Office Policies

City of Angels Dermatology

Practice Policies

Patient Payments

You should expect to make some payments

either before your office visit or at the time

services are rendered. As a patient you must

make your co-payment, deductibles and

coinsurance payments at the time you receive

care. You may also be required to pay deposits

for certain cosmetic or elective procedures.

Your payment options are as follows:

For Cosmetic or Non-Covered Services:

£ Payment Required at Time of Service

For Medical or Covered Services:

£ Option 1: Payment at Time of Service

£ Option 2: Payment up to 45 days later

Signature:_____________________Date:_____

The amount of your patient office visit fee is

based on your insurance plan, if any, and

whether the services to be provided are covered

services. You should also expect to pay fees for

procedures that are not covered by your insurance;

including certain cosmetic services and skin care

products. You may pay for these additional

procedures, services and products at the

conclusion of your appointment.

Insurance

Before your visit, you should check with your

insurance company to be sure that you have the

proper documentation with you when you arrive

(health insurance card, member id number, etc)

and are aware of your co-payment, co-insurance,

and deductible requirements and any insurance

restrictions.

If we are a participating provider on your

insurance plan, as a courtesy we will file a claim

with your insurance company. If you elect the

OPTION 2 payment plan and request that we bill

your insurance company first you must supply us

a copy of the credit card that will be billed for any

outstanding amounts; provide consent to charge

the credit card and supply certain other

information items to facilitate a complete filing of

your insurance claim. Based on the Explanation

of Benefits (EOB) response from your insurance

company we will bill your credit card the amount

that is your responsibility and send you a copy of

the receipt reflecting the charges. We will not

send you a bill or invoice. Your EOB from your

insurance company will serve as your invoice.

In the event that your insurance company denies

payment for any reason, you or your guarantors

are responsible for payment of all outstanding

charges for services rendered. We will generally,

allow 45 days from the time we submit a claim to

your insurance company for the insurance

company to acknowledge the claim, make

payment, or deny the claim. On the 46th day if

we have not received payment, the amount is

due in full by you and we will charge the credit

card you have on file with us.

If you are a subscriber of one of the HMO plans

that City of Angels Dermatology participates you

will select OPTION 1. Your total responsibility for

covered services is your co-payment and shall be

paid prior to services are rendered.

If we are non-participating provider on your

insurance plan, you are expected to pay in full at

each office visit. We will supply you with an

itemized form that you can use to submit to your

insurance provider for reimbursement.

Allowable Forms of Payment

We accept the following forms of payment for all

fees.

· Cash

· Check

· Credit Card – Visa, MasterCard, American

Express, Discover, Debit Card

Returned Check Fees

If your check payment is returned you will be

assessed a returned check fee of $35 in addition

to the office service fee.

Charges for Broken Appointments

If you are unable to make your scheduled

appointment we ask that you notify us at least

one business day prior to scheduled appointment.

Please call us during normal business hours of

9:00 am and 5:00 pm.

If you are unable to make your appointment and

neglect to notify us at least 24 hours in advance,

you will be billed accordingly: $25 for office visits

and $50 for surgery.

THANK YOU FOR TAKING THE TIME TO READ THIS

POLICY STATEMENT. WE VALUE OUR RELATIONSHIP

WITH YOU AND SEEK TO ENSURE THAT OUR POLICIES

ARE FAIR AND CLEARLY COMMUNICATED. WE HOPE

THIS DOCUMENT ANSWERS SOME QUESTIONS FOR

YOU. IF YOU HAVE ANY MORE QUESTIONS

REGARDING THESE MATTERS, PLEASE LET US KNOW.

City of Angels Dermatology

Financial Policy

Patient Payments

You must make some payments either before your office visit or at the time services are rendered.  As a patient you must make your co-payment, deductibles and coinsurance payments prior to receiving care.  You may also be required to pay deposits for certain cosmetic or elective procedures.  The amount of these patient office visit fee is based on your insurance plan and whether the services to be provided are covered services. You are expected to pay this fee to our administrative staff when you arrive for your appointment.  Before your visit, you should check with your insurance company to be sure that you have the proper documentation with you when you arrive (health insurance card, member id number, etc) and are aware of your co-payment requirements and any insurance restrictions.

You will also be required to pay fees for procedures that are not covered by your insurance; including certain cosmetic services and skin care products.  You will pay for these additional procedures, services and products at the conclusion of your encounter. 

If we are a participating provider on your insurance plan, claims will be filed to the insurance company directly. In the event that your insurance company denies payment for any reason, patients or their guarantors are responsible for payment of all outstanding charges for services rendered. We will generally, allow 30 days from the time we submit a claim to your insurance company for the insurance company to acknowledge the claim, make payment, or denied the claim.  On the 31^st day if we have not received payment, the amount is due in full by you.  We suggest you contact your insurance company to obtain refund any monies paid. We will provide you an itemized form that you can submit to your insurance company if necessary.  These forms are useful for future insurance or income tax purposes.

If you are unable to make your appointment and neglect to notify us at least 24 hours in advance, you will be billed accordingly: $25 for office visits and $50 for surgery.

Insurance

If we are a participating provider on your insurance plan, claims will be filed to the insurance company directly. In the event that your insurance company denies payment for any reason, patients or their guarantors are responsible for payment of all outstanding charges for services rendered.

