header image

Financial Policy

PDF Form

We have recognized a need for a definitive understanding between the patient and physician in regards to financial arrangements for medical care. We do encourage our patients to be well informed of their financial responsibility. A copy of your insurance card is required. We do have the option of denying services until we have proof of coverage.

Copay/Deductible/Noncovered Services

These services are payable and expected at the time of service, there will be a $5.00 fee for all missed co-pays. Medicare: We do accept assignment on all services covered by Medicare and any Medicare products. This means we will accept the approved amount as our payment in full.

Medicaid

Payment at the time of service is not required: however, patients are responsible for payment of services that are not covered. We can and will deny service without proof of coverage. If we are given, an incorrect insurance card and your claim gets denied it is your responsibility to inform us of what new insurance company you now have. There are many Medicaid Advantage plans we take with the exception of Caresource and Molina. So please make sure we get your current insurance card. The black and white Medicaid card is issued monthly to you. The managed care cards are only issued once so if you change your plan we have no way of knowing. You will be responsible for any fees incurred if we are not informed at the time of service which plan you have, as the claim may be untimely or require a referral, which in both cases we will not be paid by your insurance company.

Workers Compensation

We do accept BWC claims and provide treatment for work related injuries. Claims will be filed with proper information. All charges are ultimately the responsibility of the patient.

Insurance

The practice is participating with a variety of insurance companies. As a courtesy, the staff will file claims and attempt to contact your insurance company for any precertification and benefits. Some insurance plans do require a referral from the primary care physician. The patient is ultimately responsible to obtain and bring to their appointment the referral, from the referring physician, if a referral is required. The patient is ultimately responsible for the balance due. If we do not have your current insurance card and we find out what insurance you do have, it may be too late for us to send your claim to the correct insurance company. Some insurance companies only allow claims to be filed within 90 days of the date services are rendered. In this case, it will be your responsibility to call your current insurance company to see if they will make an allowance for this error. You may be responsible for the entire bill if they will not make an exception.

Pre-Pay/Deposit Request

This practice collects a pre-pay/deposit prior to any procedure performed. This amount will be the estimated balance due after insurance payments. The deposit/pre-pay amount requested will vary on the procedure and each individual insurance policy. It will vary depending on your deductible status and co-insurance. Without this payment, any elective procedure could be cancelled.

No Show

There will be a $20 NO SHOW charge for any scheduled visit not cancelled or rescheduled 24 hours prior to your appointment time. Should the patient or referring physician schedule the visit and the patient decide not to keep the appointment after notification of the scheduled time, a $20 NO SHOW charge will be applied. This will need to be paid prior to any additional visits being scheduled. After (2) no shows we do have the option to not reschedule additional appointments.

Self-Pay

Payment for the initial office service is expected at the time of service. Should surgery be recommended, a prepayment for the surgical treatment within two days prior to the surgery is required. Denial of services is an option should these payments not be met for any elective procedures.

Payments Accepted

CASH, CHECK & CREDIT CARDS, including Visa, MasterCard, Discover, & American Express.

Non-Sufficient Funds

We charge a $15 service fee for any returned checks “insufficient funds” or attempts at payment will be automatic by checXchange plus any applicable fees. All payments are payable to Surgical Specialists of Bowling Green.

Monthly payments will be accepted for any outstanding balances. This final balance will be expected to be paid in full within six (6) months of the final balance due. Please call to set up a payment plan before your account is turned over to our collection agency. Please call 419-352-9124 and ask for Beth.

Statement Fee

There will be a $5.00 statement fee per statement after 30 days of final billing. This $5.00 fee will re-occur for each additional statement sent without any payment made on your account.

Forms Fee

There is a $5.00 fee for FMLA paperwork & a $5.00 fee for Disability paperwork to be completed, this is due prior to their completion.

Collection Agency

Should there be failure to pay for services provided under good faith of payment we are able to send your account to a collection agency. A letter will be sent to you prior to a referral to the collection agency. This will tell the amount due. Should this letter be returned with an incorrect address we are able to send your account collect ions without prior notification. Upon your receipt of this letter, your account will be sent after 30 days if there is no response from you or a request from you to set up a payment plan. You will be responsible for the collections agency fee that is 25% of your total balance. Bankruptcy: Should any prior balance be adjusted off, further treatment will be on a cash only basis, should the practice elect to reestablish you as a patient.

Minor Children

The responsibility for payment of services provided to a minor will be the parent/responsible party who seek treatment with the child.