Synergy Family Medicine

Payment Policy and Missed Appointment Policy

Effective July 1, 2010

Thank you for choosing Synergy Family Medicine for your health care need. We are committed to providing you and with quality health care. Please review the following policy regarding patient and insurance responsibilities and sign the signature page.

1. Insurance. We participate in several insurance plans. If you are not insured by a plan we do business with, payment in full is expected at each visit. Knowing your own insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payments and deductibles. All co-payments and deductibles must be paid in full at the time of service before seeing the doctor. 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. A late payment fee of $10 will be charged if payment is not made in full at the time of service. Additional fees will be charged if full payment is not received within 30 days.

3. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. It’s your responsibility to know your copayment and coinsurance amount.

If you are insured by a plan we do business with, you fail to provide us with the correct or the up-to-date insurance information at the time of service, you will be responsible for the full payment at the time of visit. We will help you to file the claim to your insurance when you provide the accurate information in a timely manner, within the time window for claim submission. If any payment is received from your insurance company for the fully paid visits, your account would be credited after a $10 administration fee.

4. Claims submission. We will submit your claims and assist you in any way we reasonably can 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, irrespective of what your insurance company pays, the balance of your claim is your responsibility. Your insurance policy is a contract between you and your insurance company; we are not party to that contract.

5. Coverage changes. Please bring your insurance card(s) to every visit and show to our receptionist when you check in. Because insurance plans change frequently, it is important to make sure that we have your current insurance plan information. In order to help you receive your maximum benefits without extra out-of-pocket expense, it is your responsibility to notify us of any changes in your plan. If your insurance company does not pay your claim within 45 days of date of service, the balance will automatically be billed to you.

6. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 10 days to pay your account in full, including late payment fees. Partial payments will not be accepted. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

7. Missed appointments. For missed appointments not canceled or rescheduled at least 24 hours ahead of the appointment time, our policy is to charge $50 for a physical or procedure (including acupuncture) appointment and $25 for any follow up or other appointment. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.

8. Non-covered services. We would only recommend and render services, order lab or radiology tests that we believe are necessary for your medical conditions. However, please be aware that some of the services you receive may not be covered or not considered "reasonable or necessary" by Medicare or other insurers. Since what is considered "non-covered services" varies among different insurance carriers, different policies, and can even vary from one year to the next within the fine print of the same carrier, it is ultimately your responsibility to know what your policy will or will not cover. We will do our best to help you identify services that are not covered by your insurance, and we will discuss potential non-coverage issues with you before the service is rendered. We can also give you the service/procedure and diagnosis codes so that you can call your insurance carrier and find out the coverage status. If our past experience predicts certain services you need and would like to receive from us may not be covered by your insurance, you must pay for these services in full at the time of visit. Lab and radiology companies would inform you directly of your responsibility of payment if any.

9. Return check/insufficient fund. If your check is returned by the bank, you will be charged a $25 return check fee and any associated bank fees we have incurred. The total balance is due in full immediately.

10. HMO members who are not on an Open Access Plan will need to have a referral faxed to us from your Primary Care Physician prior to treatment in our office. Without a referral, you are responsible for the full payment at the time of service and you may not be reimbursed by your insurance company for the services.


Copyright © 2009 Phone: 919-869-3188