Patient Financial Policies
Payment Guarantee: For services rendered by American Health Network (“AHN”), you guarantee payment of your account at the time services are provided for the entire costs that will not be paid by an insurance carrier, government payer (including Medicaid) or other third party payer (all called “PAYER”), or if at a later date after initial approval, your Payer denies the claim. You further understand that any out-of-network charges may be your responsibility as determined by your PAYER. You acknowledge that if your dependent is provided services you will be responsible for payment under these same terms and conditions. The “Responsible Party” listed on the Patient Data Sheet will be sent the bill and agrees to pay it. If the Responsible Party is not you and that person does not pay the bill, YOU agree to pay the bill.
Assignment of Benefits: To the extent there is third party coverage for payment of services, you agree that all medical and related benefits PAID by PAYER will be assigned to AHN on your behalf.
Billing Information: It is essential that you provide us with complete and accurate information to submit billing to your insurance company (i.e. home address, phone numbers). We will make every effort to submit claims to your insurance company and promptly provide you our statements. However, if for any reason the statement is returned to our office because of a problem with an address you provided, you may be dismissed and referred to a collection agency. To avoid this, please keep your information up-to-date.
Please be sure to bring your government-issued photo identification and your insurance cards to every visit so that we may properly bill your insurance company. If you do not have your insurance card with you, you may be required to make payment in full that day.
Medicare Agreement: If you have Medicare coverage, you acknowledge that payment of benefits will be made to you or on your behalf for any services furnished to you by AHN (or the party who accepts assignment), including your physician services. You authorize any holder of medical or other information about you to release to Medicare and its agents, any information needed to determine these benefits or any benefits for related services.
Insurance Billing: As your healthcare provider we will file your claims with your insurance company as a courtesy after services are provided, unless you notify us not to file it with your Payer. It is your responsibility to understand what services are covered under your medical insurance policy. If you have any questions whether a service will be covered we urge you to contact your insurance company, before the service is provided.
The codes that are listed for the services that are provided to you are based on the guidelines of the American Medical Association. There are several factors involved when making the decision for the type of services to be billed. Among those deciding factors is whether you are a new patient (not seen within the last three years) or established patient, the reason for the visit, the amount of time the service takes and the complexity of the medical problem.
Insurance companies make their payment decision about a specific medical service by looking at what your insurance policy provides. Example: If the reason for your visit is a sport physical and your insurance company does not cover that service we cannot go back and change the reason for your visit. It is your responsibility to find this out ahead of time.
Sometimes routine services such as office visits, laboratory services, mammograms, screenings, and annual physicals are not covered under insurance policies. We suggest you contact your insurance company to find out what benefits you have under your policy, before services are rendered by us. The customer service number is usually found on your insurance card.
Be advised that your insurance company may require a pre-certification, prior authorization, or referral for some services, such as: radiology, surgery, or specialist visits. Receiving prior authorization does not guarantee that your insurance company will pay for it. Patients have the responsibility to ensure that prior authorization has been obtained prior to services rendered.
Please note: If you are injured in an accident and you have medical insurance that insurance may or may not cover our services. If you have medical payment benefits through your auto insurance, we may attempt to bill that party for you or we may ask that you deal with them directly. If we bill any Payer and we are not paid within 30 days, you will be billed and you will be responsible for full payment for the services.
You should normally receive a response from your insurance company within 30 days. This is in the form of an "Explanation of Benefits" (or "EOB"). If you do not receive it, we would appreciate you contacting your insurance company to check the status of your claim in order to expedite payment. Please call our Billing Department (the phone number is listed on your statement), if you encounter any difficulty with your insurance company. We will try to assist you. You are responsible for payment until the account is paid in full by your insurance company.
Payment terms: Depending on your insurance policy benefits, you may be responsible for a co-payment, co-insurance, deductible, or for the entire services rendered. We may require payment for these items at the time of your office visit. If you fail to make payment at the time of service we may charge a processing fee to cover our extra expense of preparing and sending out a bill.
Once we have received an EOB from your insurance company, which indicates the amount you will be responsible for, a statement for the balance will be sent to you and payment is expected by the Due Date as stated on our bill.
If amounts due for services rendered become delinquent and the amounts are referred to an attorney and/or collection service, you agree that you will be responsible for all reasonable costs and expenses incurred in the collection efforts, including any interest charges due, court costs and attorney fees.
Note to divorced parents of dependents. Unless you provide us with a court order, the statement will be sent to the “Responsible Party” listed on the Patient Data Sheet and that person agrees to pay the bill. If the Responsible Party is not you and that person does not pay the bill, YOU agree to pay the bill. If there is a disagreement it is for the parents to determine who should pay without AHN involvement.
Workers Compensation Injury If you believe you are being seen for an injury/illness as a result of your job, we must have written authorization from your employer to confirm this and their directions as to how to bill for this service. If we do not have this information we will bill you and/or your insurance company.
Self Pay Patients: Self Pay Patients are those not covered by any insurance policy or third party payer. Self Pay Patients will receive a 15% discount across the board for professional services rendered, when payment is made in full at the time services are rendered (and where no claim form is prepared or billing statement has to be mailed).
Payment is YOUR responsibility: Our relationship is with you, to provide quality healthcare to you and/or your dependent. Consequently, all charges incurred are your responsibility. The obligation to ensure payment in a timely manner lies with you. Unfortunately, we cannot always depend on your insurance company to make timely payment on your behalf. We are not responsible for delays, misplaced claims, or the need for additional information from you by your insurance company.
Payment Options: If you are unable to meet your financial obligation, payment arrangements can be made. Financing options may be available .Contact our Billing Department to discuss payment options, before your account becomes over due. In cases of financial hardship you might be considered under our hardship policy and you may ask us about it.
Making Payments: Patients may pay by cash, money order, check or personal credit card, which can include credit cards to pay from your "flexible spending account" and/or “health savings account,” if you have these. One, or all, of these cards may be used to pay your bill, and may be kept on file by us to facilitate billing. Patients agree if they have a credit balance after paying for a service, AHN can apply it to any outstanding balances on their account.
Fees Assessed by AHN: You may be charged fees for the following: (1) Returned Checks (2) Completion of Forms (e.g. Disability or Family Medical Leave) (3) Copying of Medical Records (4) Failure to Cancel Appointment ("No Show") - if you do not advise us of your inability to keep your appointment prior to 24 hours before your appointment. These fees are set by each location and may change at any time.
The patient (or representative) agrees to these terms as evidenced by signature on the Patient Data Sheet.
February 17, 2010