Patient Payment Policy

Thank you for choosing our practice! We are committed to providing you with affordable health care. In order to answer your questions regarding your responsibility versus your insurance plans responsibility for services rendered, we have developed our Financial Policy model listed below. Please feel free to ask us any questions that you may have. A copy will be provided to you upon request.

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Insurance

We participate in most insurance plans. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility.

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Claims Submission

We will submit your insurance claims and assist you in any way we reasonably can in order to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company. Performance Orthopedics is NOT a party to that contract.

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Referrals

If you have an HMO plan with which we are contracted, you need a referral authorization from your primary care physician. If we have not received an authorization prior to your arrival at the office, we will have a telephone available for you to call your primary care physician to obtain it. If you are unable to obtain the referral at that time, you will be rescheduled. If you choose to keep the scheduled appointment without a referral, you will be responsible for the charges to be pain in full the day of your appointment and to also sign a waiver.

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Co-payments and Deductibles

All co-payments must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

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Non-covered Services

Please be aware that some, and perhaps all of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

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Proof of Insurance

All patients must complete our patient information form before seeing the physician. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the full balance of a claim.

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Coverage Changes

If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

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Methods of Payments

We accept payment by cash, check, VISA, Mastercard, American Express and Discover

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Patient Statements

Unless other arrangements have been made and approved by Performance Orthopedics in writing, the balance on your statement is due and payable when the statement is issued. The balance on your statement is past due if not paid by the end of the month issued.

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Nonpayment

If your account is past due, you will receive a letter from us stating you have 10 days to pay your account in full. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency. If this occurs, you will not be able to be seen in the office until your balance is paid in full. In addition, all charges for future visits will be collected prior to your appointment. Please note that our physicians will only be able to treat you on an emergency basis for a previously treated injury or problem until your balance is paid in full.

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Returned Checks

There is a fee of $25 for any checks returned by the bank.

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Divorce

In case of divorce or separation, the party responsible for the account is the parent authorizing treatment for a child. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

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Worker’s Compensation

We require written approval/authorization by your employer and/or worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.

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Personal Injury

If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. Payment of the bill remains the patient’s responsibility. We cannot bill your attorney for charges incurred due to a personal injury case.

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Missed Appointments

Our policy is 24 hours notice on appointment changes. We do understand that emergencies arise. If an emergency keeps you from your scheduled appointment, please contact us as soon as possible, so that we can offer the appointment time to another patient. Please help us to serve you better by keeping your regularly scheduled appointments.

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Medical Records Copies

You will need to request in writing and pay a reasonable copying fee for copies of your medial records. Currently our prices are: $1 per page for pages 1-20, $0.50 per page for pages 21-50 and $0.25 per page for pages over 51. There is also a $5 postage charge if the records are to be mailed. If the chart must be retrieved from storage, $20 is added to the charge.

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If your physician recommends surgery, you will be escorted to their Surgery Coordinator. She will answer specific questions about the surgery scheduling process, discuss the paperwork and tests involved, and complete all pre-certification/authorization if your insurance company requires it.

The Surgery Coordinator may request a pre-surgical deposit, the amount of which depends on your coverage and deductible amount. The Surgery Coordinator will explain a cost estimate, which shows your financial responsibility, based on the benefit levels and coverage of your insurance plan.

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