Thank you for choosing us as your health care provider. We are commited to your treatment being successful. Please understand that payment of your bill is considered a part of your treatrment.
Medical billing has become a complex issue for most Medical Practices. For that reason, we have contracted with NCDS Medical Billing to perform this task for our Practice.
We assure you that NCDS will work hard to make sure your paperwork is filed accurately and promptly. At your visit, you will be asked to sign paperwork stating that you understand the following information. The following is a statement of our / their Financial Policy, which we require you to read prior to any treatment.
BILLING / FINANCIAL QUESTIONS?
Please contact us, we will be happy to assist you.
NCDS Medical Billing (800) 556-6236
Office / NCDS Privacy Statement
The HIPAA Privacy Standards
The United States Department of Health and Human Services has adopted privacy standards "the HIPAA Privacy Standards" which protect your health information. The HIPAA Privacy Standards establish rules for when healthcare providers and billers, such as NCDS Medical Billing, may use or disclose your health information. Importantly, the HIPAA Privacy Standards also tell us what we cannot do with your health information. Activities that are not permitted under HIPAA will require your written authorization.
Notice of Office Privacy Practices
THIS NOTICE, EFFECTIVE AS OF APRIL 14, 2003, DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The doctors and staff believe your medical information should remain confidential. The information in this notice constitutes a promise to you that we acknowledge our legal obligation to protect your health information, and it describes your rights concerning our use of health information.
We are permitted or required to disclose limited health information about you, without your authorization, in the following circumstances:
- As required by law. - For public health activities (disease, vital statistics, public health investigations). - For purposes of making required reports of abuse, neglect, or domestic violence. - Health sight activities (audits, investigations, proceedings, inspections, licensure). - Court orders. - Law enforcement purposes (gunshots, subpoenas, victims of crime). - To coroners, medical examiners, and funeral directors. - For organ or tissue donation. - Research. - To avert serious threats to health or safety. - Specialized government functions regarding military, inmates, or national security. - Workers compensation. - Marketing, appointment reminders, treatment alternatives, or other benefits.
Any uses or disclosures other than those noted above require us to obtain your written authorization, which you may revoke at any time. Any such revocation must be in writing.
With respect to your health information, you have the right to:
- Restrict certain uses of your health information; we are not required to agree to your request. - Request, in writing, a method of contact for furnishing confidential communications. You are obligated to notify us in writing of any changes. - Inspect your health information (you are entitled to a copy of your health information, except in anticipation for use in a civil, criminal, or administrative trial or proceeding). - Amend your health information in limited circumstances. We reserve the right to deny your request. - Receive an accounting of disclosures made to you. - Receive a copy of this Notice in writing.
We have the following obligations to:
If you believe we have violated your privacy rights, you may file a written complaint to our Privacy Officer and / or to the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
How NCDS Medical Billing may use or disclose your health information
The HIPAA Privacy Standards allow us to use and disclose your health information, without your authorization, to perform the activities listed below in our role as a medical billing service and management company.
Payment: We are permitted to use and disclose your health information to receive payment for our services. For example, we may:
- Contact your health plan or its agents to check your co-payment amount. - Check to see if specific treatments are covered under your plan. - Provide your health plan or its agents with the health information they need to pay the client for the services they provided.
Healthcare operations: We are permitted to use and disclose your health information for the general administrative and business activities necessary for us to operate as a medical management company. For example, we may:
- Review and evaluate the performance of our clients. - Conduct audits and compliance programs. - Collect medical history and treatment information from you. - Provide customer service. - Review and solve grievances.
No Insurance Coverage
If you do not have insurance, payment in full is expected at the time of services unless you have made prior payment arrangements with our billing office.
Although the practice accepts many insurance plans, it is virtually impossible for our office to verify whether or not our physicians are covered on your particular plan. So we ask that you must confirm participating provider status directly with your insurance plan before coming in for your appointment. We will not be held responsible for non-coverage of a visit from a plan which we or a certain staff member is not a part of the network. You will be expected to pay all balances.
(Patients covered by Ohio Medicaid must provide their current Medicaid card at every appointment.)
Because both patients and insurers often switch plans, it will be necessary for you to complete / update a new insurance informational sheet pertaining to your health coverage when checking in for EACH visit. This serves to protect you from being held responsible for an unpaid balance because of incorrect / outdated information.
