This will inform you of your financial responsibilities.
For services rendered by American Health Network (“AHN”), you guarantee payment of your account at the time services are provided for any and all costs that are not paid by an insurance carrier, government payer (including Medicaid), and other third-party payer (together, referred to as “PAYER”), including if your PAYER denies a claim after first approving it.
You acknowledge that you will be responsible for paying AHN for items and services provided to your dependents under these conditions whether or not you are listed as the “Responsible Party” on the Patient Data Sheet.
The person listed as the “Responsible Party” on the Patient Data Sheet will also be responsible to AHN for payment. All charges incurred are your responsibility.
An out-of-network provider may be called upon to render health care items or services to a covered individual during the course of treatment. Out-of-network providers are not bound by the payment provisions that apply to health care items or services rendered by an in-network provider under a covered individual’s health plan.
You should contact your health plan before receiving health care items or services rendered by an out-of-network provider to obtain a list of in-network providers that may render the health care items or services, as well as additional resources.
You understand that any out-of-network charges are your responsibility as determined by your PAYER.
Be advised that AHN physicians may refer you to a health care entity (an organization or business that provides diagnostic, medical or surgical services, dental treatment or rehabilitative care), in which the physicians have a private/individual investment, including, but not limited to: American Health Network, Knox Diagnostic Imaging Center, LLC, Damon Dialysis, LLC, Eagle Highlands Surgery Center, LLC, Beltway Surgery Centers, LLC, and various other surgery centers.
Patients are advised that in each case they may choose to be referred to another health care entity. Your signature on the Patient Data Sheet acknowledges you have received notice of physician investment(s).
Assignment of benefits
To the extent there is PAYER coverage for payment of services, you agree that all medical and related benefits paid by PAYER will be irrevocably assigned to AHN on your behalf.
You agree to provide complete and accurate information and notify us of changes to any of your information (address, phone number, insurance). We will use reasonable efforts to submit claims to your PAYER and promptly provide you with our statements.
If for any reason, amounts that you owe are not paid promptly, including if a statement is returned as undeliverable, you may be referred to a collection agency. Bring your government-issued photo identification and insurance cards to every visit. Otherwise, you may be required to pay in full that day.
If you have Medicare coverage, you acknowledge that payment of benefits will be made to you or on your behalf for any items or 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.
We will file your claims with your PAYER after services are provided as a courtesy. If your PAYER pays you directly, you are responsible for payment in full to AHN. We may estimate what your PAYER will pay, but the PAYER decides your eligibility and benefits.
It is your responsibility to understand what services are covered by your PAYER. You will be fully responsible for paying for services or amounts that are not covered. Contact your PAYER before a service is provided if you have questions about coverage.
You may request that we not file with your PAYER by completing required forms at the time the services are provided.
AHN will select the codes that are used in billing based on PAYER policies and industry standards. PAYERS make payment decisions based on the coverage policies for your insurance policy. Example: If you come in for a sports physical, AHN codes it as a sports physical.
If your PAYER does not cover sports physicals, you will be responsible for paying. AHN cannot change the reason for the visit. It is your responsibility to know what your insurance covers.
The amount that your PAYER requires you to pay may depend on whether other providers bill separately for part of the service, for instance, where AHN takes the x-ray but someone else reads it. The amount you are required to pay may also depend on whether the service is preventative (i.e. you have no symptoms suggesting a problem) or diagnostic (i.e. you have symptoms).
If you have a preventative screening scheduled, but show up at the appointment with symptoms, AHN usually needs to report it as diagnostic. This may result in you having to pay more, such as a higher co-insurance.
Your PAYER may require prior authorization or referral for some services. Obtaining authorization or referral does not guarantee that your PAYER will pay. You are responsible for ensuring that authorizations and referrals are obtained prior to obtaining services.
Please call our Billing Department if you have difficulty with your PAYER, and we will try to assist.
You are responsible for payment until the account is paid in full. It may take time for AHN to resolve payment with your PAYER (i.e. processing delays, misplaced claims, requests for additional information and appeals). You are responsible for cooperating with requests for additional information and assistance with appeals.
AHN may wait until your PAYER officially notifies us of the amount that you owe or until disputes about how much your PAYER owes are resolved, before sending a statement to you. Payment is expected by the due date contained on our statements.
If AHN is contracted with your PAYER, the terms of that contract will be followed if there is a conflict between that contract and the terms of these Financial Policies and the terms of AHN’s contract with your PAYER.
