Fraud
& Abuse/Billing Errors & Omissions Insurance
Short Form Questionnaire |
State in which
you practice: |
If
your state is missing, we are not licensed to broker
this type of insurance in your state. If you have
questions, please contact us at info@bbsocal.com or call (800) 435-6565. |
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Name: |
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City: |
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Contact: |
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Telephone: |
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E-Mail: |
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Fax: |
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Current Carrier: |
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Effective Date: |
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Specialty: |
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Describe
Operations: |
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Type of
Organization: |
Public Company
Medical Group
Clinic
Partnership
Corporation
Other
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Number of
Physicians: |
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Total
Revenue: |
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Percentage revenue
billed to: |
government payors
private payors |
Number of
Annual: |
procedures
patient visits |
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Do you use a third party billing service? |
Yes
No
If no, which compliance/audit software system do you utilize?
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Date of last Medicare / Medicaid audit (if any) |
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any physician or entity been audited or investigates for
billing fraud and abuse? |
No
Yes
If yes, please provide details:
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Has any physician or entity ever been sanctioned or had
any final adverse actions by a government or private payor? |
No
Yes
If yes, please provide details:
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Receive your
quote by: |
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| Submit: |
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AUTHORIZED REPRESENTATIVE
Name:
Title:
By filling in my Name and Title above, I acknowledge that I am providing information that may be used to evaluate my application for an insurance policy and for other purposes set forth in the Privacy Statement and the Legal Notices found at the following links: http://www.bbinsurance.com/privacy.shtml and http://www.bbinsurance.com/legal.shtml. Further, by filling in my Name and Title above, I certify that I have read, understood and accepted each of the Privacy Statement and Legal Notices.
Must provide quotes in writing or via e-mail, not orally.
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