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PRACTICE NAME: __________________________________________________________________

I.

II.

OFFICE LOCATION/INFORMATION
1.

Identify Practice location site(s) by address: ____________________________________


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2.

Provide copy of lease/amendments.

3.

If no written lease or copy not available, describe:


(a)
Size: ____________________________________________________________
(b)
Rent: ____________________________________________________________
(c)
Number of doctors that the office may accommodate: _____________________

4.

If any member of group owns building, identify name of owner, type of entity that owns
it (e.g., LLC, partnership) and ownership percentage of each owner: _________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

GOVERNANCE INFORMATION
1.

Provide copy of (as applicable):


______
______
______
______
______

Bylaws
Operating Agreement
Shareholders Agreement
Buy-Sell Agreement
Partnership Agreement

2.

Do the owners of the group have regular meetings? _______ Yes _______ No
If yes, how often? ______________________

3.

Does your group have a Board of Directors/Manager(s)/Governor(s)/Executive


Committee? _____________________________________________________________
(a)

What are the duties of the board/committee? _____________________________


_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

(b)

How often do they meet? ____________________________________________

(c)

How are the board members elected? ___________________________________


_________________________________________________________________

(d)
4.

How many board members? __________________________________________

Does your group have a managing partner, CEO, or president with management
responsibilities? __________________________________________________________

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(a)

How is the managing partner, CEO, or president selected?


(1)
(2)

(b)

By vote? _________________
Is it a position rotated among the owners? ________________________

Do you have any voting protocols such as matters that require a supermajority
vote?
Yes _______ No _______
If yes, what are those matters and what is percentage? _____________________
_________________________________________________________________

(c)

Do you have a mechanism to break a tie vote (like a senior shareholder veto or
shoot-out clause)?
Yes _______ No _______
If yes, describe: ____________________________________________________
_________________________________________________________________

III.

PHYSICIAN COMPENSATION
1.

Provide copy of written compensation plan, spreadsheet, or other document setting forth
method. (Not necessary to include actual dollars paid). If no written plan is available,
provide the following description:

2.

Are all physicians in the group compensated using the same method?
Yes _______ No _______

3.

What is the method(s) of distributing practice revenues? (Describe all, if more than one.)
Include:
(a)

Are overhead expenses shared equally or by productivity? __________________


_________________________________________________________________
If by productivity, describe which ones and how
designated ________________________________________________________

(b)

Are personal expenses (CME cost of health insurance, etc.) deducted from gross
income?
Yes _______ No _______

(c)

Are professional (E&M) revenue paid according to productivity?


Yes _______ No _______

(d)

How are profits from ancillary revenues (lab, radiology) paid to shareholders?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

(e)

How do you distribute Lupron and drug infusion revenues to the physicians?
_________________________________________________________________
_________________________________________________________________

(f)

If you use a point system to distribute revenues, please describe: _____________


_________________________________________________________________
_________________________________________________________________

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4.

Do you pay a salary/distribute bonus:


______ yearly?
______ quarterly?
______ monthly?

5.

Do you require physicians who overdraw (take salary in excess of profitability) to


repay? Yes _______ No _______

6.

What are physician benefits?


(a)
(b)
(c)
(d)
(e)

IV.

EMPLOYEE/FAMILY RELATIONS
1.

V.

Does your group employ and family members? Yes _______ No _______
If so, what is name and position? ____________________________________________

HOSPITAL AND OTHER FACILITY CONTRACTS/RELATIONS


1.

Provide copy of any hospital contract such as a service agreement, exclusivity agreement,
on-call agreement (other than medical staff requirements). Include agreements with
SNFs, ASC, home health, etc.

2.

Provide:
(a)
(b)
(c)
(d)

3.

VI.

CME (is there a cap?) _______________________________________________


Health Insurance ___________________________________________________
Vacation (describe number of days and how allocated) _____________________
_________________________________________________________________
Expenses reimbursed? _______________________________________________
Sick leave/disability (Do you pay physicians for short-term disability)? How
long? How do you qualify? What is payment?) __________________________
_________________________________________________________________

Name of facility ___________________________________________________


Length of agreement ________________________________________________
Describe service ___________________________________________________
Any non-compete? _________________________________________________

Identify the hospitals of which each doctor is on staff and type of membership (e.g.,
active, courtesy): _________________________________________________________
________________________________________________________________________

LITIGATION, AUDIT, CREDENTIALING PROBLEMS


1.

