Interventional Pain Management 2007 Benchmark Survey Date Section One: General Information Geographic location (select one) Return Deadline - vember 12, 2007 Eastern: (Connecticut, Delaware, District of Columbia, Maine, Massachusetts, Rhode Island, New Hampshire, New Jersey, New York, rth Carolina, Pennsylvania, Vermont, Virginia, West Virginia) Midwest: (Illinois, Indiana, Iowa, Michigan, Minnesota, Nebraska, rth 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? Does your pain specialty practice have more than one location? 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 Physical therapy/occupational therapy Complementary/alternative medicine (i.e. acupuncture, herbal medicine, VAX-D) Other
Section Two: Staff Information A. Physicians and n-physician Provider Staff Physicians Physician Specialty Pain Anesthesiology Neurology Neurosurgery Orthopedic Family medicine and/or internal medicine Physiatry (PM & R) Psychiatry Other (please specify) Number (FTE) % of time devoted to pain Hrs/week for clinic appointments Hrs/week for procedures/surgery Total physicians: n-physician Providers (NPP) NPP specialty Nurse practitioner Physician assistant Psychologist Physical therapist Other (please specify) Number (FTE) % of time devoted to pain Hrs/week for clinic appointments Total NPP: 2
B. Support Staff Please list the total number of FTEs (full-time equivalents) for each position listed below Staff 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 FTEs 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 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 Please check all that apply 3
Section Three: Billing Systems and Electronic Health Record (EHR) Does your practice have its own billing software and hardware (billing system)? Is billing done within the practice? 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)? Is your practice considering converting to an EHR some time in the future? 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% 4
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.) Gross Charges % or $ Net Revenue % or $ Payer 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) What percent of your gross charges are from ancillary services? 5
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 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) Hospital Outpatient Department Hospital OR/ Surgery Section Six: Comments Please include any comments or clarifying information in the space below: Please return no later than vember 12, 2007 Or by fax to: 763-514-9992 By mail to: ASIPP c/o PRACTICE Advantage 4000 Lexington Avenue, X195 St. Paul, MN 55126-2983 6 PRACTICE Advantage 2007 Pain Practice Benchmark Survey