Please take a few moments to read this section as it explains our Financial Policy related to charges, payment, billing, statements, and collections for the services we render. It is our sincere desire to provide the best possible medical care. This involves mutual understanding between the patients, doctors and staff. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services.
We encourage you, our patient, to discuss any questions you may have regarding our payment policy with one of our Patient Account Representatives.
One of the by-products of today's rapidly changing health care environment is the increasingly active role insurance carriers' play in the delivery of patient care. Some managed care companies place restrictions on the medications we can prescribe for your child, to whom referrals can be made, the types and frequency of care we can provide, the limitation and pre-authorization of the use of certain radiological services and even the hospitals to which your child can be admitted. We try to work closely with your family and your insurance carriers to ensure that quality care is delivered in a cost-effective manner.
In order to do this, YOU must inform us of what services YOUR insurance policy covers. There are thousands of different insurance benefit policies and our office can not be familiar with every one of them. Therefore, we must rely on YOU to be familiar with your insurance policy benefits and coverage. You can locate this information in your BENEFIT SUMMARY or INSURANCE COVERAGE booklet. If you do not have a current copy we encourage you to contact your Human Resources department (for employer provided health insurance) or your Insurance Carrier and request a replacement book.
By being informed, as the recipient of both this insurance coverage and our care, you play the central role insuring that any care provided fits within those guidelines. It is your responsiblity to be informed about your insurance benefit plan and to insure that any treatment plan utilizes the appropriate ancilliary service providers or drug formulary prescriptions. You are responsible for informing our office for the need of pre-approval/pre-authorization of services. Our office will work wth you to change your treatment plan as neccessary to reflect requirements of your insurance benefit plans, but please be aware that some treatment plans can not be changed due to limiting factors (i.e. antibiotic resistances, failure of previous treatment plans, unavailaibility of services in local area, medically contraidicated, etc). Our office is not responsible for any decrease in benefits for services rendered that do not fall within the guidelines of your insurance benefit plan.
Parent/Guardian Responsibilities
You can help us work cooperatively and efficiently with your insurance carrier by notifying us immediately if your coverage or insurance changes. You also are responsible for telling us before care or services are ordered about specific laboratories and other service providers that your insurance requires you to use in order to qualify for benefits. When in doubt, contact your insurers' customer service representative for clarification.
Divorced and Seperated Parents
According to Section 2.05(a) of the Texas Family Code: "Each spouse has the duty to support the other spouse. A spouse who fails to discharge the duty of support is liable to any person who provides necessaries to the spouse to whom support is owed." Section 3.201 of the Texas Family Code states in part as follows: "A person is personally liable for the acts of the person's spouse only if :" . . ."(2) the spouse incurs a debt for necessaries . . ." Texas courts have held that expenses incurred for medical and dental services for the family are expenses which are necessaries. Both a husband and a wife are personally, severally and jointly liable for all necessaries furnished by a third party. [see White vs. Lubbock Sanitarium Company, 54 S.W. 2d 1058 (Tex. Civ. App. 1932, Writ Dism. w.o.j.)]
Section 151.003(a)(3) of the Texas Family Code imposes upon each parent the duty to support their children, including providing of medical and dental care. A parent who fails to discharge their duty is liable to any third party who provides necessaries to those whom support is owed. A spouse's duty to support the other spouse and/or to support their children subjects the entire community estate and each party's separate estate to meet those oblgations. [ see Trevino vs. Trevino, 555 S.W. 2d 792 (Tex. Vic. App. - 1977 , see also Graham vs. Graham, 836 S.W. 2d 308 (Tex. App. 6 Dist. 1992 ].
Absent a court order stating that a parent has discharged their duty to support the children of a former union, both parents are liable for medical care rendered by this office.
Even if you do not bring the child in, or you do not have knowledge of the care being rendered, will not alliviate your financial responsibility. Our office may contact either spouse/ex-spouse for payment, as well as, report both spouses to an outside collection agency for collection efforts.
