Patient Financial Responsibilities

IN A NUTSHELL

POTENTIAL CHARGES OR FEES

Non-covered Services: In the event that a patient's insurance carrier determines a service is not covered under the plan, the patient will be responsible for the complete charge and is due upon receipt of a bill from The Urology Team. Services most often not covered under health plans and denied by insurance carriers typically include fertility and related workup to include mesa and vasectomy reversals, sexual dysfunction and related workup (including erectile dysfunction), and some laparoscopic procedures. The Urology Team strongly encourages each patient to contact their insurance provider prior to their visit to verify coverage for such services. The customer service number is located on the insurance card.

Returned Check Policy: There is a $25.00 returned check fee.

Reporting in the event of a default: If an account is in default, a $50.00 processing fee will be added to the account if collection action is taken. The Urology Team may also elect to terminate the physician/patient relationship.

Rebilling Fees: The rebilling fee will help offset the cost of supplies and maintaining an open account. A $20.00 re-billing fee will be added to all balances over sixty (60) days each month a statement is sent for payment.

Missed Appointments: If you cancel your appointment without providing a 24-hour advance notice, or no-show for an appointment, there will be a $45.00 dollar charge to your account. Should the appointment reminder system fail or neglect to call you, the responsibility to know when your appointment is scheduled belongs to the patient and will not negate the $45.00 charge for missing an appointment.

Form Completion Charges: The Urology Team shall charge fees for the completion of the following forms: Disability, FMLA, Social Security or Insurance Forms (HRA or HSA), Preexisting Conditions for Insurance Approval, Parking Permits, and Return to Work Forms Required by an Employer. All fees are due when the paperwork is presented to be completed. Charges are as follows: 1 page: $20.00, 2-5 pages: $35.00, and 6-10 pages: $50.00

Medical Records: There is no charge for a medical record request sent directly to another physician's office or medical institution. For personal copies of medical records, there is a $25.00 charge for the first 20 pages and a $0.25 charge for each additional page thereafter. Payment must be presented with all requests. All requests are completed within fifteen (15) days of receipt of the request. A release form is available at www.urologyteam.com.

Lost Items: Should you misplace any items generated by this office, there will be a $15 charge for each item replaced. The most frequently lost items include lost lab requisitions, specimen cups, and physicians' orders for testing.

DETAILS

The Urology Team is dedicated to providing each patient the best possible care and service. As part of the service, it is important that all patients fully understand their financial responsibilities. In an effort to reduce confusion and misunderstanding between our patients and practice, we have adopted the following policies 01/01/2011. Should you have any questions regarding these policies or your financial responsibilities, please do not hesitate to call.

INSURANCE:

Patients at The Urology Team are required to provide all insurance information to registration personnel. The Urology Team billing offices will send claims on behalf of the patient to all insurance plans, but patients are ultimately responsible for following all insurance plan guidelines and any outstanding balances as a result from non-covered or out-of-network services, co-insurance, co-payment, deductibles, etc.

It is in each patient's best interest to know and understand their insurance plan benefits and their responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. Not all services are covered under all health plans. If a patient's health plan does not cover a service or procedure, the patient is responsible for payment of these charges.

To find out what a health plan covers and what the financial obligation may be, the patient should call the customer service or member services department of the patient's insurance carrier (the phone numbers are on the insurance card). The patient's employer's human resources department may also be a source of information and assistance.

It is each patient's responsibility to know their insurance carrier's patient responsibilities and procedures. If proper procedures are not followed, the patient may be liable for full payment of the bill. If the insurance carrier requires a referral and/or prior authorization, contact the primary care physician prior to seeing a specialist.

Patients who have coverage through a Health Maintenance Organization (HMO): In order to visit a specialist, patients covered through a HMO must first obtain a HMO referral from the patient's primary care physician. It is the patient's responsibility to obtain the referral from the patient's primary care physician prior to the patient's visit with The Urology Team specialist. If a patient does not have a HMO referral, The Urology Team will make every attempt to assist the patient in obtaining the referral. If The Urology Team is unable to obtain the referral, the patient may be required to reschedule the appointment or the patient may be responsible for full payment of the bill at the time of service. Whether the visit with the specialist is medical necessity and covered under the patient's policy will be determined by the HMO and not The Urology Team. The co-payment made at the front desk is for the visit or encounter with the specialist only.

Other services may have the patient's deductible and/or coinsurance applied.

Patients who have coverage through other insurance: The co-payment made at the front desk is considered a patient's initial expense to visit with a Urology Team specialist. However, procedures performed during the visit will most likely not be covered by the patient's co-payment made at the front desk. After a patient's insurance carrier has received and processed a bill for services rendered to the patient, only then will a determination be made regarding the patient's financial responsibility, which may include co-insurance, co-payment, deductibles encounter fees, etc.

