Thank you for choosing Maxillofacial & Implant Surgery of Western Mass, P.C. (MISWM) to keep you informed of our current office and financial policies we ask that you read and sign our financial acknowledgement prior to treatment. We are committed to providing you with the best possible care. If you have any questions, please ask one of our staff to assist you with an explanation. If you require further explanation, the practice administrator may be contacted.
IN NETWORK: We refer to “in network” as the insurance companies that we have a contractual agreement. If we are in network, we have agreed upon a pay scale with the insurance company. In other words, we have agreed to a discounted rate for members of the insurance carrier with whom we are contracted.
OUT OF NETWORK/ NON-PARTICIPATING INSURANCE: If we are not in network with your insurance carrier, we will bill your carrier as a courtesy. You will be asked to pay for your visit in full and will be refunded if payment is received by your insurance company. You, the patient, will have to contact your insurance company to determine why payment has not been made. Please be aware, you may incur more out of pocket expenses for seeing a doctor out of network. It is your responsibility to check with your insurance company for benefits.
INSURANCE REFERRAL: Most HMO’s and other managed care organizations, require a referral from your primary care physician to see a specialist.
TREATMENT REFERRAL: Most referring physicians and dentists will give you (or mail or email us directly) a treatment referral slip for you to be evaluated and treated by one of our surgeons, this is your doctor’s recommendation for surgical treatment. It is very important that the referral slip includes your first and last name, date of birth and teeth numbers if applicable.
FINANCIAL POLICIES AND PROCEDURES
At Maxillofacial & