Rochester Gastroenterology Associates Financial Policy:

Rochester Gastroenterology Associates manages billing on behalf of your doctor’s practice, herein referred to as the “Practice”.Please read the agreement below before accepting enrollment into the Health-e-Pay™ Program.

We know that choosing a physician is a very important decision and we thank you for choosing our Practice. We also recognize that insurance plans and payments have become increasingly more complex for our patients and their families. We have developed some services to help with those complexities. Please carefully read this overview of our practice’s financial policies.

Payment is due at the time of the visit. This includes all co-pays, deductible and coinsurance amounts. Co-pay amounts are listed on your insurance card. All deductible plans must be paid in full at the time of the visit.

Patient or Guarantor's Responsibility:

You will be responsible for any payment for any services requested and/or approved by you, if not covered by your insurance carrier. In addition, you will be responsible for any services rendered for services requiring interpretation by an outside agency and billed by them directly (i.e. labs, etc.).

You must be informed of and understand the details of your health insurance coverage and fulfill any associated requirements (e.g., pre-certification, obtaining referrals, providing information regarding pre-existing conditions, etc.). Obtaining these is the responsibility of the patient prior to the visit or the patient will be responsible for the total amount due. It is also your responsibility to provide our office with all required information regarding your health insurance coverage. You must promptly respond to our requests for insurance information and notify us if there are any changes to your insurance information.

Payment Options we can provide:

We provide the following payment options regarding care provided for our patients.

As a service, we will keep a copy of the patient’s insurance card on file and will submit an insurance claim on your behalf to your insurance company with the information you have provided us. Payment options at the time of service include cash, check and credit card or a signed enrollment in Health-e-Pay™ Program.

We recognize just how difficult it can be to understand all the details of your insurance plan. Therefore we are willing to accept enrollment in our Health-e-Pay™ Program. This allows us to charge an approved credit card for the patient balance as determined by the insurance company once we have submitted a claim and received the explanation of benefits.

The most common reason for a claim being rejected is an ineligible policy or plan number. In the case there is an incorrect number or other information, you will be billed for the full amount of the visit.

We CANNOT provide Financial Services.

It is the responsibility of the patient and/or parents/guardians to know what is covered and not covered by their insurance carrier. If you are unsure, you must either pay in full for the visit or sign up for our Health-e-Pay™ Program.

Loans – The Practice cannot loan people money to cover the cost of their services until such times they collect monies from their insurance companies.

Balances that remain outstanding for a period of 90 days or more may be referred to a collection agency or attorneys’ office. If an account is sent to collection, all collection fees and attorney fees will be added to the balance due. Additionally, patients may be dismissed from the practice as per legally accepted protocols.

Agreement:

By my electronic signature capture, I have selected THE PRACTICE to provide medical services and attest that I accept the responsibility for full payment of all services rendered. I also agree that we will:

• Provide accurate insurance information for the patient and update THE PRACTICE with any changes in insurance.
• Make full payment or co-payment at the time of service including all deductibles OR allow authorization of payment via the Practice’s Health-e-Pay™ Program.
• Keep the account current through timely payments and communications required.
• Grant the right to collect all reasonable costs, billing fees, attorney’s fees, collection agency fees and disbursements associated with any legal action taken to recover a debt for services rendered.

I understand that:

• I am enrolling in the Health-e-Pay™ Program today. I have specified the name(s) of the patients for which I am the guarantor on their insurance plan.
• All accounts not current are subject to THE PRACTICE’S collection program and could result in a loss of privileges/relationship with THE PRACTICE.
• In the event the bank returns a check to the Practice, a service charge of $40 (maximum) in addition to any bank fee will be added to the patient’s account.
• All credit card information is kept on a secure server in compliance with Federal Privacy and Security Standards.
• By enrolling in this program, I agree to receive email confirmation of your enrollment in the Health-e-Pay™ Program.
• I also agree to receive an email confirmation when my credit card is charged. The information that may be sent will be the date of service and total fees due. There will be no diagnosis codes or visit details on that receipt. This is to maintain the confidentiality of health information.

Financial hardship should never stand in the way of medical care. Since open communication can benefit both parties, any hardship should be confidentially discussed with THE PRACTICE earlier rather than later. This will simplify a difficult situation. Please feel free to speak with the physician or our office manager if you have any questions about our policy.

I HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS SET FORTH ABOVE AND AGREE TO THE TERMS AND CONDITIONS THEREIN. I FURTHER UNDERSTAND THAT FAILURE TO COMPLY WITH THIS AND ANY OTHER POLICIES OF THE PRACTICE MAY RESULT IN TERMINATION OF PROFESSIONAL SERVICES. I WILL RECEIVE A COPY OF THIS AGREEMENT UPON ENROLLMENT IN THE Health-e-Pay™ PROGRAM.