FinancialPolicyWelcometoMcIntoshClinicandPriviaMedicalGroup!Wearepleasedthatyouhavechosenusasyourcareprovider.Ourmissionistoprovideyouwiththehighestlevelofprofessionalmedicalcarewiththehighestdegreeofpatientsatisfaction.Oneimportantaspectofoptimalpatientcareistohaveanagreementastofinancialresponsibilitytoavoidanymisunderstandingsandtoensuretimelypaymentforservices.

McIntoshClinicandPriviaMedicalGrouppolicyrequiresthatallpatientssigntheAuthorizationandConsentforTreatmentFormpriortoreceivingmedicalservices.Theformconfirmsthatpatientsunderstandservicesbeingprovidedarenecessaryandappropriate.Theformalsoadvisespatientsoftheircompletefinancialresponsibilityforallmedicalservicesreceivedwithoutregardtoinsuranceeligibilityorcoveragedeterminations.

PaymentResponsibilityPatientsortheirlegalrepresentativeareultimatelyresponsibleforallchargesforservicesrendered.Paymentisexpectedattimeofserviceforallchargesowedforthecurrentvisitaswellasanypriorbalance.Forthoseinsuranceplanswithrealtimeadjudication,paymentwillbecollectedatcheckoutforchargesincurredthatday.Forinsuranceplansthatdonotprovideimmediatepatientresponsibleinformation,settlementofyourbalancecanbeaccomplishedviacard-on-file(preferred)oryoumaypayadepositondateofservice.

Forcard-on-file,wewillchargeyourcardforthebalanceyouoweassoonasyourinsurancecompanyinformsusofthepatient’sresponsibility.Underthedepositoption,youmaypayanestimateoftheexpectedpatientresponsibilityandwewillsettlethebalanceuponreceiptoftheExplanationofBenefits(EOB)fromyourinsurancecompanybyeithersendingarefundincaseofoverpaymentorsendingastatementforthebalancedue.Bothpaymentoptionsbenefityoubyreducingadministrativeburdenandsettlingyourportionofthebillinatimelymanner.

ForAnnualWellnessvisitsorPhysicalExamsforwhichyourequireadditionalservicesbeyondthescopeofthewellnessexamorphysical,anadditionalchargewillbeincurredandyouwillbeaskedtopayresultingadditionalcopaymentsorpatientresponsibilityamounts.

TYPESOFPATIENTPAYMENTS1. Co-payments-Wearecontractuallyrequiredbyinsurancecarrierstocollectco-paymentsatthetimeofservicesarerendered.Thepatient’sappointmentmayberescheduledifhe/sheisnotpreparedtomakethispayment.2. Deductibles-Someinsuranceplansrequirepatientstopayapredeterminedamountbeforeserviceswillbecovered.3. Co-insurance-Someinsuranceplansrequirethatpatientspayapredeterminedpercentage(e.g.20%)oftheallowedchargeamount.

• Ifamountcanbedeterminedattimeofservice,amountwillbecollected.4. UninsuredPatients(Self-Pay)-Paymentforallservicesrenderedisdueatthetimeofservice.Patientspayingthetotalofchargesforthatdaysvisitwillbegivenapromptpaydiscount.Ifthetotalchargeamountisnotavailableatthetimeofcheckout,thepatientwillberequiredtopayadepositthatwillbeappliedtohis/hercharges.Ifthedepositexceedsactualchargesthenarefundwillbeissued.

• Newpatients:totalchargeoraminimum$300deposit.• Establishedpatients:totalchargeoraminimum$150deposit.• Uninsuredpatientshavingaprocedurewillberequiredtopaythetotalchargeamountoftheanticipatedchargesoraminimum$250paymenttotheprovider’sofficepriortotheprocedurebeingperformed.

5. Out-of-Network-PatientsbeingseenasOutofNetworkwillberequiredtopayapaymentforthatday’svisitatthetimeservicesarerendered.Wewillcourtesybillyourinsurancecompany.Ifthetotalchargeamountisnotavailableatcheckout,thepatientwillberequiredtopayadepositthatwillbeappliedtohis/herchargesasdescribedinthePaymentResponsibilitysectionabove.

