Patient Financial Responsibilities

Patient Responsibilities

You can help ensure an efficient experience by assisting with the following:

• Providing us with your picture identification, insurance card(s) indicating the correct order
  (primary, secondary, etc.)and Social Security number to enable us to submit your claims
  promptly and accurately.
• Employer
• Knowing your insurance benefits and limitations
• Ensuring there is an authorization for our providers to treat you if it is required by your insurance, including obtaining a referral
• Providing us with copies of any pertinent medical records, including tests (MRI/CT/Arthrogram) and X-rays
• Paying your estimated portion of the charges at the time of service
• Paying any additional amount owed when due
• Completing required incident/accident forms within 30 days of date of service
• Maintaining a current account with Proliance Surgeons at all times
• Providing us with at least 24 hours’ advance notice should you need to cancel or reschedule
  an appointment

Please note that co-payments, co-insurance, and deductibles are a contractual agreement between you and your insurance carrier. We cannot change or negotiate these amounts.

Insured Patients

We will bill your primary and secondary insurance carrier in a timely manner. If you are disputing payment with your insurance carrier or have a balance over $100.00 with us, you must notify our business office and make payment arrangements.

• Co-Pays/Deductibles/Co-Insurance: Please be prepared to pay for your portion of the charges on the date of service. Office procedures (e.g., casting, scopes, tests, x-rays) will be billed separately from the office visit.
• Surgery: If surgery is indicated, a pre-payment of both physician and facility fees is required for all elective, non-emergent procedures prior to the surgery being performed. Your out-of-pocket cost is estimated based on your benefits and our fees. Anesthesia and other providers are separate fees.
• Please note: Your surgical global period includes one pre-operative visit after the decision for surgery is made, the surgery, and follow-up visits during your post-operative period. Any services outside of your follow-up visit (e.g., such as casting, x-rays, tests, scopes) will be billed separately. 
• Non-Participating Insurance: If we do not participate in the insurance you have, we will file a claim as a courtesy. An out of network consent form and a $300.00 deposit may be required for all new patients and a $200.00 deposit for all established patients. All unpaid claims will become your responsibility 45 days following filing and will be immediately due and payable. 

Uninsured Patients

• Office visits: A $300.00 deposit for new patients and a $200.00 deposit for all established patients, may be required toward services provided. If visit and services are paid in full at the time of service, we offer a 20% discount. Office procedures (e.g., casting, Scopes, office procedures, CTs, allergy shots, injections, tests, X-rays) will be billed separately from the office visit.
  
• Surgery: For uninsured patients having surgery, we offer a 20% discount when charges are paid before or on the day of service (see exclusions below).
• Exclusions: The discounts referenced above do not apply in cases of cosmetic procedures, motor vehicle accidents, third-party insurance claims or in other cases when the patient may be reimbursed in full.
• Private pay patients who receive retroactive Medicaid coverage need to immediately notify our business office.

Motor Vehicle Accidents (MVA) Insured and Third-Party Patients

If your third-party insurance is processed through Multiplan, you are considered an in-network patient. Please refer to the Insured Patient section above. If you are unsure if your plan processes through Multiplan, please speak with a patient service representative.

For all other plans, we do not extend discounts for MVA-insured accidents, third-party insurance claims, or in other cases when patients may be reimbursed in full. We will bill the MVA insurance carrier one time. The bill becomes your responsibility if not paid by the carrier in 30 days. We regret that we are not in a position to confer with attorneys or defer payment obligations while a case settles. If your personal injury protection benefit on your MVA policy is exhausted, we will bill your private insurance at your request provided we are furnished the necessary information at the date of service.

Workers’ Compensation

If your visit is work related, we will need the case number and carrier name prior to your visit in order to bill the workers’ compensation insurance carrier. If your workers’ compensation claim is not yet accepted and you have no other insurance, you may be required to pay a deposit at time of service.

Other Charges

• No Show: Please provide us with at least 24 hours’ advance notice if you need to cancel or reschedule an appointment. We may charge a fee for missed appointments.
• Forms: There may be a charge associated with our completion of some forms. We require payment of the charge before returning the completed form to you. A signed Release of Information may also be necessary. Please allow five business days for us to complete forms.