In Office Procedures: As a courtesy to our patients, The Urology Team will accept and file claims for numerous insurance carriers. However, The Urology Team will not know in advance how each insurance carrier will process the charges for procedures provided to the patient. The majority of medical procedures performed by The Urology Team are not subject to prior authorization by the insurance carrier. The Urology Team will make an effort to notify patients of potential charges for scheduled procedures. The Urology Team strongly encourages each patient to contact their insurance provider prior to a scheduled procedure to verify coverage for such services. For unscheduled procedures which are determined to be necessary by the physician at the time of a schedule visit, The Urology Team is not responsible for contacting the patient's insurance carrier and determining whether or not such services are covered under the patient's health plan.

Potential Surgical Charges: Patients may be required to schedule a surgical procedure for a later date. If surgery is necessary, a Urology Team scheduler will be available to assist the patient with pre-authorization and schedule any necessary pre-operation testing. The Urology Team will bill a patient's insurance carrier for all surgical procedures. The balance, if any, shall be the patient's responsibility and is due upon receipt of a bill from The Urology Team. Should a Urology Team physician visit a patient in a hospital or perform surgery, please keep in mind that all physician fees are separate and distinct from surgical assists, hospital, anesthesia, lab or pathology fees.

Approved Provider: It is important that each patient understand what will or will not be cover by the patient's health plan. Any time a patient calls The Urology Team to schedule an appointment, the patient should first verify that the health plan is accepted. If a patient's primary care physician refers a patient to a specialist, the patient should verify that the specialist is an approved provider under the patient's health plan. While it is likely that The Urology Team has an agreement to provide services with a patients' insurance carrier, health plans continue to change and are typically renegotiated each year. It is each patient's responsibility to know if a physician is an approved provider under the health plan. Patients are also responsible for knowing which locations the health plan may require the patient to obtain labs, x-rays and other ancillary services and to obtain any referrals that may be necessary.

Medicare Patients: The Urology Team accepts assignment on Medicare insurance claims. Please remember that Medicare pays 80% of approved charges. The patient will be responsible for the remaining 20% co-insurance, any yearly deductible, and any items deemed medically unnecessary by Medicare. If a patient has a secondary insurance that covers the co-insurance and deductible, The Urology Team will file on the patient's behalf.

PRIVATE PAY:

Private pay or insurances not accepted by The Urology Team: All private pay patients are required to make a deposit prior to seeing a Urology Team physician. We strongly suggest that, prior to the service being performed, all private pay patients inquire about the cost of care or services that will be provided. At the end of the visit, private pay patients will be expected to pay for additional charges, if any. Private pay patients will also be entitled to receive a refund of any overcharges.

Out of Network: If a patient has a health plan for which The Urology Team does not have a prior agreement, the patient is considered out of network. Out of network patients will be responsible for any and all co-insurance and deductibles. The Urology Team strongly encourages each patient to contact their insurance provider prior to a scheduled procedure to verify coverage for such services. As a courtesy, The Urology Team will prepare and send the claim on behalf of the patient on an unassigned basis. This means that the patient's insurance carrier will send the payment directly to the patient. Consequently, the charges for the patient's care and treatment will be due at the time of the service.

Patient Payment Responsibility:

I have requested medical services from The Urology Team, P.A. on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

Other than co-payments, deductibles or co-insurance collected with each visit, patients will receive a billing statement itemizing the services rendered, claims submitted on their behalf, payments received and appropriate balances due. Amounts applied by the patient's insurance carrier to the patient's deductible, co-insurance and /or co-payments are non-negotiable and cannot be waived, discounted or rebated. The Urology Team is obligated to collect these amounts when applied to covered services pursuant to an agreement with the insurance carrier. Should you have any questions regarding the amounts due, please contact the insurance carrier directly.
Each patient will receive a first statement after The Urology Team has received its first response from the patient's insurance carrier. A delay in the patient's receipt of the statement may occur should The Urology Team need to appeal the insurance payment on the patient's behalf. The statement will itemize the services rendered, claims submitted on the patient's behalf, payment received and balance due.
Patient balances are payable in full within thirty (30) days of the date on the statement unless prior arrangements are made with the billing office.
The Urology Team accepts many forms of payment. In the event there is a returned check, a $25.00 fee will be charged.
In the event of default, The Urology Team may use an outside collection company and/or report returned checks to the Attorney General Office for the State of Texas. The patient's account will be reported to the credit bureau. If it is deemed that the account has been in default of the payment obligations or compliance of these policies, a $50.00 processing fee will be added to the patient's account.
The Urology Team may also terminate physician/patient relations and any further medical care.

REBILLING FEES: A $20.00 re-billing fee will be added to all balances over sixty (60) days past due