FINANCIAL POLICY. I understand and agree to Woodbourne Family Practice Financial Policy. Print Name Date. Signature

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1 FINANCIAL POLICY Woodbourne Family Practice believes that communicating our financial policy is good healthcare practice. Charges incurred for services rendered are the patient s responsibility regardless of insurance coverage. Your insurance coverage is a contract between you and your insurance company, not your insurance company and us. We will file your primary and secondary insurances as a courtesy. Please realize that having secondary insurance does not necessarily mean that your services are covered 100%. Secondary insurances typically pay according to a coordination of benefits with the primary insurance. It is your responsibility to provide us with accurate insurance information and to inform us of any changes in your coverage as they occur. You are responsible for all copays, coinsurance, deductibles, and non-covered services. We are obliged to collect your copay at the time of service per your insurance company. We accept cash, debit card, check, (except starter checks & not from new patients), MasterCard & Visa. Statements are sent out monthly, and we ask that balances due be paid when you receive your statement or at your next appointment, whichever is sooner. Patient payments are typically applied to the oldest balances first, except for copayments and coinsurances they are applied to the current date of service. There is a $25.00 bounced check service charge. Payment will then need to be made by cash, money order or credit card for the balance due. When you receive healthcare services from us and we bill your insurance, it is the same as though we are extending you credit. You receive the service and we await payment from you and/or your insurance. Due to the high cost of rendering care and the lowering reimbursements by many insurers, including Medicare, we simply cannot afford to carry large balances. Balances not paid within 90 days will be turned over to an outside collection agency, unless prior payment arrangements have been made and of course a service fee will be generated. Some patients may accrue large balances for services provided. We will work with these patients to set up a mutually feasible payment plan. In some cases, if the minimum payment due cannot be paid, we will need proof of financial hardship. Please understand that we cannot waive deductibles, coinsurances or copays that are required by your insurance. This is a violation of our contracts with the insurance plans. Completing disability forms, FMLA forms, and other requested supplemental insurance forms requires time away from patient care and day to day business operations. Prepayment of $15.00 per form is required. Please understand that in order to complete forms your medical record must be reviewed, forms completed and signed by the physician and copied into your medical record. Some of these forms can be quite complicated and tedious to fill out. Please provide us with pertinent information, especially dates of disability and return to work. We request that you allow 5 business days for this process. I understand and agree to Woodbourne Family Practice Financial Policy. Print Name Date Signature

2 Woodbourne Family Practice FINANCIAL POLICY DEFINITIONS & DETAILS Please be assured that everyone in this practice is dedicated to providing medical care of the highest quality possible to all of our patients, in an atmosphere of caring, trust and mutual respect. Your complete understanding of your financial responsibilities is essential; it takes a team that includes patient participation, to succeed with insurance processing and reimbursement. Failure by the insurance company to pay results in the balance being transferred to the patient for payment. In order to become a provider of medical services through your health plan, the physicians at Woodbourne Family Practice are required to enter into a contract with selected insurance companies. Many such contracts stipulate that the physicians will not provide or charge for unnecessary medical services, as determined by the insurance companies. Past experience has shown that some health plans have very different ideas than members, such as yourself, with respect to what is or is not medically necessary. In the more recent years it has become increasingly difficult to collect the fees rightfully due to the provider for services rendered in good faith to their patients. To this end we have found it necessary to be very explicit in the financial polices of this practice. All too often we are finding patients presenting to the office stating they have no form of payment for the services they are about to receive. We ask that you please present to the office with a form of payment to meet your obligations to your insurance provider and to your healthcare provider. We thank you in advance for taking the time to review these policies and your understanding of our need to have in place such an in depth policy. Things to bring with you to your visit: Health Insurance Card we are required to verify these with a government approved form of ID Drivers License Method of payment for your convenience we accept cash, debit card, checks (exceptions starter checks and new patients) Visa & MasterCard Assignment of Benefits: Woodbourne Family Practice will only bill contracted insurance plans as a courtesy to our patients provided that the patient has provided the required insurance information in a timely manner and has signed a current financial policy. Appointment cancellation, rescheduling and no-shows We verify appointments for our two business days Monday and Tuesday. If you do not show for your appointment, cancel or reschedule within 24 hours of your appointment time, we will bill you an administrative fee of $15. Additional Testing: For preventative care exams the physician may request you to undergo certain additional screening tests. Please contact your insurance company to determine if these are covered benefits to avoid incurring charges for which you will be held responsible years: pap testing, screening lab work (CBC, CHEM, TSH, CRP), gonorrhea, chlamydia screening, mental health benefits (libido issues, depression, anxiety these are considered Mental Health Issues by Insurance Companies and may not be covered if you do not have Mental Health Benefits) years: screening lab work (CBC, CHEM, TSH, CRP), gonorrhea, chlamydia screening, baseline mammogram at age 35, mental health benefits (libido issues, depression, anxiety) Page 1 of 5

