Please enter the information indicated below.

1.  Bed Size  (The total # of licensed beds.)

2.  Beds in Service  (The total # of operational beds.)

3.  Average Daily Census  (The average daily inpatient census.)

4.  Total Accounts Receivable $  (The total dollar amount of any open patient accounts where monies are owed the organization for services provided.  This does not include accounts in bad debt status.)

5.  Cash Receipts Per Month $  (The actual cash received by the organization as payment for services rendered on any patient accounts for the monthly reporting period.)

6.  Gross Revenue Per Month $  (The total amount of charges on accounts for patient services rendered for the monthly reporting period.)

7.  Accounts Receivable $ Over 90 days  (The total dollar amount of all open accounts that are older than 90 days.  This does not include the accounts in bad debt status.)

8.  Monthly $ Cost of Admissions/Registration Staff (including benefit load)    (The total of salaries/wages including benefit load (i.e. health benefits, payroll taxes, and other non-direct payroll costs) for ALL individuals (staff and management) that work in admissions/registration.  Admissions/registration staff and management includes but is not limited to:  schedulers, insurance verifiers, financial counselors, pre-registrars, registrars, etc. and all supervisors, managers, and/or directors of this staff.)

9.  Monthly $ Cost of Business Office Staff (including benefit load)   (The total of salaries/wages including benefit load (i.e. health benefits, payroll taxes, and other non-direct payroll costs) for ALL individuals (staff and management) that work in the Business Office. Business office staff and management includes but is not limited to:  cash posters, refund specialists, billers, insurance and self-pay collectors, analysts, data entry, charge master specialist (based in business office), receptionists, customer service and all supervisors, managers, and/or directors of this staff.)

10.  Administrative Write-Off $ Per Month (not including contractuals)     (The dollar amount of accounts that are written off to codes other than bad debt and charity.  An example would be denied accounts that could not be overturned and will not be paid.)

11.  Bad Debt Write-Off $ per Month   (the dollar amount of accounts that are written off to bad debt.)

12.  Charity Write-Off $ Per Month   (the dollar amount of accounts that have been approved and written off to charity care.)

13.  Number of Open Accounts  (Number of open accounts being worked by the business office.  Do not include those accounts that have been assigned to outside collection agencies or specific financial classes that are assigned to an outsource vendor for follow up.)

14.  Number of FTEs in Business Office (excluding admissions)   (Active number of full time employees that are performing business office functions i.e. management, supervisors, billers, collectors, posters, etc.)

15.  Percentage of AR in Self Pay >90 days   (Dollar amount of self pay as a percentage of accounts receivable that are greater than 90 days old.  Do not include any accounts that have been referred to an outside collection agency.  This can be determined by taking the total dollars in AR > 90 that are self pay and dividing it by the total dollars in AR >90.) 

16.  Number of Days Cash on Hand  (This is the actual amount of cash on hand divided by average cash usage per day for hospital expenses.)

17.  Amount of $ Discharged But Not Final Billed (DNFB)  (Dollar amount of accounts on patients that have been discharged and the billing has not been sent.) 

18.  When was your ChargeMaster last updated? (dd/mm/yy)   (The last date that your ChargeMaster was completely updated using the latest available code changes and respective pricing?)

19.  Date Data Compiled (dd/mm/yy)   (The date the information was compiled on your Information System.  (i.e.  These numbers are from my March Month End Data – so the date would be 3/31/12).

20.  What is your Patient Accounting System?  ( This is the hospital’s main Health Information System i.e. Meditech, Dairyland, CPSI, Siemens’s, HBOC, HMS, etc.)