SURGICAL SPECIALISTS OF BOWLING GREEN LLC
MICHAEL J. BIELEFELD, M.D. TODD R TAMLYN, M.D.
We have recognized a need for a definitive understanding between the patient and physician in regards to financial responsibility for medical care. We encourage our patients to be well informed of their financial responsibility. Update 11-1-2013
COPAY'S-DEDUCTIBLES-NONCOVERED SERVICES are payable and expected at the time of service.
PRE-PAYMENT FOR PROCEDURES: This practice does prefer to collect your responsible amount due prior to any procedure being performed. You will be given the approximate amount due, to be paid in the office no later than two days prior to the scheduled procedure. Any credit balance on the account after final insurance payment will be refunded to the patient.
SELF PAY PATIENTS: Payment for the initial office service is required at the time of service. Should surgery be recommended, a prepayment for the surgical treatment is required. This will need to be paid in the office no later than two days prior to the surgery. Denial of services is an option should these payments not be received.
TYPES OF PAYMENT ACCEPTED: CASH
CREDIT CARD - MC/VISA/DISCOVER/AMERICAN EXPRESS
CHECK - $15 Non-Sufficient Fund charge will apply.
Attempt at collection may also be made by checXchange along with any applicable fees.
INSURANCE: This practice participates with a variety of insurance companies. As a courtesy the staff will file claims and attempt to contact your insurance company for any required precertification and benefits. Some insurance plans do require a referral from the primary care physician. The patient is ultimately responsible for any balance due after all insurace is processed.
MEDICARE: We do accept assignment on all services covered by Medicare. This means we will accept the approved amount. Medicare payments are 80% of the approved amount. Services provided that are not a covered benefit are the patient’s responsibilities
MEDICAID: Payment at the time of service is not required; however patients are responsible for payment of noncovered services. A copy of the Medicaid card is required and we do have the option of denying services until proof of coverage.
WORKERS COMPENSATION: We do accept BWC claims and provide treatment for work related injuries. All charges are ultimately the responsibility of the patient. Claims will be filed with the proper information and paperwork.
FORMS FEE: FMLA and/or disability paperwork will have a $5 charge.
SCHEDULED PAYMENTS: We also offer the option to have your credit card automatically billed monthly on the date and for the specified amount authorized by the card holder on outstanding balances.
STATEMENT FEE: There will be a $5.00 statement fee per month after 60 days of final billing for services provided if no payment is recieved.
COLLECTION POLICY: Should there be any 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 would show the amount due. Should this letter be returned with an incorrect address we are able to send your account to collections without prior notification. Upon your receipt of this letter, your account can be sent after 30 days if there is no response.
BANKRUPTCY: Should your financial situation be bankruptcy and a prior balance is adjusted off, further treatment will be by a cash only basis.
MINOR CHILDREN: The responsibility for payment of services provided to a minor will be the parent/responsible party who seek treatment with the child.
NO SHOW POLICY: There will be a $20 NO SHOW charge for any scheduled visit not cancelled or rescheduled. Should the visit be scheduled by the patient or referring physician, and the patient decide not to keep the appointment after notification of the scheduled time, a $20 NO SHOW charge will be applied and paid prior to any additional visits being scheduled. After two (2) NO SHOW we do have the option to not reschedule additional appointments.