Dr. Perryman is In-Network for many insurance carriers. This list of carriers is constantly changing, so be sure to verify that Dr. Perryman is on your list. It is your responsibility to verify the network status of Dr. Perryman in relation to your insurance and benefit plan. Consult your insurance carrier’s Provider Directory or call the Customer/Member Services department listed on your insurance card. Our practice does not accept liability, including decreased benefits coverage, because of any inaccuracy, error, misrepresentations, omission or incorrect information that we give you when based on the information provided by your insurance carrier. Your insurance benefits are described in a contract between you and your insurance carrier. If the insurance carrier misinforms you of our status they are responsible and you have rights of appeal and legal avenues that would be unavailable to you if we were to provide confirmation of our status.
Because many insurance carriers require Primary Care Physicians ("PCP") to be "gate-keepers" of speciality care we may be required to provide a referral for any care provided by specialist. Depending on the type of referral required depends on how long it takes. Most PCP-only referrals (i.e. notice to specialist office that we are aware of the need of the services and approve) require a minimum of 48 hours notice prior to any appointment in order for our office to have sufficient time for completing the referral process. If your insurance carrier requires "Prior Authorization" in addition to PCP referral, this process can take up to seven (7) days to complete. Our office does not provide referrals for services that are not Medically Necessary, for conditions previously untreated by Dr. Perryman, when not required by insurance (i.e. most "female problem"/gynecological related medical care can be rendered by a Gynecologist without referral, mental health issues can be seen without referral by psychologist and psychiatrist).
Dr. Perryman will only process and authorize referrals that are received PRIOR to services being rendered. The only exception to this would be due to an emergency (which should not require a referral) or due to circumstances outside of the control of your office. Exceptions will be reviewed on a case by case basis. In order for our office to begin the referral process we must receive a "Request for Referral" at least 48 hours prior to your appointment or services being rendered. Referrals must come from the specialist office and must include the name of the specialist being seen, their insurance identification numbers (i.e. National Provider Identifier or NPI), the procedure codes (CPT-4) and the diagnosis codes (ICD-9) related to the procedures. If the referral is for Blue Cross/Blue Shield HealthSelect we also need the phone number of the office where you will be seen (not the main office number).
Because of rules and regulations set by the Insurance and Healthcare industries, your visit charges will be dependent on several factors. Factors that contribute to your visit charges include, but are not limited to, the complexity of the presenting problems/illness, performance of procedures and diagnostic testing, and administration of immunization/drug therapies. Given the nature of the above mentioned factors, it is not possible to determine the exact cost of a visit prior to services being rendered.
Any pricing information given prior to your visit is based on the estimated charge of the office visit only, and does not include any procedures, diagnostic testing, and administration of immunizations or drug therapies. Such pricing information is an estimate only and actual charges may vary greatly from the estimate provided.
Any questions concerning a specific visit or episode of care can be directed to one of our Patient Account Representatives.
Diagnostic Tests and Laboratories
Some diagnostic tests can be performed in the lab at our office. Your insurance may designate specific laboratories or facilities to which you must be referred in order to receive full coverage for these tests and procedures. You will be billed separately for tests and service provided by an outside facility.
It is your responsibility to know which facilities are covered by your plan and to communicate this to us. If you are unsure, contact your insurer's customer service representative for clarification. As previously stated our office is not liable for any denial of benefits due to failure on your part to notify us of requirements as set forth in your insurnace benefit plan.
Payment is due when services are rendered.
We accept cash and checks, Mastercard and Visa. Prompt payment allows us to control costs. Outstanding accounts cost both of us time and money; therefore, all patients will be required to establish financial arrangements for payment of their account. If you make full payment at the time of your visit, we can provide you with a Time of Service Discount.
All new patients will be required to remit full payment to establish an account. As a courtesy, our practice will establish a reasonable monthly/weekly payment plan to accommodate your needs.
If we are In-Network for your benefit plan you are contractually obligated to pay your Co-Payment, Co-Insurance and/or deductible portions at the time of service.
As we stated above, the primary goal of our practice is to provide medical care and services to the children of our community. Since our practice also has financial obligations, which must be met, we ask that all patients arrange to pay for services in full on the day of each visit to our office.
