeal claims denied, no matter who the payer is.
Use this letter to show payers that the claims you are sending are not dups, but corrections.
Appeal Letter for Claims Denied for Improper Bundling
Appeal Letter for Claims Denied for Not Using Designated Provider
Use this letter is a claim is denied becasue a patient saw a physician in your group who is not his or her designated primary care physician.
Appeal Letter for Prompt Payment
Appeal Letter Justifying Emergency Treatment
Appeal Letter Justifying Fee Schedule as Fair and Reasonable
Appeal Letter Justifying Medical Neccessity
Business Associate Agreement: HIPAA
The Health Insurance Portability and Accountability Act requires physicians to have their business associates -- claims processors or third-party billers, for example -- agree to protect private patient data. Here's a sample form to use for this purpose. Forms provided by Reece Hirsch, attorney with Davis Wright Tremaine, LLP.
Business Manager Evaluation Form
Consider this template for annual or quarterly reviews of the performance of business managers in your practice. Of course, make sure your review reflects goals set at the beginning of the year or in a job description.
Confidentiality Agreement
Ask staff to sign this agreement, showing that they understand the need to protect patient confidentiality.
Consultation Request
Tell 'em what you want and how you'd like to hear about what happened.
Documentation Template - Established Patient
Use this sample template for guidelines on documenting established patient visits. Provided by Hill & Associates.
Documentation Template - General
Use this sample template for guidelines on documenting patient visits in general. Provided by Hill & Associates.
Documentation Template - Inpatient
Use this sample template for guidelines on documenting inpatient visits. Provided by Hill & Associates.
Documentation Template - Outpatient
Use this sample template for guidelines on documenting outpatient visits. Provided by Hill & Associates.
E&M Coding Worksheet
This Excel worksheet, provided by Lighthouse MD, is meant to expedite E&M coding.
Executive Summary: The 14 Toyota Way Principles
Abstracted with permission from Chapter 4 of The Toyota Way by Jeffrey Liker. This chapter summarizes the principles of lean manufacturing, now being used in medical practices. Order the book at www.amazon.com.
Fee Schedule Setter
Base your fee schedule on the Relative Value Unit (RVU) scale. We'll show you how -- and help you with the math.
Internal Investigation Form
Use this form to document internal review of and response to complaints concerning compliance with human resource, HIPAA, Medicare billing or other ethical and legal guidelines.
IPPE Basics
A quick overview of the Initial Preventive Physical Examination (IPPE),
a new Medicare benefit effective 1-1-05. Understand the components and how to bill for the exam.
IPPE Basics
A quick overview of the Initial Preventive Physical Examination (IPPE),
a new Medicare benefit effective 1-1-05. Understand the components and how to bill for the exam.
Lab Tracking Tool
Need a better way to track the status of lab work you've ordered -- but not ready for an EMR? This Excel document provides semi-automation.
Be sure to turn on your macros and review the instructiosn on the last worksheet.
Provided by www.docsboard.com.
Medical Practice Management Technology Resources
Modifier Manual
Plain language advice on using common modifiers.
Neurohormonal Blockade Across the Spectrum of Cardiovascular Disease
New Practice Start-up Checklist
Opening a new practice? Here are some of the things you will need to get done before the doors open.
Physician Evaluation Form
You give annual reviews to staff, why not to physicians? This form gives physicians feedback about their clinical quality, bedside manner, and ability to work with others.
Questions to Ask EMR Vendors
Ask before you buy and find out what your vendor really can do. Guidance from Physician MicroSystems.
Refer to Collections Form
Physicians often want to review an overdue patient account before it is sent to a collection agency. Staff can use this form to summarize the status of the account, making review easier.
Referral Form
Smooth patient referrals -- and your relationship with specialists -- with this easy form.
Sharps Evaluation Form
If you are shopping for sharps or syringes, make your selection easier using this template. Provided courtesy of Quality America, Inc. For more information about OSHA compliance, please visit www.quality-america.com.
Sharps Injury Log
Use this form to track sharps injuries. Provided courtesy of Quality America, Inc. For more information about OSHA compliance, please visit www.quality-america.com.
Sign-in Form
Placing a sign-in sheet on the reception desk makes the reception process less friendly. Instead, try asking patients to fill out this slip -- and do the necessary paperwork immediately.
Staff Performance Review
A sample review form for staff performance.
Staff Workload Benchmarks
General benchmarks on productivity for front and back office staff. Use these to evaluate the current performance of your staff and establish workload expectations.
Surgery Scheduling Form
Make sure you know everything you need to know.
Telephone Message/Triage Form
Get the message right the first time. Use this form to make sure all the information is covered.
Test Tracking Workflow Sheet
Make sure the tests you ordered get done, that you get the results and that the patients knows if anything is wrong. Print this form on carbon paper to create two copies: Send one copy to the lab. Keep the other in the office, but don't file it until the results come back and the patient is notified. If the form is still sitting out a month after the test was ordered, you'll know to follow-up.
Time and Administration Errors of Pegasys vs. Peg-Intron
A white paper provided by Roche
Workflow Considerations
Detailed elements to consider when reviewing workflow in your office. Use this checklist to help define staff responsibilities and best methods to make workflow seamless.
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