| Portal Payment, Financial Policy, Surprise Billing |
Guest Portal Payment: For online bill pay click link below.
https://www.medentlink.com/openedge/guestpay/index.php?practice_id=1XQz7E19&auth_key=15147750-8015-11eb-9439-0242ac130002
Financial Policy
Basic Policy: Payment is due in full at the time service for self pay patients.
Participating Insurance: We will bill your insurance carrier directly. We require a copy of your insurance card to obtain the proper information. All co-payments and deductibles are due at the time of service. Please call our billing department at 315-786-8700 to verify participation with your insurance.
Medicare Patients: We will bill Medicare for you. We will also bill your secondary insurance carrier for you. All co-payments and deductibles are due and payable at time of service.
Medicaid Patients: You must provide a current and valid Medicaid card when you check-in for each visit. If your Medicaid card is invalid for any reason, payment will be due by you at the time of service.
Non-covered Services: Any care not covered by your insurance carrier will require payment in full at the time services are provided or upon notice of insurance claim denial.
No Fault: If your injury is auto related, we require the proper insurance carrier's name, address and phone number at the time of service. We will also need policy and case numbers to complete claim forms.
Annual physicals: Annual physicals, work, school and other preventive health care services may or may not be covered under your health insurance policy. You will need to check with your insurance carrier prior to your appointment to determine coverage. To insure proper billing please inform your healthcare provider at the time of service if you expect your insurance to cover any of the above services. We will not change our billing AFTER the fact. Any non-covered services are due at the time service is provided.
Missed Appointments: In fairness to other patients and our health care providers, we require at least 24 hours' notice to cancel appointments.
Electronic Signatures Collected At Check-in:
Medicare Patients Signature on file: I request payment of authorized Medicare benefits to be made to Watertown Internists for any services furnished by Watertown Internists. I hereby give my consent for Watertown Internists to use and disclose Protected Health Information (written or electronic) about me to carry out treatment, payment and healthcare operations (TPO) to CMS (Center for Medicare & Medicaid Services) and its agents, any information needed to determine benefits or benefits payable to related services. I understand my signature requests that payment be made and authorizes release of any PHI necessary to pay the claim. If "other health insurance" is indicated in Item 9 of the HCFA-1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of PHI to the insurer or agency. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare Carrier.
***SIGNATURE OF PATIENT ON FILE VIA EMR (ELECTRONIC MEDICAL RECORDS) ***
Insurance Assignment: I hereby assign all medical benefits, to include major medical benefits to which I am entitled from private insurance and/or any other health plans including Medigap or Medicare secondary polices, to Watertown Internists. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand I am financially responsible for all charges whether or not paid by said insurance, and that I am responsible for all related late fees ($10/month) that are associated with any overdue balances. I hereby give my consent for Watertown Internists to use and disclose any necessary PHI about me to carry out treatment, payment and healthcare operations (TPO).
***SIGNATURE OF PATIENT ON FILE VIA EMR (ELECTRONIC MEDICAL RECORDS) ***
General Consent For Treatment:
*I hereby request, consent, and authorize the healthcare providers of Watertown internists, P.C. to administer and perform all medical treatments as he/she feels is medically necessary. This includes general & preventative medical care, medical examinations, diagnostic procedures, laboratory tests and cultures, prescribed medications, arrange referrals and administer immunizations.
*I understand that certain medical conditions may require photographic documentation and hereby consent to medically necessary photographs of any procedures or conditions.
*I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of any procedure, treatment or examination.
*This consent shall remain effective until I revoke it in writing, which I may do at any time, except to the extent that the healthcare providers of the practice have acted in reliance upon this authorization.
***SIGNATURE OF PATIENT ON FILE VIA EMR (ELECTRONIC MEDICAL RECORDS) ***
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing." This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
*You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
o Cover emergency services without requiring you to get approval for services in advance (prior authorization).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed and your coverage is subject to New York State law ("fully insured coverage"), you may contact the New York State Department of Financial Services at 1-800-342-3736 or surprisemedicalbills@dfs.ny.gov. Visit http://www.dfs.ny.gov for information about your rights under state law.
Contact CMS at 1-800-985-3059 for self-funded coverage or coverage bought outside New York State. Visit http://www.cms.gov/nosurprises/consumers for information about your right under federal law.
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