Payment

• Payment Options: We accept all major credit/debit cards and money orders for payment (no post-dated or third-party checks). It is up to the sites discretion if they accept checks as a form of payment. Please verify prior to issuing payment in the form of a check.
• Please note: We charge a $40.00 NSF fee for any returned checks
• Delinquent Accounts: We may assign an account to collections if balances are unpaid after 120 days. Patients assigned to collections may be denied additional service.
• Patient Credits: Any credit on a patient account shall be moved to a different date of service and/or any unpaid balance owed to another Proliance location prior to issuing a refund.
• Alternative Payment Arrangements: If you are unable to pay your balance when due, please contact our business office to make alternative arrangements. Any patient with a past-due amount may be denied additional service until the amount is paid or the patient is complying with an alternative payment arrangement.
• Bankruptcy/Prior Bad Debt: Patients who have previously filed for bankruptcy or never satisfied their payment obligations for prior episodes of care may be required to pay for their portion of new charges at the time of service.

Patient Responsibilities

You can help ensure an efficient experience by assisting with the following:

• Providing us with your picture identification, insurance card, and Social Security number to enable us to submit your claims promptly and accurately
• Knowing your insurance benefits and limitations
• Ensuring there is an authorization for our providers to treat you if it is required by your insurance, including obtaining a referral
• Providing us with copies of any pertinent medical records, including tests (MRI/CT/Arthrogram) and X-rays
• Paying your estimated portion of the charges at the time of service
• Paying any additional amount owed when due
• Completing required incident/accident forms within 30 days of date of service
• Maintaining a current account with Proliance Surgeons at all times
• Providing us with at least 24 hours’ advance notice should you need to cancel or reschedule
  an appointment

Please note that co-payments, co-insurance, and deductibles are a contractual agreement between you and your insurance carrier. We cannot change or negotiate these amounts.

Insured Patients

We will bill your primary and secondary insurance carrier in a timely manner. If you are disputing payment with your insurance carrier or have a balance over $100.00 with us, you must notify our business office and make payment arrangements.

• Deductibles/Co-Insurance: A pre-payment of facility fees is required for all elective, non-emergent procedures prior to the surgery being performed. Your out-of-pocket cost is estimated based on your benefits and our fees. Anesthesia and other providers are separate fees.
• Non-Participating Insurance: If we do not participate in the insurance you have, we will file a claim as a courtesy. All unpaid claims will become your responsibility 45 days following filing and will be immediately due and payable. 

Uninsured Patients

For uninsured patients, we offer a 20% discount when charges are paid before or on the day of service. This discount does not apply in cases of cosmetic procedures, motor vehicle accidents, third-party insurance claims, or in other cases when the patient may be reimbursed in full.

Private pay patients who receive retroactive Medicaid coverage need to immediately notify our business office.

Motor Vehicle Accidents (MVA) Insured and Third-Party Patients

If your third-party insurance is processed through Multiplan, you are considered an in-network patient. Please refer to the Insured Patient section above. If you are unsure if your plan processes through Multiplan, please speak with a patient service representative.

For all other plans, we do not extend discounts for MVA-insured accidents, third-party insurance claims, or in other cases when patients may be reimbursed in full. We will bill the MVA insurance carrier one time. The bill becomes your responsibility if not paid by the carrier in 30 days. We regret that we are not in a position to confer with attorneys or defer payment obligations while a case settles. If your personal injury protection benefit on your MVA policy is exhausted, we will bill your private insurance at your request provided we are furnished the necessary information at the date of service.

Workers’ Compensation

If your visit is work related, we will need the case number and carrier name prior to your visit in order to bill the workers’ compensation insurance carrier.

Other Charges

• No Show: Please provide us with at least 48 hours’ advance notice if you need to cancel or reschedule an appointment. We may charge a fee for missed appointments.
• Please provide us with at least 48 hours’ advance notice if you need to cancel or reschedule an appointment and an interpreter has been scheduled. Otherwise, you may be charged for the interpreter.

Payment

• Payment Options: We accept all major credit/debit cards and money orders for payment (no post-dated or third-party checks). It is up to the sites discretion if they accept checks as a form of payment. Please verify prior to issuing payment in the form of a check.
• Please note: We charge a $40.00 NSF fee for any returned checks
• Delinquent Accounts: We may assign an account to collections if balances are unpaid after 120 days. Patients assigned to collections may be denied additional service.
• Patient Credits: Any credit on a patient account shall be moved to a different date of service and/or any unpaid balance owed to another Proliance location prior to issuing a refund.
• Alternative Payment Arrangements: If you are unable to pay your balance when due, please contact our business office to make alternative arrangements. Any patient with a past-due amount may be denied additional service until the amount is paid or the patient is complying with an alternative payment arrangement.
• Bankruptcy/Prior Bad Debt: Patients who have previously filed for bankruptcy or never satisfied their payment obligations for prior episodes of care may be required to pay for their portion of new charges at the time of service.

