Orthopaedic & Spine Specialists

FINANCIAL / PAYMENT POLICY

Thank you for choosing Orthopaedic & Spine Specialists as your health care provider. We are committed to the success of your medical treatment and care.

For your convenience, we have answered a variety of commonly asked questions regarding our financial policy. If you need further information about any of these policies, please ask to speak with one of our staff from our patients accounts department.

How May I Pay?

We accept payment by cash, personal check, VISA, Mastercard, and Discover. A $25.00 fee will be charged for all returned checks.

Do I Need A Referral?

If you are a member of an HMO that we participate with, you will need a referral form from your primary care physician. Your HMO requires us to obtain a referral form regardless if another payer is involved or not, i.e., workers’ compensation or auto insurance. If you do not have a form at the time of the visit, you will have the option to sign a waiver for personal responsibility, pay for the charges at the time of service, or you may reschedule.

Which Plans Do You Contract With?

Please see the attached list.

What Is My Financial Responsibility?

Insurance is an agreement between you and your insurance company. We do not become involved in disputes between you and your insurance company regarding deductibles, co-payments, non-covered or denied services. Your financial responsibility depends on a variety of factors, explained below.

Durable medical equipment (splints, crutches, slings, etc.) may not be covered under your insurance policy and will become your responsibility if denied by insurance.

What if My Child Needs to Be Treated?

A parent or legal guardian must accompany patients who are minors (under age 18) on the patient’s first visit. The accompanying adult is responsible for payment of the account, according to the policy outlined below. If a minor attends follow up appointments on their own, the same payment policy will apply.

May I receive a “discount” on any of my charges?

We receive many requests to discount our fees from patients who are uninsured or underinsured. In order to address those needs we have developed a “Prompt Pay Policy” that may be applied when charges are paid in full at the time of service. This does not apply to co-payments or co-insurance which are a requirement from your insurance company. Please ask to speak to one of our Patient Accounts representatives if you think you may qualify for this discount.

If You Have.....	You Are Responsible .....	Our Staff Will....
Commercial Insurance Also known as indemnity, regular insurance or an 80% - 20% plan.	For a minimum payment of 20% of the total for services rendered will be due at the time of service.	Submit your insurance claim for you. We will assist in any pre-certification or pre-authorization process necessary. We will collect all payments that are due following your visit.
HMO & PPO plans with which we are a participating provider. (Please see attached list.) **MAMSI – RADIOLOGY SERVICES	If the services you receive are covered by the plan: All applicable co-pays and deductibles are “required” at the time of service. If the services you receive are not covered by the plan: Payment in full is “required” at time of service. To know if you may have radiology services performed in this office. Some MAMSI plans will not contract with OSS for radiology services. MAMSI may require you to have your x-rays, MRI, or CT scan at another facility.	Submit your insurance claim for you. We will assist in any pre-certification or pre-authorization process necessary. We will collect all payments that are due following your visit. If co-pays are not paid at time of service a re-billing fee will be applied. Bill you for radiology services not covered by your insurance.
HMO & PPO plans that we do not participate with….	For payment in full at the time of service.	Submit your insurance claim for you. We will collect all payments that are due following your visit.
Point of Service Plan or Out of Network Plan	For payment of the patient responsibility – deductible, co-pay, non-covered services – is due at time of service.	Submit your insurance claim for you. We will collect all payments that are due following your visit.
MEDICARE	If you have regular Medicare, and have not met your $131 deductible, you will be billed for any balance due. Payments for any services not covered by Medicare are to be paid at the time of service. If you wish to be on “automatic crossover” for your secondary insurance, you must call your secondary insurance to set this up.	Submit your insurance claim for you as well as any claims to your secondary insurance.
If You Have……	You Are Responsible For….	Our Staff Will….
AUTO INSURANCE	Providing accurate and complete policy and claim and accident information for your auto insurance, including your agent’s name and telephone number. You must also provide your health insurance information in the event your policy has exhausted.	Call to verify your coverage. Submit your insurance claim for you.
WORKERS’ COMPENSATION	Providing accurate and complete information including your claim number, date of accident, and a contact name and number from your place of employment. You must also provide your health insurance information in the event your claim is denied.	Verify that we are an approved panel provider. Call to confirm that your claim has been reported and to verify your claim number. We will submit your claim and all required information.
NO INSURANCE	A minimum payment of $100 is required at time of service followed by minimum monthly payments of $50.00. Charges must be paid in full within (6) months.	Will counsel you should you have a need for a payment plan or other payment arrangements.

It is important to the physicians of OSS that our patients remain informed about our practice. Our physicians have financial interest in the OSS Ambulatory Surgery Center, Imaging Center, and Therapy Center. You have a choice whether or not you wish to receive services in these facilities.

I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance, as well as applicable co-payments and deductibles, are my responsibility. I authorize my insurance benefits to be paid directly to Orthopaedic & Spine Specialists. I authorize Orthopaedic & Spine Specialists to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.

I understand that my account may be turned over to a collection agency after 60 days and will be assessed a 30% collection fee. I will be responsible to pay the collection fee should that occur.

Date Patient Signature

Signature of Parent / Guardian for Minor Patient

Printed Name of Patient

0/01/07