Request your pricing report

This is the intake for the full ChargeBench report. (The free charge check needs only your NPI and an email address, on the homepage.) About ten minutes; answer what you can, blanks are fine. What the report needs: your fee schedule exported from your practice-management system (code and charge are enough), or, if that isn't handy, your Work Comp Fee Schedule plus your work comp authorization letter to start, and the six short questions below: what you want from this, solo or group, payer mix, in-network plans, work comp volume, and what else you bill. Nothing here involves patient information.

About you

Your name as it appears on Medicare claimse.g. Dr. Jane Smith

Practice name

Your individual NPI (10 digits)Type 1 NPI; look it up at npiregistry.cms.hhs.gov

Practice state

SpecialtyPick the closest

What do you want out of this?

Confirm fees are in line Raise fees Stronger position with carriers at renewal Price cash / cosmetic services Medico-legal fees Something else

Are you solo, or in a group that sets your fee schedule and contracts? Do you bill the same charge to every payer? When was the fee schedule last updated?

Where the revenue comes from (rough percentages)

Medicare

Commercial insurance

Work comp

Auto / PIP / letters of protection

Self-pay (non-cosmetic)

Cosmetic / elective cash

Medico-legal (IMEs, depositions, testimony)

Total: 0%

Which commercial plans are you in network with? Do you know what any of them pay relative to Medicare, or pay a percentage of billed charges?

Work comp and medico-legal (skip if not part of your practice)

New work comp patients per month

Depositions per month

IMEs per month

Court appearances per year

Do you pre-negotiate anything with work comp carriers (initial evaluation, surgery)? What fee? Medico-legal feesOne per line: item, fee. e.g. "Deposition per hour, $1,300" or "Court testimony, $1,750/hr, 3-hour minimum". Or upload the schedule below. Roughly what does an hour in clinic produce for the practice? ($)Used only to price time out of the office (court, travel)

Cash, cosmetic and ancillaries What else is billed through your practice (therapy, splints/DME, imaging, injections, PRP)? At what price?

Fully self-pay patients per month

Self-pay prices you publish or quoteOne per line: service, price. e.g. "New patient visit with x-rays, $300" Cosmetic fee sheet (if applicable)One per line: procedure, surgeon fee (surgeon fee only, as quoted) Competitors you think about mostOne per line: name, city, website

Documents Your fee scheduleExport from your practice-management system (CSV or Excel with code and charge is ideal), or a PDF. If you don't have one handy, your Work Comp Fee Schedule plus your work comp authorization letter works to start. Medico-legal fee schedule(s)

Please don't upload EOBs, remittances or anything with patient information. If a contract review is part of your engagement, we send de-identification instructions first.

Last things Anything else we should know?

You may use an anonymized version of my results as a sample

Best email for the report link

Phone (optional)

The report arrives within three business days. Public Medicare data and your own fee inputs only; no patient records, ever.