Thank you for selecting Integrated Gastroenterology Consultants. P.C. (the “Practice”) for your healthcare needs. To help you understand your financial responsibilities in relation to your medical care, we would like to summarize our Practice financial policies.
At time of service, patients are expected to provide identification and, if insured, a current insurance card. Patients are financially responsible for all services provided by the Practice and are expected to pay for such services when rendered. In the event that the patient is a minor child, the patient’s parent or accompanying adult will be financially responsible regardless of whether the accompanying adult is the patient’s legal guardian. All returned checks shall be subject to a fee of $25.00 per returned check.
Medicare: If you are enrolled in the Medicare program, the Practice will bill Medicare forcovered services rendered. Medicare patients are responsible for the following payments:
- Annual Medicare deductible;
- All applicable co-payments of the allowed charge;
- Any services not covered by Medicare;
- Any covered service ordered by a Practice provider that does not meet Medicare’s medical necessity rules and for which the beneficiary signed an Advanced Beneficiary Notice (ABN).
In the event that you carry both Medicare and secondary insurance(s), the Practice will bill both Medicare and the secondary insurance(s); provided, that if you do not provide the practice with both your Medicare ID and secondary insurance ID(s), the Practice will not bill the secondary insurance provider and you will be solely responsible for paying the balance of fees for services rendered and filing a claim with the secondary insurance provider(s).
Medicaid/MassHealth: If you are enrolled in the Medicaid/Masshealth program, you must provide the Practice with a current Medicaid/Masshealthcard at each visit. Medicaid/Masshealth patients are responsible for applicable co-payments and for all non-covered services. Medicaid/Masshealth patients are responsible for securing any referrals required under Medicaid/Masshealth from the patient’s primary care physician.
Commercial Insurance Plans: If you are enrolled in a commercial insurance plan, at the time of service you are responsible for payment of (i) the co-payment, deductible, and/or co-insurance, or the amounts for non-covered services rendered, and (ii) any services and/or charges for which the patient failed to secure prior authorization (if necessary). Insurance is filed as a courtesy and you authorize that benefits are to be paid directly to the Practice. You are responsible for the balance in full if not paid by the insurance company within thirty (30) days. In the event that the Practice files a claim with your insurer following an appointment and the claim is denied, you will be charged $125.00 per appointment.
Self-Pay: If you do not have insurance coverage and elect to pay out-of-pocket for services provided by the Practice, you are responsible for payment in full for all services at the time services are rendered.
Outside Pathology, Lab Fees: Pathology and lab samples sent outside of our office are billed independently of the Practice. You may receive a bill from the outside lab and will be solely responsible for payment to the lab company.
Out of State Insurance: If you present to the Practice an out-of-state HMO/PPO insurance card, then you must verify your benefits for out-of-state or out-of-network benefits. You may be required, in the sole discretion of the Practice, to make payment in full, or pay any co-payment, co-insurance, or deductible. Any sums paid by you for services later reimbursed by the out-of-state insurance company shall be repaid to you by the Practice.
“No Show” and Late Cancellation Policy: In the event that you cannot keep a scheduled appointment, you are requested to notify the Practice at least 7 days in advance. If you (i) do not notify the Practice 7 days in advance of any missed or cancelled appointment, (ii) arrive more than fifteen (15) minutes later than your scheduled appointment time, or (iii) do not keep your appointment without cancelling in accordance with these policies, you will incur a cancellation fee of $125.00 per missed appointment. Patients enrolled in the Medicaid program are not subject to the cancellation fee. You agree to provide us with your credit card information, which we will keep on file at the Practice. You authorize us to charge your credit card in the event you incur any fees pursuant to this “No Show” and Late Cancellation Policy, and you will notify us should your credit card information change at any time.
Collection: All outstanding balances owed by you shall be paid within thirty (30) days of receipt of a bill by the Practice. Any balances greater than ninety (90) days in arrears will be turned over to a collection agency if not addressed.
ACKNOWLEDGMENT
I UNDERSTAND AND ACKNOWLEDGE THAT IT IS MY RESPONSIBILITY TO VERIFY WITH MY INSURANCE PLAN THAT THE PHYSICIAN I AM SEEING IS A PARTICIPATING PROVIDER. IT IS ALSO MY RESPONSIBILITY TO VERIFY THE EXTENT OF MY INSURANCE COVERAGE FOR VARIOUS SERVICES OFFERED AT THE PRACTICE, AND TO VERIFY (A) WHETHER I AM REQUIRED BY MY INSURANCE TO PAY ANY DEDUCTIBLE, COPAYMENT, CO-INSURANCE, OUT OF-NETWORK, USUAL AND CUSTOMARY LIMIT, OR (B) ANY OTHER TYPE OF BENEFIT LIMITATION FOR THE SERVICES I RECEIVE. I FURTHER ACKNOWLEDGE THAT I AM RESPONSIBLE FOR ALL CHARGES THAT MY INSURANCE DOES NOT COVER, AND THAT I MAY BE RESPONSIBLE FOR ANY SERVICES RENDERED BY THE PRACTICE WITHOUT PRIOR AUTHORIZATIONS OR REFERRALS AS MAY BE REQUIRED BY MY INSURANCE COMPANY. I UNDERSTAND AND AGREE THAT IT IS MY RESPONSIBILITY TO KNOW IF MY INSURANCE REQUIRES A REFERRAL FROM MY PRIMARY CARE PHYSICIAN AND THAT IT IS UP TO ME TO OBTAIN THE REFERRAL. I UNDERSTAND THAT WITHOUT THIS REFERRAL, MY INSURANCE WILL NOT PAY FOR ANY SERVICES AND THAT I WILL BE FINANCIALLY RESPONSIBLE FOR ALL SERVICES RENDERED.
I HEREBY AUTHORIZE INTEGRATED GASTROENTEROLOGY CONSULTANTS, P.C. TO RELEASE NECESSARY MEDICAL INFORMATION TO MY INSURANCE COMPANY, ITS AGENTS, OR ANY THIRD PARTY IN ORDER TO DETERMINE PAYABLE BENEFITS FOR THE SERVICES RENDERED, AND ASSIGN AND AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE PRACTICE BY MY INSURANCE COMPANY.
I have read and understand the above Patient Financial Policies.