3 40-64 years: yearly mammograms, bone densitometry, colonoscopy referral after age 50, screening lab work (CBC, CHEM, TSH, CRP), mental health benefits (libido issues, depression, anxiety) 65& above: yearly mammogram, bone densitometry, screening lab work (CBC, CHEM, TSH, and CRP), mental health benefits (libido issues, depression, and anxiety), and pap smear every 2 years unless risk factors exist. Please instruct your physician if you wish to have the pap completed yearly at your expense. Cash Pay/Fee for Service We require an $80.00 up front payment before your physicians visit and $ from a new patient. Upon completion of your visit, the front desk will be able to either issue you a refund or will ask for payment if the services rendered exceed $80.00 Charges for copies of medical records You will be charged for copies of medical records as per Medical Association, State and Federal guidelines. These charges cover the administrative costs of copying and mailing such records. In Pennsylvania, these fees are set by ACT 26 and they allow us 30 days to process your request. Checks We gladly accept checks as a form of payment. However, we have two exceptions. No checks are accepted from new patients and we do not accept starter checks. We charge a $25.00 bounced check fee. If a check bounces on your account, you will no longer be able to write checks Payment will then need to be made by cash, debit card, money order or Visa & MasterCard. Co-pay and co-insurance: We are obligated to collect the co-pay at the time of your visit, even if you are sick. We are required to do so by your insurance plan. The co-payment amount is determined by your individual insurance policy. All payments are due at time of service. If a situation arises and your co-payment is not paid at time of service, your account will be assessed $10.00 for the cost of creating an invoice Deductibles: Some insurance plans require that patients pay a predetermined dollar amount prior to services being covered. Deductibles processed by your insurance company are due by your next visit or billing statement which ever procedure comes first Filing Secondary Insurances Woodbourne Family Practice, as a courtesy, does file secondary insurance claims. However, it is the patient s responsibility to alert us of this coverage. FMLA and other Disability Paperwork There is a charge of $15 per form, payable prior to these forms being completed. Understand that these forms can be quite complicated and tedious to fill out. Please provide pertinent information like dates of disability and return to work date. Please allow the office 5 business days in which to review your medical record for the information requested, complete it, copy, mail or fax it. Foreign Exchange Students & Out of State Student insurances: We do not accept any foreign exchange or out of state student insurances. You must pay cash before the visit and will be given a receipt so you may submit to your insurance company for reimbursement. These types of insurance are for emergency care only and the will not cover any routine services. Page 2 of 5

