We recognize the need for a definite understanding between you and your physician concerning healthcare and the financial arrangements for this medical care. Our commitment is to provide the very best healthcare to our patients while recognizing the need to limit services to only those medically necessary. The responsibility for payment of fees for these services is the direct obligation of the patient.
Your health benefit plan is an arrangement between you, the enrollee and the insurance company, HMO or your employer. While we will try to be helpful, and we may participate in the plan, your health benefit plan determines your coverage, any requirements for prior authorizations or referral and establishes the limit on your coverage for medical services. We cannot know the benefits and exclusions of each patient’s policy. It is the patient’s responsibility to know and understand her coverage and benefits
For insurance plans we participate with, we will seek to obtain verification of your eligibility, however, even when such eligibility and/or benefits are verified by this office, your insurance plan will not guarantee the accuracy of their confirmation of coverage or benefits, and that you are eligible and that your benefits are in force. Therefore, it is our policy to obtain your credit card number and authorization to assume acceptance of financial responsibility, should your insurance plan not honor the claim we submit for the services we provide to you.
It is also your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals from primary care physicians, pre-certification, limits on outpatient charges, specific physicians and/or hospitals to use. You should be knowledgeable of any deductibles, co-payments and/or coinsurance. You agree to accept responsibility for co-payments, deductibles, and medical care and other services that are provided to you which are not specifically covered by your insurance plan or not covered due to the absence of authorizations/referrals you are obligated to obtain under your insurance plan. The services, plans, and benefits under your insurance plan may be subject to and governed by applicable contracts and government regulations. This agreement is not intended to conflict with or circumvent the provisions of such contracts and regulations, including any provision regarding grievance procedures that maybe available to you.
You will receive monthly statements. The first statement will show all charges, with subsequent statements showing any insurance payments (it takes 4-6 weeks for most carriers to pay). You are responsible for any unpaid balances.
Please be sure we have the most current demographical and insurance information at all times. It is your responsibility to provide us with this information. The information you provide us must match the information you provide the insurance carrier. Filing insurance claims with the wrong information delays processing and increase patient’s financial responsibility. Please note if you fail to provide us with correct insurance information, we will not re-file a claim to the correct insurance carrier after 30 days and the balance will become your financial responsibility.
A well women exam is when a healthy patient is seen to screen for various illnesses and diseases; this is considered preventive medicine. A problem visit is one where the patient has a specific concern, symptom or complaint. Some insurance carriers only provide benefits for prevention while other may only provide benefits for problems. We recommend you contact your insurance carrier prior to each visit and inquire about the type of benefits you have. Once a claim has been submitted to your insurance carrier, the office will not change the coding in order to circumvent an insurance denial.
Bills from Hospital and Labs:
When you have a pap smear, any type of blood work or a culture or biopsy, the specimen is generally sent to an outside lab or hospital for analysis. When this occurs you may receive a separate bill from that entity.
Any New GYN, and any patients scheduled for an office procedures that:
A charge in the amount of $100.00 may be billed to the patient’s account.
Established GYN patients that:
A charge in the amount of $25.00 may be billed to the patient’s account.
A charge in the amount of $50.00 may be billed to the patient’s account.
A charge in the amount of $100.00 may be billed to the patient’s account, and patient may be released from the care of the practice.
Should your insurance carrier require a referral or authorization, it is your responsibility to obtain or request one prior to your appointment. Please note some insurance carriers will not allow your OB/GYN physician to issue a referral. In this care, you will need to consult your primary care physician (PCP). The office will not issue a referral or authorization for a service already performed or back date a referral or authorization.
Should you require specialized forms for employment, school, summer camp, disability, or for any other purpose, you must assume the cost of preparing these forms. Should you request that this office discuss the contents of any form, a telephone consultation charge will be required. The patient must authorize such communications in writing. Forms requested for completion must be provided at least two (2) weeks before the due date.
Single-page forms (front and back) that are submitted at least two-weeks in advance are free of charge. The standard fee for any additional forms of any length after the first is $25.00 per form. Please note this fee does vary and is based on the complexity and time involved to complete and submit the form and any additional information and materials that may be required.
If you make a payment by check to the office and it is returned to us for any reason, you will incur a fee of $35.00. Any fees Grace Women's Clinic may incur due to returned check(s) will be added to your account in addition to the $35.00 returned check fee.
Additionally, no appointments or services will be provided for non-emergent care, until the balance is paid in full.
This practice provides prescriptions that are medically necessary and appropriate in your treatment. It is your responsibility to promptly fill the prescription. Should the prescription become lost, or you have moved to a new pharmacy, and a replacement is necessary, there is a $25 fee that must be paid before the replacement prescription is provided.
It is your responsibility to make all co-payments at the time of service. You know the co-payments in you health benefit plan. Should you fail to make co-payments at the time of the visit, this practice will invoice you for that co-payment, and a $10 statement fee will be added as the cost of handling and billing for this obligation of yours.
It is our intention to maintain all patient accounts in our office. However, if your account becomes past due the office will take the necessary steps to collect this debt. Any and all additional costs associated with the collection of the debt may become your financial responsibility.
We realize that temporary financial problems may affect timely payments on your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.
If you have any further questions about the information above or any uncertainty regarding our financial policy, please don’t hesitate to ask us.
Our staff and our billing service's staff are here to help you and work with you.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total
expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.