If AHN is not contracted with your PAYER or AHN is unable to verify that your Payer will be responsible for payment, you may be required to pay in full at the visit.
Interest and attorney's fees
For any past due amounts, AHN shall be entitled to payment from you of interest at the rate of 1.5 percent per month (18 percent per annum), and you shall be responsible for all costs and expenses incurred in efforts to collect past due amounts from you, including interest charges, court costs and reasonable attorney's fees.
If a check is returned for insufficient funds, all charges incurred by AHN shall be your responsibility.
Note to parents of dependents
The statement for your child will be sent to you, and you are responsible to AHN for prompt payment. You are responsible for paying AHN. If you believe that someone else is responsible for the child’s medical expenses, you may take action against that person to recover the amounts for which they are responsible.
Workers compensation injury
If you believe you are being seen for an injury/illness as a result of your job, you need to provide written authorization from your employer to confirm this, and direction from your employer on who AHN should bill.
If you do not provide this information at the time services are provided, AHN may bill you and/or your insurance company.
If you do not have insurance or if the services are not covered by your PAYER, you will receive a 15 percent discount for professional services rendered when payment is made in full at the time services are rendered.
This discount does not apply to amounts that you owe due to co-pays, coinsurance or deductibles.
If you are unable to meet your financial obligations, payment arrangements can be made. Financing options may be available.
Contact our Billing Department to discuss payment options, before your account becomes overdue. In cases of financial hardship, ask about the practice’s hardship policy. Hardship policies vary by practice; limitations and restrictions apply.
Patients generally may pay by cash, money order, check or personal credit card. This includes cards for "flexible spending accounts" and/or “health savings accounts.” Card information may be kept on file by AHN to facilitate billing.
If you have a credit balance, AHN may apply it to any outstanding balances on your account or the accounts of your dependents. Some locations may restrict payment by cash or check.
Fees assessed by AHN
You may be charged fees for: (1) returned checks, (2) completion of forms (e.g. disability or family medical leave), (3) copies of medical records, and (4) failure to cancel appointments in advance ("No Show").
Notify AHN of cancelations at least one business day in advance to avoid No-Show fees. The No-Show fee may be assessed up to the amount in our current fee schedule.
Termination of services
If you fail to keep your account current or fail to respond to three notices to the address we have on file for you, you agree that AHN may terminate your relationship with any or all of its offices.
In such event, you agree that you are no longer a patient, and AHN will not offer you a future appointment. You will have deemed yourself as terminating our relationship if you do not obtain services from AHN for three years or if you notify us that you will no longer be a patient.
Acceptance back into the practice is at the discretion of AHN. AHN may terminate your relationship with us for other reasons, such as disruptive behavior or non-compliance with care plan or for no reason.
Authorization for release of medical information
The authorizations described in this Financial Policy may include records about infectious diseases and drug and alcohol abuse treatment. You authorize the release of information by AHN to third-party payers (including insurance companies and their contractors), health care institutions, physicians and others involved in your medical care.
You agree that as appropriate for your care, AHN may share information with family members and friends. You agree that AHN may provide your medical records to third party payers, review agencies, employers, welfare departments and others for treatment, payment or health care operations purposes.
AHN participates in one or more Health Information Exchanges. Health care providers can use these electronic networks to securely provide access to your health records for a better picture of your health needs.
With this authorization, you agree that AHN, and other health care providers, may allow access to your health information through the Health Information Exchanges for treatment, payment or other health care operations.
This is a voluntary agreement. You may opt out at any time by notifying an AHN Practice Manager or Compliance Officer. Your opt out notice needs to be in writing.
Accidents and motor vehicle injuries
AHN’s providers have the discretion to decide whether or not to see patients injured in motor vehicle accidents or for other liability injuries.
AHN’s providers also have discretion to decide whether or not to bill the liability insurance involved (i.e. home, auto, etc.).
AHN does not have to agree to subrogate or accept liens. You must provide accurate information about the injury and may be required to complete an injury questionnaire.
In all cases, you bear responsibility for the costs of your care and must pay them promptly at any time that location decides, which may include requiring payment in full at time of service.
Continuing Agreement: I have read this information carefully and agree that everything in this Agreement applies to current and future health care services provided by AHN. I acknowledge that AHN may change these terms without notice to me.
Note: Patient (or representative) agrees to these Conditions as evidenced by signature on Patient Data Sheet.