Once your insurance has cleared, you may receive a bill for additional amounts based on your insurance carriers' determination of benefits. For your account to remain in good standing with our office you, need to remit payment within 30 days.
Retuned Checks for Insufficeint Funds (NSF): Our policy related to NSF checks is based on the fact that most people make honest mistakes when balancing their checkbooks. Therefore, we follow this procedure when we receive a check returned unpaid.
1) If this is the first check returned to our office unpaid, we will send notice that the check was returned with a request for payment to be made within ten (10) days. If paid in ten (10) days our office will charge a $3.00 fee in addition to the amount of the check. This $3.00 is the fee charged to our business by our bank. (This $3.00 fee is subject to change without notice, at any time, but shall not exceed the fee charged by our bank.)
2) If payment is not made within ten (10) days, our office will charge a $25.00 Returned Check Collection fee, this fee is inclusive of the above mentioned $3.00 charge. This $25.00 Returned Check Collection fee may be changed at anytime, without prior notice, but shall not exceed the maximum allowable under State law.
3) If this is a second returned check, the above procedure will be followed with the exception that our office reserves the right to charge the Returned Check Collection fee without an opportunity to pay just the $3.00 fee charged by our bank. Again this fee may be changed at anytime without prior notice, but shall not exceed the maximum allowable under State Law.
4) If this is a third returned check, the above procedures will be followed, your account will be placed on a "CASH ONLY" basis
5) Failure to maintain your account in good standing after 3 returned checks will result in termination of the patient/physician relationship.
"CASH ONLY" Account Status
1) Any future services will be on a "CASH ONLY" basis. Payment in full of all patient responsibility is expected prior to any services being rendered. An estimate based on a Level 3, Established Patient visit will be used if visit for Illness or Injury, an appropriate level office visit for the age of the patient shall be used for any well child care and shall include any immunization administration fees.
2) If your insurance plan is a deductible plan, instead of a co-payment plan, our office reserves the right to require a cash deposit equal to the deductible for each child. Any such deposit will be held on account for 12 months. This deposit will not earn any interest of any kind. At the end of 12 months if the account has remained in good standing, we will credit the deposit to future services, in lieu of payment, until funds are depleted. Alternatively, a written request for refund may be submitted at which time our office will refund any remaining balance within thirty (30) days. If the account does not remain in good standing, our office may require the deposit to remain on account until such time as the account has been in good standing for 12 consecutive months or the family notifies our office in writting that they wish to terminate the physician/patient relationship and will be seeking medical care from another physician. If the family terminates the relationship, then we will use our best efforts to issue a refund as timely as possible.
3) At any point if a "CASH ONLY" account is not paid in full at the time of service, our office shall use any deposited funds to cover the charges for the services rendered. Deposited funds will be required to be brought back to the required deductible level within 15 days. Failure to do so will result in the account being taken out of "Good Standing" status.
4) Any "CASH ONLY" account that does not maintain "Good Standing" can be dismissed from the practice and the physician/patient relationship terminated with thirty (30) days written notice.
If you have insurance, a valid, verifiable insurance card must be presented at the time services are rendered. If you do not provide insurance information at the time of service you will be held financially responsible for all charges incurred. Our office does not accept retroactive Insurance.
It should be mentioned that your insurance coverage is an agreement between you and your insurance company. Unless we have a contract directly with the insurance plan, we cannot accept the responsibility of negotiating claims. We cannot guarantee the payment of your claim. If we are Out-of-Network our office does not submit claims on your behalf.
Please be aware that few insurance companies attempt to cover all medical costs. Some pay fixed allowances for each procedure while others pay only a percentage of the costs. If your insurance company pays only a portion of the bill or denies the claim, any contact or explanation should be made to you, their policyholder. Reduction or rejection of your claim by your insurance company does not necessarily relieve you of the financial obligation that you have incurred.