Patient Responsibilities

You can help ensure an efficient experience by assisting with the following:

• Providing us with your picture identification, insurance card, and Social Security number to enable us to submit your claims promptly and accurately
• Knowing your insurance benefits and limitations
• Ensuring there is an authorization for our providers to treat you if it is required by your insurance, including obtaining a referral
• Providing us with copies of any pertinent medical records, including tests (MRI/CT/Arthrogram) and X-rays
• Paying your estimated portion of the charges at the time of service
• Paying any additional amount owed when due
• Completing required incident/accident forms within 30 days of date of service
• Maintaining a current account with Proliance Surgeons at all times
• Providing us with at least 24 hours’ advance notice should you need to cancel or reschedule
  an appointment

Please note that co-payments, co-insurance, and deductibles are a contractual agreement between you and your insurance carrier. We cannot change or negotiate these amounts.

Insured Patients

We will bill your primary and secondary insurance carrier in a timely manner. If you are disputing payment with your insurance carrier or have a balance over $100.00 with us, you must notify our business office and make payment arrangements.

• Co-Pays/Deductibles/Co-Insurance: Please be prepared to pay for your portion of the charges on the date of service.
• Non-Participating Insurance: If we do not participate in the insurance you have, we will file a claim as a courtesy. All unpaid claims will become your responsibility 45 days following filing and will be immediately due and payable. 

Uninsured Patients

• Visits: Visits must be paid in full at the time of service. In return, we offer you a 20% discount. This discount does not apply in cases of motor vehicle accidents, third-party insurance claims or in other cases when the patient may be reimbursed in full.
• Private pay patients who receive retroactive Medicaid coverage need to immediately notify our business office.

Motor Vehicle Accidents (MVA) Insured and Third-Party Patients

If your third-party insurance is processed through Multiplan, you are considered an in-network patient. Please refer to the Insured Patient section above. If you are unsure if your plan processes through Multiplan, please speak with a patient service representative.

For all other plans, we do not extend discounts for MVA-insured accidents, third-party insurance claims, or in other cases when patients may be reimbursed in full. We will bill the MVA insurance carrier one time. The bill becomes your responsibility if not paid by the carrier in 30 days. We regret that we are not in a position to confer with attorneys or defer payment obligations while a case settles. If your personal injury protection benefit on your MVA policy is exhausted, we will bill your private insurance at your request provided we are furnished the necessary information at the date of service.

Workers’ Compensation

If your visit is work related, we will need the case number and carrier name prior to your visit in order to bill the workers’ compensation insurance carrier. If your workers’ compensation claim is not yet accepted and you have no other insurance, you may be required to pay a deposit at time of service.

Other Charges

• No Show: Please provide us with at least 24 hours’ advance notice if you need to cancel or reschedule an appointment. We may charge a fee for missed appointments.
• Forms: There may be a charge associated with our completion of some forms. We require payment of the charge before returning the completed form to you. A signed Release of Information may also be necessary. Please allow five business days for us to complete forms.

Payment

• Payment Options: We accept all major credit/debit cards and money orders for payment (no post-dated or third-party checks). It is up to the sites discretion if they accept checks as a form of payment. Please verify prior to issuing payment in the form of a check.
• Please note: We charge a $40.00 NSF fee for any returned checks.
• Delinquent Accounts: We may assign an account to collections if balances are unpaid after 120 days. Patients assigned to collections may be denied additional service.
• Patient Credits: Any credit on a patient account shall be moved to a different date of service and/or any unpaid balance owed to another Proliance location prior to issuing a refund.
• Alternative Payment Arrangements: If you are unable to pay your balance when due, please contact our business office to make alternative arrangements. Any patient with a past-due amount may be denied additional service until the amount is paid or the patient is complying with an alternative payment arrangement.
• Bankruptcy/Prior Bad Debt: Patients who have previously filed for bankruptcy or never satisfied their payment obligations for prior episodes of care may be required to pay for their portion of new charges at the time of service.