Practice Services Intake | MCS MSO

Section A

Practice & Contact

Who are you and how do we reach you?

Practice / group name *

Primary contact name *

Title / role *

Phone *

Email *

City / State *

Number of locations

Number of providers (MD/DO/NP/PA)

2. Approximate annual collections (most recent full year)

3. Payor mix (approximate %) Helps us scope coding posture and prior-auth load. Numbers should total to about 100%.

Medicare

Medicare Advantage

Commercial

Medicaid

Self-pay / cash

Section B

Current Billing & Operations

How does revenue cycle work today?

4. How is your billing handled today?

In-house billing staff Outsourced Hybrid (in-house + outsourced) Not sure

5. If outsourced, who is your current billing / RCM vendor, and are you under contract?

6. What practice management / EHR system do you use?

Would you consider standardizing onto a recommended platform?

Yes No Open to discuss

7. Roughly what does your AR look like? Best estimates are fine. We can quantify precisely once we engage.

% of AR over 90 days

Approximate denial rate

Are denials consistently appealed?

Yes No Unsure

8. For procedural / surgical practices: how is surgical coding handled?

Provider self-codes In-house certified coder Outsourced Not applicable (E&M only)

Section C

Where It Hurts & What You Need

Pain points and services of interest.

9. Which of these are causing you the most pain right now? Check all that apply; we'll dig into prioritization on the call.

Collections / aging AR Denials not worked or appealed Prior authorization burden Credentialing / enrollment delays Coding accuracy / lost revenue Lack of financial visibility Staffing / turnover Payor contracting / rates Compliance / audit risk

11. What would a successful engagement look like for you in the first 6–12 months?

Section D

Goals & Growth

Where you're headed.

12. Are you considering any of the following in the next 1–3 years?

Adding providers Adding locations Adding ancillary services / ASC Value-based / MA risk Succession / eventual sale Acquiring another practice Staying the same size, run better

13. What are your top goals for the practice? Examples: cut days in AR, capture missed revenue, free up staff time, improve margins, prepare for growth or sale.

Section E

Diligence Inputs

Helps us prepare an accurate scope. Nothing here is binding.

14. Which of these do you currently have available?

Recent P&L / financials Payor contracts summary AR aging report Provider roster + credentials Fee schedule None readily available

15. Do you currently work with an attorney and/or accountant for the practice?

16. Is there anything else we should know to scope the right services for you?

Section F · Next Step

Schedule the conversation.

We will review your intake and respond within one business day to schedule a 30-minute confidential conversation. You can also book directly using the Calendly link.

Would you like us to contact you to schedule the conversation?

Yes, please contact me Not yet — submitting for review

Best way and time to reach you

Or schedule directly via Calendly →