Non-Covered Services
You are responsible for knowing what beneifts are covered under your insurance plan. Our office can not keep track of the hundereds of different benefit plans and what is and is not covered. Most Insurance carriers ask that offices obtain an Advance Benefit Notice (ABN) for non-covered services. The requirements of these ABNs are such that our office could not comply until after services are rendered. Therefore, we ask our patients to sign a statement (included on our Assignment of Benefits form and Patient Profiles) that states that you understand that you will be financially responsible for any charges that are considered Non-Covered under your insurnace benefit plan. If you do not agree with our policy you may provide our office with written notice that you will not accept responsiblity of Non-Covered Charges. In such case, our office reserves the right to accept you as a PRIVATE PAY patient only for all future visits. As a PRIVATE PAY patient you will be seen just as any other patient without insurance and be held responsible for all charges (without benefit of insurance contract rates/discounts) additionally our office will not file insurance claims or forms on your behalf.
For Indemnity and Out-of-Network Insurance products
Many insurance companies use a fee schedule that may include providers outside of this region and may not be applicable for this geographical area. You are responsible for payment regardless of any insurance company's determination of usual and customary rates which may bear no relationship to the current standard and cost of care in this area.
In the event that your insurance coverage changes to a plan where we are not participating providers, you will be responsible for payment of all fees at the time service is rendered.
We ask that you participate in any disputes with your insurance carrier regarding your policy guidelines and insurance payments.
Our staff is trained to help you with any insurance question you may have. Remember, though, that we can only answer questions relating to how your claim was filed, and provide any additional information the carrier might need to process your claim. Coverage issues, however, can only be addressed by your employer or group plan administrator.
Although our assistance is available to you at any time, we cannot act as a mediator with the carrier or your employer.
We normally do not file claims for Out-Of-Network insurance coverage. We will provide you with a receipt that contains all of the information required for you to file your own claim.
TDH Forms 1027A, 1027B, 1027C, and 3087 are the ONLY documents that are honored as verification of Medicaid eligibility. It is the responsibility of Medicaid recipients to bring and provide a current copy of one of these forms in order for our practice to see you as a Medicaid Client. If you do not have one of these forms for the current month, we will see your child(ren) on a Self-Pay/Private Pay basis ONLY.
Please be aware that a Temporary Medicaid card is not sufficient for Well Child Care (EPSDT/Texas Healthstep) visits. For Well Child Care visits, we require a CURRENT Form 3087 to be presented in order for us to bill under your Medicaid benefits. If you do not have this Form, we will see you either on a self-pay/private pay basis or reschedule your appointment when you do have a current Form 3087. Due to changes in program requirements related to the Vaccines for Children program, as of 2006 our office no longer provides Medicaid Well Child Care visits. If your children are on Medicaid, you will need to seek out another healthcare provider that can perform these visits for your children.
Mothers who are Medicaid eligible at the time of birth of their child have 30-days from the "Add Date" to notify our office of their child's Medicaid Number. Failure to provide our office with your child's Medicaid Number in a timely manner, can result in your becoming financially responsible for all charges. Should the 30th day from the "Add Date" fall on a Saturday, Sunday or Holiday, you must provide our office with the child's Medicaid Number prior to 5:00pm of the last business day prior to the 30th day.
Patients who have APPLIED FOR MEDICAID or are PENDING MEDICAID
Our office does not accept retroactive Medicaid.
Patients who present with No Insurance and No Medicaid are seen on a self-pay/private pay basis ONLY. We will not go back after a visit and file Medicaid, if a patient becomes Medicaid eligible. This includes services for Newborns, Hospitalizations, and Office Visits.
Each month you will receive a monthly statement for services rendered which is due and payable within 30 days.
Please notify us immediately if a mistake appears on the statement.
Any account that is not paid in 30 days is subject to a recurring late fee of 1.5% of the total outstanding balance each month. Our patient accounting systems calculates late fees on a "per-visit" basis. If any visit is "past due" or subject to "late fees" then all visits on the statement will incur late fees regardless if the 30 day timeframe for that specific visit has passed or not. The late fee will be a minimum of $1.00 (again "per visit" of all visits included on a statement regardless of the 30 day timeframe if any one visit exceeds the 30 days). This billing fee may be included on accounts at any time and for every subsequent 30-day period in which an outstanding balance remains unpaid.
