OFFICE BILLING POLICY

BARBARA LEVY, M.D., P.S. and PACIFIC NW UROGYNECOLOGY, PLLC

 

                It is our goal to provide our patients with the most thorough and up-to-date health care possible.  This requires good communication and “partnership” between you, the staff and your physician.

 

                We will submit a claim for you to insurance companies with which we are contracted. In order to do so, we must have a current insurance card.  If you do not have a current insurance card we appreciate and expect payment at time of service.  We will provide you with the information you will need to submit the claim yourself.  We have an obligation, by contract with insurance companies, to collect all co-pays at time of service.  We do accept cash, check, Visa or MasterCard.

 

ADDITIONAL FEES FOR SERVICES REQUESTED:

 

To bill you for your office co-pay that is due at time of service.

 

        Letter Requests:

-          Pre-authorizations for non-formulary drugs.

-          Oral Contraception for medical reasons. (If requested more than one time per year).

-          Duplicate prescription requests within a year’s time. Most prescriptions have 1 year refills. 

-          Rebilling insurance claims.  There will be a charge to re-bill a claim due to wrong insurance information given at time of service. 

-       Any other type of letter for military, work or personal reasons.

 

        -  All returned checks for Non-Sufficient Funds.

        -  Telephone Management for a medical condition or modification to your treatment plan.

           (Example:  urinary tract infection, yeast infection, or change in medication)

 

-          “No-Show” to your scheduled appointment.

-          Less than 24 hour notice for cancelled appointments.

      (New patient’s are required to give us a credit card number or write a check in the

       amount of $100.00.  This is returned to you at time of your appointment.)

 

Annual Physical Exam

                The annual physical exam includes a comprehensive history, risk factor identification, medication review and complete gynecological exam.  Many insurance companies classify these services as preventive (i.e. routine pap, cholesterol screening, urinalysis, breast and colon cancer screening, diabetic screening and family history risk factor identification).  Legally we are not permitted to resubmit claims with a new diagnosis or office code if the claim was accurately submitted as a preventive care visit and denied by your insurance company.  They consider this fraudulent and take measures against physicians including criminal indictments who code to accommodate coverage.

 

Denied Services

                In the event your insurance company does not cover preventive exams or other office visits with no referral or non-Gyn diagnoses, you will be responsible for these services.    If this is a concern to you, please discuss this with the office manager before seeking medical care.

 

                I have read and understand the Office Billing Policy stated above and agree to pay for any services not covered by my insurance.

 

Signature ____________________________________  Date_______________________     (8/12/05)