FSO Member Survey
on Third Party Hassle Factors

Question Title

1. FSO Member Name

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2. Office Contact Person

Name

Title

Phone

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3. Preferred Contact Information (Please check one and include information.)

Cell Phone

Office Phone

Home Phone

Contact Information

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4. Who is the Specific Hassler? (insurance carrier, review firm, government agency or managed care plan)

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5. Plan Type (Required.)

PPO

HMO

POS

Indemnity

Workers Comp

Medicare

Erisa/Self-Funded

Other

Other (please specify)

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6. Problem Categories (Please check all that apply.)

Inappropriate payment reductions

Inappropriate bundling of services/procedures

Inappropriate application of modifiers

Inappropriate denials of CPT codes (services, procedures, tests) or HCPCS codes (items/supplies)

Failure to follow general CPT guidelines

Payment delays

Contract dispute

Deficient appeals process

Inappropriate medical policy/coverage policy

Limits on physician autonomy

General customer service

Exclusion from provider network

Other (please specify)

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7. Complaint Specifics (Please do not use this to address a specific patient concern OR include identifiable patient information.)

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8. What action(s) have you taken to resolve the issue?

Telephone calls

Letter and/or narrative report

Resubmit claims

Copy and send medical records

Seek outside assistance

Consult colleagues

Retrieve, review and send hospital medical records

Other (please specify)

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9. Have you reported the issue to any other entity or filed a formal complaint?

Yes

If yes, to whom did your report the issue or file a complaint?

Question Title

* 1. FSO Member Name

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* 2. Office Contact Person

Question Title

* 3. Preferred Contact Information (Please check one and include information.)

Question Title

* 4. Who is the Specific Hassler? (insurance carrier, review firm, government agency or managed care plan)

Question Title

* 5. Plan Type (Required.)

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* 6. Problem Categories (Please check all that apply.)

Question Title

* 7. Complaint Specifics (Please do not use this to address a specific patient concern OR include identifiable patient information.)

Question Title

* 8. What action(s) have you taken to resolve the issue?

Question Title

* 9. Have you reported the issue to any other entity or filed a formal complaint?

1. FSO Member Name

2. Office Contact Person

3. Preferred Contact Information (Please check one and include information.)

4. Who is the Specific Hassler? (insurance carrier, review firm, government agency or managed care plan)

5. Plan Type (Required.)

6. Problem Categories (Please check all that apply.)

7. Complaint Specifics (Please do not use this to address a specific patient concern OR include identifiable patient information.)

8. What action(s) have you taken to resolve the issue?

9. Have you reported the issue to any other entity or filed a formal complaint?