All patients who have failed to remit payment after 91 days of notice without pending insurance or financial arrangements will force us to limit future credit until the previous balance is paid in full or written financial arrangements are brought current or risk being assigned to an outside collection agency.
Our practice tries to avoid the use of an outside collection agency. The only way that we can do this is if you COMMUNICATE with our OFFICE. If we send statments and letters and never get a response from you (either a phone call or a quick note) we have no way of knowing of problems that you may be faced with, and have no way of providing assistance or help related to our charges. PLEASE COMMUNICATE WITH OUR OFFICE SO WE CAN HELP YOU.
Once an account reaches 120 days past due (from date of service or in the case of insurance covered services, date of payment by the insurance carrier) with no communication or payments from you, we will turn the account over to our outside collection agency. You will be responsible for all additional fees charged by the collection agency, and any additional cost related to collection of the account. Please see our Collection Agency Fee section at the bottom of this page.
In the past our office has dismissed patients (and their siblings) and sent the account to an outside collection agency. The patient family started paying the collection agency within a short time period after placement. I always ask myself "WHY?" Why did the family ignore our letters, why did they not send us a note or call us and explain any problems, why did they not send partial payment to keep their account active? These families needlessly caused us to terminate the relationship with them and to place their account with the collection agency. If only they had communicated with us we could have worked with them. Again, as long as YOU communicate with us and are willing to work with us, we will work with you. Let me reiterate one last time, we can not work with you if you do not communicate with us.
Payment Plans & Financial Assistance
Right off the bat we offer families multiple methods of meeting their financial obligation with our office. We offer the following payment arrangements for families that have large outstanding balances. These options are offered for the convenience of our patients and may be withdrawn or revised at any time without notice. Any payment arrangements made prior to withdrawal or revision shall remain unaffected.
TOS Discount
Pay in full at the time services are rendered and we will provide you with a discount that represents the cost to our business to send out statements and collect normally outstanding balances. It is our beleife that you should not have to pay more if your not the cause of the added expenses. This discount ranges from 15%-25% depending on services. If you have insurance and this discount is greater than what your insurance carrier normally recieves we will be glade to extend this "Prompt Payment" or "Time of Service Discount" to them. All they need to do is have cash or check payment in our office for the full amount (less discount) prior to you leaving the office. Additionally, any contract between our office and the insurance carrier is null and void for that visit. Our office will not be required to provide any contractual administrative services nor be obligated to participate any in quality review, medical necessity review or other administrative burdens otherwise contained in the contract. Finally, the insurance carrier would agree to no "refund", "overpayment" or "retroactive denial" recourse. Have your insurance carrier contact our office if they are interested in this simplier solution to healthcare cost control. This discount can not be combined with or in addition to any other discount (i.e. on top of insurance contracted rates, our office allows one or the other but all terms and conditions must be met). This discount is at the sole discretion of our office and may be discontinued at any time without notice.
This program allows families to make equal payments each month for up to 12 months with no interest charges. The balance on account is divided based on the following table:
|
Amount Owed |
Max. Months |
Min. Dollars |
|
< $100 |
3 |
$30 |
|
$101-$250 |
4 |
$40 |
|
$251-$500 |
6 |
$50 |
|
$501-$999 |
9 |
$75 |
|
$1000+ |
12 |
$100 |
Therefore, an account balance of $275 can be paid off over 6 months but payments will not be less than $50 per month.
Provided payments are made timely and the balance is paid off within the above timeframes, no interest will be charged. If the balance is not paid off within the above timeframes, then interest at the rate of 1.5% per month (18% per annum) will be charged retroactive to the first payment. Payments that are more than 10 business days past the payment due date will incur a $5.00 late fee to be deducted from the next payment prior to application toward any balance.
This program allows for families to make smaller payments by extending the time to pay off the account beyond 12 months, but less than 48 months. Our office charges 1.5% interest (18% per annum) on the total outstanding balance each month under the terms of an Extended Payment Plan Agreement. You will be asked to enter into a legally binding Agreement which will detail the specifics of this arrangement.
This program is designed to provide needed medical services to families with limited resources. Based on Federal Poverty guidelines this program provids discounts on services ranging from 30% to 80% and up to 12 months to pay any remaining balance interest free. In extreme cases of Financial Hardship, patient families may receive 100% discounted services.