•Newpatients:thetotalchargeamountoraminimum$300deposit. •Establishedpatients:totalchargeorminimum$150deposit.6.Non-Covered-“Non-covered”meansthataservicewillnotbepaidunderapatient’sinsurancecontract.Ifapatientisunsurewhetheraserviceiscoveredbyhis/herplan,itisultimatelythepatient’sresponsibilitytocallhis/herinsurancecarriertodeterminewhatthescheduleofbenefitsallows.Ifnon-coveredservicesareprovided,thepatientwillbeexpectedtopayfortheservicesatthetimeofservice.Appealproceduresaregenerallyavailableandbillingstaffwillassistpatientsinattemptingtoresolveadversedeterminations.Undernocircumstanceswillbillingstafffalsifyorchangeadiagnosisorsymptominordertoconvinceaninsurertopayforcarethatisnotcovered.ForMedicare,allnon-coveredserviceswillbecommunicatedtothepatientpriortotreatmentanddocumentationofhis/heracceptanceoffinancialresponsibilitywillbeobtainedpriortoprovidingtreatment.TheCentersofMedicareandMedicaidServices(CMS)hasmandatedtheform"AdvanceBeneficiaryNotice(ABN)"tobeusedforthisnotification.InsuranceAllpatientsmustpresenttheirinsurancecard(ifapplicable)andproofofidentification(e.g.PhotoID,Driver’slicense).Patientswhodonotprovidecurrentproofofinsurancemaybebilledasaself-paypatient.Ifatalatertimethepatientpresentshis/herinsurancecard(s),servicesalreadyrenderedmayormaynotberetroactivelybilleddependingontheinsurance’sclaimfilingrequirements.Thepatient’sinsuranceisacontractbetweenhim/her(and/oremployer)andtheinsurancecarrier.McIntoshClinicandPriviaMedicalGrouparenotapartofthiscontract.Forthisreason,wecannotwaivecopaysordeductibles.Patientsareresponsibleto: •Knowifareferralisnecessaryforofficevisits.(IfpatientchoosestoNOTfollowpayerpolicy regardingobtainingareferralfromPrimaryCareProvider,patientcanbeseenasaSelf-Pay andpaymentinfullattimeofservicewillberequired.) •Checkwiththeirinsurancecarriertodetermineifrecommendedtestingiscoveredundertheir medicalcoveragepolicy.(Ifpatientchoosestohavenon-coveredtesting,paymentinfullat timeofservicewillberequired.) •Contacttheinsurancecarriertodeterminethescheduleofbenefitsandifaco-paymentor deductibleapplies. •Arriveforappointmentswithproperdocumentation. •Appealadversedeterminations.InsuranceVerification-Verificationofpatient’sinsuranceeligibilitywillbedone2businessdayspriortoscheduledvisits.Ifstaffmembersareunabletoconfirmactiveinsurancecoverageforapatient,thepatientwillbecontactedandadvisedofhis/herinsuranceeligibilitystatus.PatientswhoareunabletopresentanalternativeformofactiveinsurancecoveragepriortothevisitwillbeinformedthattheyclassifyasSelf-Payandwillberequiredtopayatthetimeservicesarerenderedormayrescheduletheirappointment.Forsamedayappointments,eligibilitywillbecheckedastheappointmentismade.InsuranceClaimsProcessing-McIntoshClinicandPriviaMedicalGroupacceptsassignmentofbenefitsformanythirdpartycarriers.Inaccordancewiththeinsurancecarriercontractspatientswillberequiredtopayco-paymentsatthetimeservicesarerendered.McIntoshClinicandPriviaMedicalGroupwillsubmitchargesforservicesrenderedtotheinsurancecarrier.Thepatientorguarantorwillbeexpectedtopaytheentireamountthatisdeterminedtobepatientresponsibility.Thesefeesareforphysicianservicesonlyandtheremaybeadditionalchargesfromlaboratory,radiology,orotherdiagnosticrelatedproviders.

