Healthcare Reimbursement Optimization Assessment Form
Use this form to assess reimbursement workflows, denial drivers, payer mix, and optimization priorities for your organization.
Organization Profile
Organization name
*
Organization type
*
Please Select
Hospital
Clinic
Physician practice
Dental practice
Therapy practice
Imaging center
Billing service
Other
Primary specialty or service line
*
Number of locations
*
Reimbursement Operations
Current billing model
*
In-house
Outsourced
Hybrid
Main payer mix
*
Current billing/claim management software
Optimization Assessment
Denial Rate Severity
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Top Reimbursement Pain Points
*
Claim denials
Underpayments
Delayed payments
Coding errors
Prior authorization delays
Eligibility issues
Missing documentation
Appeal workload
Other
Optimization Assessment Survey
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Workflow efficiency
1
2
3
4
5
Documentation quality
6
7
8
9
10
Payer follow-up process
11
12
13
14
15
Visibility into reimbursement performance
16
17
18
19
20
Goals and Follow-up
Primary reimbursement improvement goal
*
Preferred follow-up method
*
Email
Phone call
Virtual meeting
Submit Assessment
Should be Empty: