Basic Policy – Charges that are not covered by insurance, as well as deductibles, copays and/or coinsurances are due at the time of service. If you are a self-pay patient, or will not be using health insurance for our services, or if we are an out-of-network provider with your primary insurance company, all charges are due at the time of service. You are responsible for payment of any charge that has been denied or unpaid by your insurance carrier.
Procedure Fees – All payments for non-covered interventional or surgical procedures are due prior to your procedure. Your insurance carrier may require preauthorization. All anesthesia and laboratory fees that are not covered by the insurance carrier will be billed directly to the patient.
For Patients with Health Insurance – We will bill your insurance carrier for you if we are a participating provider (in-network), and if the proper paperwork is provided to us. Referrals (if required) must be obtained before the scheduled visit for initial (new patient) visits and follow-up visits. There are many ways in which we can receive the referral request – it may be faxed to us, or sent from your referring provider through our electronic referral system (P2P). If you have the referral document, you may upload it in the patient portal, or bring it to our office on the day of your clinic visit. Copayments and deductibles are due at the time of service. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than anticipated for care. If an insurance carrier has not paid within 60 days of billing, office and procedure fees are due and payable in full from you.
Medicare Patients – We will bill Medicare for you. We will also bill secondary insurance for you. All copayments or deductibles are due and payable at the time service is provided.
Medicare Patients – Signature on File – I request payment of authorized Medicare benefits be made either to me or on my behalf to Relieve – Pain and Spine Center for any services furnished to me by my pain provider at that practice. I authorize any holder of medical information about me to release to the Health Care Financing Administration (HCFA) and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in Item 9 of the HCFA-1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services.
Non-Covered Services – Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or upon notice of insurance claim denial.
Missed Appointments – In fairness to other patients and to our office, we require at least 24 hours’ notice to cancel appointments. You may be charged $50 for missed appointments, or be discharged from the practice for recurrent no-shows.