Financial Information

     Our office policy requires that full payment by cash, check or credit card is required at the time the service is rendered unless other arrangements are made with our staff prior to this time. We are sorry to say that we cannot accept out-of-state checks. A $20.00 service fee will be added to your account for any check that is returned to us from the bank. Credit cards accepted by this practice are: MASTERCARD (credit/debit), VISA (credit/debit), DISCOVER, and AMERICAN EXPRESS. We also deal with CARE CREDIT. Talk to our staff about this payment option if interested.

     This practice participates with many different insurance companies and their various plans. We try to keep up with the terms of each, but this is not always possible. It is your responsibility to know and understand your insurance policy and benefits as you are the one who has a contract with the insurance company. Nevertheless, as a courtesy to you, we will try to verify your insurance coverage and determine an estimate of your financial responsibility. Actual benefits will be determined by your insurance company after the claim is submitted. We cannot and will not be responsible for any incorrect information provided to us by your insurance company, or for any errors or omissions made on our part in obtaining information. If you are concerned with your coverage, the safest thing to do is to check with your insurance company yourself or have us pre-determine your coverage with them.

     If you should be a member of a Managed Care Plan, you should be aware that most of these plans require your Primary care Provider to provide prior referral authorization for specialist visits. Please check with our staff prior to your appointment to make sure that your referral has been received. If no authorization has been obtained prior to your being seen, your insurance will NOT cover the charges for today’s visit and you will be responsible for them.

     Even if prior authorization is obtained, any insurance carrier has the ability to deny payment at a later date, claiming that the procedure is non-covered or not medically necessary. This might be because of an error, an exclusion in the policy, or because of a change in your policy between the time the surgery was confirmed and the time it was carried out. It is also possible for them to determine that your coverage is no longer valid on the date that the surgery is performed. Should any of these unforeseen occurrences take place, you will become responsible for the charges involved regardless of what we may have estimated your responsibility to be.

     A finance charge will be applied to all balances over 30 days old, including accounts with outstanding balances from insurance companies. The finance charge is one percent (1%) per month with an annual percentage rate of twelve percent (12%). If it becomes necessary for our practice to use an outside means of collecting on your account (eg, a collection agency, lawyer or court) you will be held responsible for the fees incurred by our practice.

     We request 24 hours notice of cancellation of appointments. A $75 charge will be applied to your account for missed appointments or those cancelled in a shorter period of time except for emergencies.

     I hereby assign all benefits payable to Dr. Pepper of OMSI. I understand that I am responsible for any portion of the services not paid by my insurance company regardless of any estimates given prior to treatment and regardless of the reason. I have read the above statements and understand them and my responsibilities. I also understand my financial responsibilities with respect to paying all charges not covered by my insurance for any reason (not to exceed the allowable fee as determined by my insurance company.) I waive my rights to insurance benefits if I have not accurately informed you of my insurance coverage prior to my treatment.

     Insurance companies require claims to be submitted in a timely fashion. If you do not hear from your insurance company or us within two (2) months of treatment, please contact us. You will be responsible for any fees that have not been paid by your insurance company within three (3) months of the date of service, regardless of the reason. We will not become involved in disputes between you and your insurance company.