Dr Simai is committed to providing you with quality care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about this financial policy.
To assist us in establishing your Dr Simai financial account, please:
- Supply all necessary information for the accurate billing of your claims, including your insurance card, employer information, and demographic information.
- Satisfy all insurance co-payments, deductibles, and non-covered services on the day services are rendered.
- Provide your insurance company and Dr Simai with any additional information requested to complete the processing of claims filed on your behalf.
- Authorize release of information necessary for insurance filing and pre-certification.
Minors must have an authorization for medical treatment signed by his/her parent/guardian and is responsible for providing current insurance information for self. Please note that co-payments and/or deductibles are expected at the time of service.
Dr Simai does not get involved in disputes between divorced parents. Regarding financial responsibility for their child's medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree or other arrangement places that obligation on your former spouse.
REGARDING CONTRACTED MANAGED CARE PLANS (HMO, PPO, POS, EPO)
Each time you make an appointment with Dr Simai it is your responsibility to make sure that Dr. Simai is currently under contract with your managed care plan. Verification of your coverage and benefits may be required. Often this verification requires us to share the reason for your visit with your managed care plan. Please plan to show your current card at each visit.
If you are referred to a specialist or decide you need a specialist, you may be required by your managed care plan to call your Primary Care Physician in order to obtain an insurance referral. It is your responsibility to keep track of the expiration dates and for giving your doctor's office a minimum of 48-hours notice before being seen by a specialist. Retro referrals may not be allowed on all managed care plans. Therefore, if a referral is not obtained, you may be held responsible for payment in full by the Specialist.
Insurance is a contract between you and your company. We are not a party to your contract. We will not become involved in disputes between you and your insurance company regarding deductibles, non-covered charges, co-insurance, secondary insurance, coordination of benefits, pre-existing conditions, or a reasonable and customary charges other than to supply the factual information as necessary. You are responsible for timely payment of your account.
OTHER INFORMATION REGARDING INSURANCES AND PAYMENT OF SERVICES
- I have read and understand that I am personally responsible for payment on this account.
- Assignment: I hereby authorize payment directly to Dr Simai. Any changes in this authorization must be received in writing within thirty days of the effective date.
- I understand that this practice has a No-show Appointment fee of $20.00. I am responsible for paying this fee if I do not cancel an appointment with 24-hours notice.
- A Returned Check fee of $30 will be charged for any check returned for insufficient funds.
- In the event my insurance company deems a service to be a non-covered I understand that I am personally responsible for payment.
- I agree to the release of any and all medical information, including HIV test results, and financial information necessary to process this and any future claims to my insurer or payer of health benefits, as I may designate that person or entity from time to time, for an indefinite period or until I submit a written revocation of this release. Any changes to this authorization must be received in writing within thirty days of the effective date.
Thank you for choosing Dr Simai for your child's medical care. We are providing you with the following information to help you understand our insurance and billing policies.
- You must show your current insurance card at every visit. This is to protect you from receiving a bill because we did not have correct insurance information. We will attempt to validate your insurance benefits at time of service and alert you to any problems. If we cannot validate your coverage, we may assign your account to self-paid status and request full payment at the end of your visit.
- You must pay your co-payment at the time of the office visit. Our contracts with insurance companies require us to collect your co-pay at the time of service. We accept cash, credit cards (VISA, MasterCard, American Express), and checks as forms of payment. In the event a personal check is returned unpaid from your bank, your account will be charged with a returned check fee of $30, and your account may be placed on a "cash only" basis for up to one year.
- If your insurance plan is subject to routine deductibles and co-insurance, we ask that you allow us to keep a credit card on file at our Credit Card Merchant Service provider so we can collect those charges as soon as your insurance carrier assigns the appropriate amount of patient responsibility. During the time you leave a credit card on file, if it expires or otherwise becomes un-collectable, we will expect you to promptly provide a new means of payment.
- You must cancel any appointment you cannot keep at least 24 hours prior to your scheduled start time. Otherwise you may be assessed a $20 missed appointment fee.
- Know your insurance benefits. Your insurance policy is a contract between you and your insurance company, even if your employer provides it. There are many subtle differences in insurance policies, and employers frequently change coverage and co-payments. You are responsible for knowing what services are covered (and how often, in the case of well visits), and how much of the cost is your responsibility. You will be responsible for any portion of services that your insurance doesn't cover, or for which you have a deductible that has not yet been met. You should also be aware of where your insurance wants you to go for any lab or radiology procedures, so that in an urgent situation, you are seen at the appropriate facility and will not receive a bill.
- If your insurance plan requires you to choose a primary care provider, you must contact your carrier and select our office as soon as your medical records are transferred. In accordance with carrier guidelines, we cannot schedule any appointments or write any referrals until we receive notice that you have been added to our roster.
- If you have a newborn or newly adopted child, congratulations! Your child is typically covered for the first 30 days by the mother's policy, regardless of which parent will provide ongoing insurance coverage. You should contact your carrier as soon as feasible to add the new child to your policy. Permanent coverage must be in place before the automatic newborn coverage expires.
- If your child is covered by more than one insurance policy, be sure you know which is considered primary. We must submit claims to the appropriate carrier(s) in the right order.
- Carefully read all Explanation of Benefits (EOB) statements you receive from your insurance carrier. We receive the same statements, and any charges which your insurance carrier designates as "patient responsibility" will be billed to you directly from our office if you do not have a credit card on file.
OUR COLLECTION PROCEDURES
- If your account is self-paid, all services must be paid for at the time of your visit. This may include situations where we cannot validate active coverage with your insurance carrier. In such cases, we will collect payment at time of service and refund any amounts subsequently collected from your carrier.
- If you have valid coverage with a participating insurance carrier, we will file an insurance claim after your date of service. If there are any problems with this submission, we will notify you immediately and request your prompt assistance with any conditions under your control that are causing a delay in processing. If your insurance carrier does not respond within 30 days, we will submit a second claim. If your insurance carrier does not respond to our secondary submission within 60 days from the original date of service, we will send you a statement, and payment will become your responsibility. You will need to contact your insurance carrier if you think it is responsible for payment. We will expect payment from you or them within 30 days of receipt of your statement.
- If your participating insurance policy is subject to routine deductibles and/or co-insurance that cannot be collected on the date of service, we will charge your credit card on file as soon as your carrier provides an EOB designating your financial responsibility for the claim. We will only charge your credit card without prior notice if, in our sole opinion, the claim was adjudicated normally. If the claim is denied, we will contact you to resolve the situation before collecting any amounts indicated as due or non-covered services.
- If you are insured by a non-participating insurance carrier, we will expect payment from you at time of service, and it will be your responsibility to submit any claims to your insurance company for direct reimbursement to you. We will provide you with the appropriate information to assist you in this process.
- All statements are due on receipt. If charges remain unpaid after 30 days, a second statement will be rendered with a notice requesting immediate payment. If charges still remain unpaid after 60 days, a final statement will be rendered with a letter informing you that our relationship is subject to cancellation after 30 days of urgent and emergent care. All further services will be provided on a cash-only basis.
- We reserve the right to place your account with our collection agency after all internal efforts to obtain payment have been exhausted. You are then responsible for any collection costs in addition to your outstanding bill. If you are presently in collection, the practice will use its discretion as to providing you with further treatment or asking you to find another physician.