If we are non-participating provider on your insurance plan, you are expected to pay in full at each office visit.  We will supply you with a itemized form that you can use to submit to your insurance provider for reimbursement.

Allowable Forms of Payment

We accept the following forms of payment for all fees.

• ·     Cash
• ·     Check
• ·     Credit Card  – Visa, MasterCard, American Express, Discovery

Returned Check Fees

If your check payment is returned you will be assessed a returned check fee of $35 in addition to the office service fee. 

Charges for Broken Appointments

If you are unable to make your scheduled appointment we ask that you notify us at least business day prior to scheduled appointment.  Please call us during normal business hours of 9:00 am and 5:00 pm.

If you are unable to make your appointment and neglect to notify us at least 24 hours in advance, you will be billed accordingly: $25 for office visits and $50 for surgery.

FOR EMPLOYEES EYES ONLY

Payment Plans

Please apply the following guidelines to the establishment of patient payment plans.  Payment plans are provided to patients that elect……  Payment plans are not to be used for……

Interest Charges

We do not charge any interest on outstanding bills or payment plans.

Authority to Write Off a Portion of Balance

Write offs of a portion of the patient’s bill may be required in certain situations due to ………..  Our goal is to provide the highest level of patient care and exceed our patient’s expectations for service……..

The Office Manager may write off up to $100 off of a patient’s bill without the Practice Manager or Lead Physician approval.

The Practice Manager can approve the write off of up to $300 off of a patients bill without Lead Physician approval.

Any write offs in excess of $300 require Lead Physician approval.

Delinquent Accounts

If a patient has not paid his bill in accordance with the office visit fee or payment plan terms then the account is delinquent.  A letter or email is to be sent to the patient informing them that there payment is delinquent if the payment has not been received within 15 days of the due date. This letter will inform the patient that if patient is not received within the next 15 days there ability to schedule appointments with the practice will be suspended.  A second letter is sent 45 days after the due date informing the patient that their ability to make appointments and receive care has been suspended and that if payment is not received within the next 30 days they will be dropped as a patient.

If payment is not received within 90 days of the due date the patient is dropped from the roles of active patients and the account is sent to the offices’ collections agency.

Hardship Patients

City of Angels Dermatology offers discounts or charity care for uninsured or under-insured patients.  This service is limited to patients that have seen Dr. Billips is seminar…….  For those individuals we cannot discriminate in who receives this care and we must first verify the patients ability to pay.  These patients must provide a pay stub or W2 form. Further, for these patients we must note in their file to re-check their financial hardship situation annually.

Rules for Determining Hardship

………….these must be established

FINANCIAL PAYMENT POLICY
For
BRAZOS VALLEY WOMEN’S CENTER

AT BRAZOS VALLEY WOMEN’S CENTER, WE FIND THAT WITH EVER-CHANGING HEALTH INSURANCE IT IS IMPORTANT TO COMMUNICATE WITH OUR PATIENTS REGARDING OUR FINANCIAL POLICY.

1. INSURANCE: We will expect a copy of your insurance card prior to each visit. Failure to produce an insurance card may result in rescheduling your appointment.
1. MANAGED HEALTH INSURANCE: Insurance is a contract between you as the insured and the insurance company. Therefore it is advantageous for you to know your insurance policy such as, but not limited to: Benefits, limitations, co-pays, referrals, and precert requirements. By law, the insurance company has 30 days to pay, deny or acknowledge receipt of a claim. On day 31, if no payment has been received by BVWC, the amount is due in full by you and we suggest you contact your insurance company to refund the monies paid.
2. NON-PARTICIPATIN INSURANCE POLICIES: Patients covered by insurance policies that your office is not contracted with will be expected to pay in full at each visit and you will file the insurance.

Furthermore, you will receive a statement from our office on the 31st day. Again, after a 30 day period, this balance will be expected from you in full.

2. BALANCES:
1. Greater than day 30 are expected in full prior to further treatment.
2. Failure to comply with payment policies may result in collection proceedings to be initiated.
3. RETURN CHECKS: There will be a $25.00 service charge on all returned checks. Your name and account information will be sent to the County Attorney’s Office if all charges are not paid.
4. REFUND POLICY: In the event that a credit balance is created on your account and it is determined that the funds belong to you, you will be issued a refund check.
5. APPOINTMENT POLICY: It has become necessary for us to charge a fee for any appointments missed that have not been cancelled 24 hours prior to appointment times. Although we hope that this will not apply to you, please be aware that this is our office policy.

THANK YOU FOR TAKING THE TIME TO READ THIS STATEMENT. WE HOPE IT ANSWERS SOME QUESTIONS FOR YOU. IF YOU HAVE ANY MORE QUESTIONS REGARDING THESE MATTERS, PLEASE LET US KNOW.

Dear Patients,

If you have a managed care plan, you need to be aware that most managed care plans require the policy holder to use certain doctors, laboratories, radiology, or hospitals. if you do not, you plan will not cover the service.

With so many different plans, Brazos Valley Women’s Center cannot be responsible to direct you to the facilities that are approved by your plan. It is your responsibility to know what your plan covers.

Please read your policy or call your Human Resource department if you are unsure what facilities your plan covers.