Non-contractedInsurance-Ifnon-contracted“outofnetwork”insurance(aninsurancecompanywithwhichourprovidersarenotcontracted)hasnotpaidwithinthirty(30)days,theremainingbalance,beyondtheamountwecollectattimeofservice,isthepatient’sresponsibility.OutstandingBalancesAnyoutstandingbalancethatisduefromthepatientispayableinfulluponreceiptofstatement.Intheeventapatientpresentsforanofficevisitandhasanoutstandingbalance,arequestforpaymentwillbemade.Statementsaregeneratedonatwenty-eight(28)daycycle.Patientswhofailtorespondtostatementswillbeplacedintocollectionstatus.Patientswithanoutstandingbalanceformorethan(90)daysmaybereferredtoanoutsidecollectionagencyandwillbechargeda$20collectionfeeinadditiontothebalanceowed.Apatientwithunpaiddelinquentaccountsoraccountswhichhavebeenwrittenofftobaddebtmaynotreceiveadditionalscheduledservicesunlessspecialarrangementshavebeenmade.Thepatientmaybedischargedfromthepractice,however,inallsituationstheurgencyoftreatmentwillbetakenintoconsideration.LateArrivals,CancellationsandNo-showsLatearrivals-Patientswhoarrivelateforascheduledappointmentmaybeaskedtorescheduletheappointmentorwaitforanopenappointmenttimeonthatday’sschedule.Thephysicianmaydecidetoworkthepatientinbutthisisatthediscretionofthephysician.Thereisnooptionorpreferencegivenforaparticularprovider.Cancelations-Patientsshallcallatleastone(1)businessdayinadvanceifunabletokeepascheduledappointmenttimeorthepracticewillconsiderthepatienta“no-show”.Inaccordancewithourpracticeguidelines,apatientmaybedischargedfromthemedicalpracticefor“no-showing”forascheduledappointment.No-showswillbedocumentedinthepracticemanagementsystemandahistoryofno-showsmayresultinrefusaltoschedulefutureappointments.McIntoshClinicandPriviaMedicalGroupstaffwillnotifyapatientviaregularmailwhenthisdecisionismade.Firstvisitappointmentsthatarerepeatedlycancelledandnewpatientno-showswillcounttowardthepatient’sno-showrecordandmayresultinnon-acceptanceordischarge.

NewCard-on-FileFeatureAsyouknow,ifyouhaveevercheckedintoahotelorrentedacar,thefirstthingyouareaskedforisacreditcard,whichisscannedandlaterusedtopayyourbill.Thisisanadvantageforbothyouandthehotelorrentalcompany,sinceitmakesthecheckoutprocesseasier,faster,andmoreefficient.Wehaveimplementedasimilarpolicyatourpractice.Youwillbeaskedforacreditcardatthetimeyoucheck-in,wewillscanthecardinoursystem,andtheinformationwillbeheldsecurelyuntilyourinsurancehaspaidtheirportionandnotifiedusanyadditionalamountowedbyyou.Atthattime,youwillreceiveanotificationthattheremainingbalanceowedwillbechargedtoyourcreditcard,andyouwillreceiveareceiptforthecharge.Thiswillbeanadvantagetoyou,sinceyouwillnolongerhavetoreceivestatements,writeoutandmailuschecks.Itwillbeanadvantagetousaswell,sinceitwillgreatlydecreasethenumberofstatementsthatwehavetogenerateandsendout,andreducethedifficultyinfollowingupwithpatients,allowingustofocusonmoreimportantissues,likeyourcare.Thecombinationwillbenefiteverybodyinhelpingtokeepthecostofhealthcareadministrationdown.Thisnewprogramwillinnowaycompromiseyourabilitytodisputeachargeorquestionyourinsurancecompany’sdeterminationofpayment.