Having more than one insurer DOES NOT necessarily mean that your services will be covered 100%. Secondary insurers will pay based on the response of your primary carrier payment. We may bill your secondary carrier as a courtesy. You are responsible for any balances after your primary insurance has cleared.
All insurance co-pays are due at the time of serviceas required by your insurance company - NO EXCEPTIONS. This is federally mandated and is law. Even if you carry a secondary commercial insurance that may cover your primary insurance co-pay, you are still required to pay your co-pay at the time of service. WeDO NOTbill secondary insurance for the primary carrier co-pay.
A $30 surcharge will be added to you bill if you insist on being seen without your co-pay.
If you do not know your co-pay amount and wish to be seen, a charge of $30 for the visit co-pay will be administered for the visit until the actual amount can be determined. Once determined and paid, any credit due will be always paid back to you.
If you belong to an insurance plan that requires a referral for specialist care it is your responsibility to obtain the referral form from your Primary Care Physician (PCP) prior to your visit. Your PCP must send a copy of the referral to the practice's office ahead of your visit.
(Our agreement with your plan does not allow us to see you until we have a completed referral form.)
Insurance and Insurance Collection
Please understand that insurance reimbursement can be a long and difficult process for our office. In fact, insurers will routinely stall, deny, and reduce payments. To that end, our billing staff is extensively trained to maximize your insurance reimbursement while reducing the time in which they pay.
However, sometimes involvement from the subscriber (you) is essential in expediting processing and payment of a claim by your insurance plan. We would greatly appreciate your prompt attention to any materials or questionnaires your insurance company may send to your by responding to them immediately, as payment of the claim(s) may be pending your response to such inquires.
Motor Vehicle Accidents
This office does not bill Auto Insurance for motor vehicle accidents.
Patient Account Statements
An account balance becomes the patient's responsibilty for three basic reasons:
1) Your insurance has paid for services and the balance remaining is member liability.
2) Your insurance has been billed and either denied or pended the claim(s) or not responded at all to claim submission within 60 days from the billing date.
3) No insurance information or invalid information for you exists in our files.
If you are unable to make immediate payment of your plan deductible or co-insurance, or if you do not have insurance (or services are not covered by your insurance plan) and you are unable to pay in full at the time of your visit, please discuss this matter with NCDS.
PLEASE REFRAIN FROM CALLING THE OFFICE REGARDING BILLING QUESTIONS THAT SHOULD BE HANDLED BY NCDS.
In such situations, we are very amenable to developing creative reimbursement plans PRIOR to services being rendered. However, if prior arrangements are not made,your account may be turned over to collection when it is overdue more than 90 days.
You will receive a monthly statement with your account balance. If you have insurance your statement will show what has been determined to be your responsibility from the response of the carrier.
(If your primary carrier is a managed care plan or Medicare a statement will only be mailed when there is a balance on the account that is your responsibility. Be aware that we consider the balance your responsibility even if there is a secondary carrier.)
An unpaid balance is considered past due after 45 days. If two consecutive statements have been sent to you but no attempt at payment has been received on your account to reduce your responsibility, you may receive a collection letter and be considered for further collection activity. If your account must be turned over to a third party collection agency, you risk possible damage to your credit. This action would also cause a breach in the physician / patient relationship, resulting in discharge from the practice.
The office reserves the right to not call in any prescriptions or render any services if the patient has an outstanding deliquent balance on their account.
No surgeries will be scheduled if a patient has an outstanding delinquent balance, except in the case of an emergency.
If you are unable to keep your appointment, we request that you give us at least 48 hours advance notice of your cancellation. There is a $50 fee for "no-shows".
Pending or Threatening Litigation
Dr. Croak takes care of many patients who have had suboptimal surgical outcomes elsewhere. Some situations may not be able to be helped to a patient's degree of satisfaction despite Dr. Croak's best efforts. Because of this fact, Dr. Croak makes it clear that if you are threatening or involved in pursuing litigation for a prior suboptimal outcome, it is your responsibility to inform him of your plan at the time of your first consultation. Dr. Croak reserves the right to decline care at anytime pending investigation into your specific situation. The failure to disclose litigation will result in immediate termination from the practice.
This office is NOT a party to your divorce decree. Adult patients are responsible for their bill at the time of service. The financial responsibility for minors rests with the accompanying adult.
Visits involving a minor must have written permission from all legal parents/ guardians to treat the minor present and will require one parent/guardian present at the time of the visit. Unaccompanied minors may be denied non-emergent treatment.