Responsibilities (UNDER ALL PROGRAMS)
-
Your responsiblities
- You are responsible for providing true and accurate information.
- You are responsible for responding in a timely manner (10 business days) to any request from our office.
- You are responsible for insuring our receipt of information.
- You are responsible for making a good faith payment based on the program you choose.
- You are responsible for making payments on the specified due date regardless of receipt of a monthly billing statement.
- You are responsible for any late charges for failure to pay timely.
- You are responsible for reading, understanding and asking questions regarding the Program Description and related Materials upon receipt.
- You are responsible for abiding by all terms related to any Program.
- You are responsible for paying all future charges for services rendered at the time of service, any agreement is for past charges only.
- We are responsible for taking reasonable actions to protect your personal financial information and prevent inappropriate or unauthorized disclosures.
- We are responsible for determining the application of payments and the calculation of interest and late charges.
- We are responsible for responding to inquires concerning your account in a timely fashion (typically 10 business days).
- We are responsible for providing you with a full disclosure of program features and benefits.
- We are responsible for maintaing your account ing accordance with the terms of any of the above described programs if you qualify for the program.
- We are responsible for requesting supplemental information in a timely manner (typically 10 business days from receipt of application).
- We are responsible for verification of employment, paychecks and other financial disclosures.
- We are responsible for providing a determination of eligibility in timely manner (typically within 30-45 days of application).
- We are responsible for providing you with the contact information of any organization in which we receive credit information which results in an adverse decision.
Our responsiblities
If an account is released to an outside collection agency the guarantor will be responsible for all collection fees assessed to our clinic. These fees may include, but not be limited to: collection agency fees, reasonable attorney fees and court costs.
Payment plan payments are considered delinquent if your payment is more then five (5) days late.
If you are experiencing a set of circumstances out of your control, please call our practice and we will be happy to make special arrangements.
If you are experiencing extreme financial hardship, please call our practice and one of our staff will gladly assist you in seeing if you qualify for Financial Hardship Assistance that provides for discounted services.
Please ask one of our staff members about these programs.
Overpayments will be applied to oldest balances. Any credit balances will be refunded to the responsible party within 30 days of written request.
Accounts that are not maintained in Good Standing, risk being sent to an Outside Collection Agency. Accounts sent to an outside agency for collection will be legally responsible for all collection costs involved with the collection of the account including, but not limited to, court costs, reasonable attorney fees, and any other expenses incurred with collection.
Accounts that are inactive for 120 days or more can result in listing of the balance as bad debt with local, regional, and national Credit Reporting Agencies. Any listing to a credit bureau will appear on your credit report for seven (7) years and can negatively impact your credit rating.
Calculation fo Collection Agency fees: Our collection agency charges 35% of total account balance for charges that are turned over that are < 1 year of age. For charges 1 year old or older, they charge 50%. These charges are subject to State Sales Tax. Our office calculates the total amount to be turned over to the collection agency based on these factors. The calculation that we use is as follows -
ACCOUNTS WITH BALANCE < 1 Year Old
(Total Account Balance Owed to Practice (TABOP) divided by (1.00 minus 0.35)) = Total Owed Before Tax (TOBT)
(TOBT minus TABOP) multiplied by .0825 = Sales Tax
TOBT plus Sales Tax = Total Turned Over to Collections (TTOC)
EXAMPLE: TABOP = $100.00
then: $100/(1.00-0.35)= $100/0.65=$153.85 TOBT
(($153.85 - $100) * .0825)= ($53.85 * .0825) = $4.44 Sales Tax
$153.85 + $4.44 = $158.29
Collection Agency will actually charge us ($158.29 *.35) = $55.40 * 1.0825 = $59.97
$158.29 - $59.97 = $98.32 paid to our practice for the $100 balance owed.
As you can see this calculation pretty closely represents the cost to our practice for placement with the collection agency. To avoid these extra charges...simply pay your bill timely, contact our office to make special arrangements (and stick with the arrangements made) or contact our office and work out an alternative payment due date.