Sample Patient Financial Policy
Thank you for choosing our practice. Our physicians are committed to the success of your treatment and care. Because patients have told us they want to know our financial policies prior to consultations and procedures, we have outlined them below. If you need further information about any of these policies, please ask to speak with a Billing Specialist or the Practice Manager.
How may I pay?
We accept payment by cash, check, VISA, Mastercard, American Express and Discover.
Do I need a referral?
If you have an HMO plan with which we are contracted, you need a referral authorization from your primary care physician. This is also true for Medicare HMO plans. If we have not received an authorization prior to your arrival at the office, we have a telephone available for you to call your primary care physician to obtain it. If you are unable to obtain the referral at that time, your appointment will be rescheduled or you may pay out-of-pocket for the visit.
Which plans do you contract with?
Please see the attached list of contracted plans.
What is my financial responsibility for services?
Your financial responsibility depends on a variety of factors, which are outlined below.
Financial Responsibility — Office Consultations and Services
If You Have... / You Are Responsible For... / Our Staff Will...Commercial
Insurance
(Also known as indemnity insurance or “80%/20% coverage.”) / For office services:
All applicable copays and deductibles will be requested at the time of the office visit. If the physician recommends a procedure:
We will estimate your coinsurance payment and provide this information to you. A deposit will be requested prior to scheduling the procedure. / Call your insurance company ahead of time to determine deductible and coinsurance amounts.
File an insurance claim as a courtesy to you.
Contracted HMO &
PPO plans / If office services/tests are covered:
All applicable copays and deductibles are requested at the time of the office visit.
If the physician recommends a procedure plans that is covered :
We will estimate your coinsurance payment and provide this information to you. A deposit will be requested prior to the procedure.
If the test or procedure recommended is not covered by the plan:
Payment in full is requested prior to the procedure. / Call your insurance company head of time to determine copays, deductibles, and non-covered services.
Explain your financial responsibility before any test or procedure is scheduled.
File the insurance claim on your behalf.
If You Have... / ... You Are Responsible For... / Our Staff Will
Noncontracted and Out of Network Plans / For office services:
Payment of unmet deductible and full visit charges will be requested at the time of the visit.
For tests and procedures:
We will estimate your payment and provide this information to you. A deposit will be requested prior to the procedure. / Call your insurance company ahead of time to determine out of network benefits, copays, deductibles, and noncovered services.
Explain your financial responsibility before any test or procedure is scheduled.
File an insurance claim on your behalf.
Regular Medicare / For office services:
Your $100 deductible (if it has not been met) will be requested at the time of service. If you
do not have secondary coverage, we will also request your coinsurance be paid.
For tests and procedures:
We will estimate your payment and provide this information to you. A deposit will be requested prior to the procedure. / File the claim on your behalf, as well as any claims to your secondary insurance.
Explain your financial responsibility before any test or procedure is scheduled.
Participating Medicare HMO / For office services:
Your copay will be requested at the time of the visit.
For tests and procedures:
We will estimate your coinsurance payment and provide this information to you. A deposit will be requested prior to the procedure. / File the claim on your behalf, as well as any claims to your secondary insurance.
Explain your financial responsibly before any test or procedure is scheduled.
No Insurance / For office services:
Payment in full is requested at the time of the visit.
For tests and procedures:
We will estimate your payment and provide this information to you. A deposit will be requested prior to the procedure. / Work with you to settle your account. Please ask to speak with our staff if you need assistance.
What if I cannot pay my bill?
We offer affordable payment plans to patients who wish to have non-elective procedures but who cannot pay their bill in full prior to the procedure. Our Patient Counselor will discuss your specific financial situation and determine an agreeable solution. In some cases, this may require you to provide information such as pay stubs or W-2 forms.
If your procedure is elective, it must be paid in full prior to the date of service. Installment plans may also be arranged.
What is a pre-procedure deposit?
We believe patients should be empowered to know what their financial responsibility is prior to any medical procedure. Because of this, we have hired a skilled Patient Counselor who will talk to you about the cost of the recommended procedure. S/he will contact your insurance plan to determine the coinsurance and deductible owed, and calculate a deposit based on this information.
After determining your deductible and copay for the procedure, the Patient Counselor will provide you with a written cost estimate which shows your financial responsibility, based on the benefit levels and coverage of your insurance plan. S/he will also request a pre-procedure deposit, which secures your procedure on the physician’s schedule. The amount varies depending on your insurance coverage and deductible amount, but is typically between $500 to $1,000, or higher.
What if my child needs to see the physician?
A parent or legal guardian must accompany patients who are minors on the patient’s first visit. This accompanying adult is responsible for payment of the account, according to the policy outlined on the previous pages.
I have read, understand, and agree to this financial policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility.
I authorize my insurance benefits be paid directly to (name of your practice).
I authorize (name of your practice) to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.
______
Patient/Guardian Name (Printed) Signature Date
2