FSO Member Survey
on Third Party Hassle Factors

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* 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

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?