Describe any pending lawsuits, claims, or threatened lawsuits against group or any
physicians:
(a)
Identify amount claimed: ____________________________________________
(b)
Describe expected resolution: _________________________________________
(c)
Brief description of claim: ___________________________________________
_________________________________________________________________
(d)
Include arbitration, administrative actions: ______________________________
_________________________________________________________________

2.

Describe any current, threatened, or previous (last 3 years) audits or investigations by


government (do not include specific claim review information):

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(a)
(b)

(c)
(d)

VII.

Provide copy of letter claiming refund/repayment


Describe basis government says that gave rise to audit (e.g., billed improper level
of service): _______________________________________________________
_________________________________________________________________
Identify amount claimed: ____________________________________________
Brief description of expected resolution: ________________________________
_________________________________________________________________
_________________________________________________________________

3.

Identify any limitation on credentialing/medical staff appointments for reasons related to


quality of care/professional conduct in last 3 years:
(a)
Identify hospital: ___________________________________________________
_________________________________________________________________
(b)
Describe complaint: ________________________________________________
_________________________________________________________________
_________________________________________________________________
(c)
Describe actual or expected resolution: _________________________________
_________________________________________________________________

4.

Provide copies of any judgments, settlements, or releases entered into in the last three
years or describe:
(a)
Parties: __________________________________________________________
(b)
Amount of judgment or settlement, and any ongoing obligations: _____________
_________________________________________________________________
_________________________________________________________________

CALL OBLIGATIONS
1.

Describe how your group covers call (e.g., do you rotate nights/weekends?):
________________________________________________________________________
________________________________________________________________________

2.

Describe any exceptions to the routine call rotation (e.g., senior status) _______________
________________________________________________________________________
________________________________________________________________________
If there are any exceptions, what is policy?
(a)
(b)

(c)
3.

VIII.

Provide copy, in writing; or


Describe financial penalties or consequences, if any, to limit call
obligation ________________________________________________________
_________________________________________________________________
Age limits on reducing call: __________________________________________

Do you cover for any physician not in your group? Yes _______ No _______
If yes, identify and describe obligations: _______________________________________
________________________________________________________________________

AFFILIATED PRACTICE ENTITIES


1.

Do you or any member of your group have an interest in any entity (other than the group
practice) that provides health care related services, such as lithotripsy, ASC, radiology
equipment, lab, etc. _______________________________________________________
________________________________________________________________________

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2.

Provide copy of partnership agreement, operating agreement, or other governance


document.

3.

Do any individuals, other than members of your group practice, have an


ownership/financial interest in the entity? Yes _______ No _______

4.

Are you contemplating acquiring such an interest in the near future, such as an ASC,
lithotripter, lab, radiology? Yes _______ No _______
If yes, describe nature of proposed venture, whether physicians outside group would
participate, and whether any non-competes are proposed: _________________________
________________________________________________________________________
________________________________________________________________________

4.

Does your group have a contract with a third party to manage any part of your practice,
such as infusion services? Yes _______ No ________
If yes, provide copy or describe:
(a)
(b)
(c)
(d)
(e)

Name of entity: ____________________________________________________


Term of contract: __________________________________________________
Ability to terminate: ________________________________________________
Describe service: ___________________________________________________
Any non-compete? _________________________________________________

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IX.

MEANINGFUL USE ASSESSMENT


1.

Have you attested for Meaningful Use? _______ Yes _______ No


If yes, at what stage and year are you currently? _________________________________

2.

Does your EMR provide a MU Dashboard? _______ Yes _______ No

3.

Are you currently using a patient portal? _______ Yes _______ No


If yes, is the portal a part of your EMR or a 3rd party vendor? _____EMR _____Vendor
Name of portal ___________________________________________________________

4.

Do you have a lab interface? _______Yes ________No

5.

Are you successfully submitting electronic immunization data from you EMR to an
immunization registry or immunization information system? _____Yes ______No

6.

Do you have the capability to submit electronic syndromic surveillance data to public
health agencies? _____Yes _____No

7.

How is the security risk analysis conducted; i.e. IT or through EMR?


________________________________________________________________________

8.

Are you aware if your drug-drug and drug-allergy checks are on?
______Yes they are on _______No they are not on ______ I am not aware

9.

Are you aware if your drug-formulary check is on?


______Yes it is on _______No it is not on ______ I am not aware

10.

Do you have a clinical decision support implemented? _____Yes _____No

11.

Are their specific Clinical Quality Measures you are consistently reporting/tracking?
_____Yes ______No

12.

How is your database maintained; i.e. host environment or do you manage your own
servers?
________________________________________________________________________
________________________________________________________________________

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