4 Health Savings Accounts / Healthcare Debit Cards: If we are contracted with the health insurance with which you have this kind of plan, we may only bill you the full amount of our contracted allowable fee. We ask that you do not ask us to bill you for services rendered, we will require payment in full at time of service. Insurance: We are contracted with multiple insurers to accept assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the authorized co-payment, co-insurance and deductible at the time of service. If you have insurance coverage under a plan with which we do not have a contract, you will be treated as a cash pay patient and will be provided documentation to assist you in filing your claim If we are unable to verify your benefits, we will ask that you pay for your visit We are required to file with your primary insurance carrier only. It will be your responsibility to pay any balance not covered by the primary or secondary when applicable Laboratory, Radiology and other diagnostic services bills Please check with your insurance company to verify what your schedule of benefits allows for any laboratory, x-ray or other diagnostic studies (bone densitometry, mammogram etc.) that may be ordered by the doctor during your visit. These services will be billed separately by the laboratory/ diagnostic facility that does these tests and are not covered by the payments that you make at this office. Any insurance claims or problems associated with an off-site laboratory must be dealt with through that facility or their billing agent. Medicare Patients Please make sure you have a full understanding of your Medicare benefits and what might be your responsibility if not covered by Medicare. Your doctor wants to diagnose a condition you may have or evaluate how well your treatment is working. To do that the doctor needs to have certain diagnostic tests performed. The doctor will tell you what those tests are and why they are necessary. Before your tests are performed, you may be asked to sign an Advanced Beneficiary Notice or ABN. Why do we ask you to sign the ABN? We ask patients to sign an ABN whenever Medicare appears likely to deny payment for a specific service. Medicare requires that we provide patients with a written notification whenever it is likely that you will be responsible for the bill. Medicaid Patients Please do not ask to be seen under Medicaid if you have other health insurance. You must be seen under your primary insurance. We are now have a closed panel for this insurance. Motor Vehicle Accidents We do submit claims to motor vehicle insurances. You cannot be seen without the name and address of your insurance company, claim number and date of accident If your services are declined, we then will submit the claim to your personal health insurance along with the letter of declination. However, the patient is ultimately responsible for any denials, copayment, co insurance or deductibles It is the patient responsibility to know if we accept or are on the panel of their personal health insurance. Out of Network: Full payment is due at time of service. Appropriate claim documentation will be provided for filing with the insurance company. Outstanding balances/ Collections: Prior to providing additional services to you, payment in full of total outstanding balances will be required. Outstanding balances will be referred to an outside collection agency. Once we receive an EOB (explanation of medical benefits) from your insurance, we will mail to you a statement. If we do not receive payment within a reasonable time, your account will be referred to a collection agency and a $25.00 fee will be accessed to your account. Page 3 of 5

5 Patient Responsibility: Minor Patients: For all services rendered to minor patients, we will look to the accompanying adult, for payment. We do not get involved in custody battles. Understanding of benefits: It is the patient s responsibility to call their insurance company and find out what your schedule of benefits allows and what services they will and will not cover. Payment Responsibility: The patient or his/her legal representative is ultimately responsible for all charges for services rendered. Non-covered means that a service will not be paid under your insurance contract. If non-covered services are provided, you will be expected to pay for these services at the time they are provided, or at the time of receiving a statement or EOB from your insurance provider denying payment. Your insurance company offers appeal procedures. We will not under any circumstances falsify or change a diagnosis or symptom in order to convince an insurer to pay for care that is not covered, nor do we delete or change the content in the record that may prevent services from being considered covered. We cannot offer services without expectation of payment, and if you receive non-covered services, you must agree to pay for these services in the event that your insurance company does not. If you are unsure whether a service is covered by your plan, ultimately it is your responsibility to call your insurance company to determine what your schedule of benefits allows, if a deductible applies and your potential financial responsibility. Phone Appointments If you need to discuss a healthcare issue or abnormal test results, you will be asked to schedule an appointment to see your provider. Results usually take 7 days to reach our office or even longer depending on the testing you had performed. Referral for Outside collection: Accounts which have not been paid according to the financial policy will be referred to an outside collection agency/attorney for further action. The patient s care with Woodbourne Family Practice maybe required to seek an alternative medical provider. Refunds: Refunds are issued to the appropriate party. Patient refunds will not be processed until all active or past due charges are paid in full. Well visit and Problem/sick visit on the same day Some insurance companies will cover well visits and some will not. It is your responsibility to know what healthcare benefits your insurance covers, prior to your visit. If you need to discuss any health problems that require evaluation and management, this must be documented and appropriately billed for. Your insurance company may not pay for additional problems that are addressed during the well exam. During your discussion with your provider, they will manage your problem first and may ask you to make another visit for you well exam. Workers Compensation Visits Under Pennsylvania state law we are allowed to see our patient for workers compensation visits if it meets the following criteria: If your employer has a physician panel posted and we are a member of that panel. If your employer does not have a listed panel If your date of injury is over 90 days old and you have been give permission to visit our office from your workers compensation insurance. At appointment time, you will be required to have the name and address of your workers compensation carrier along with your claim number If Workers compensation declines your claim, we will then bill your health insurance along with the declination. The patient is responsible for any co-payment, co-insurance, deductible as well as making sure we accept their personal health insurance. Page 4 of 5

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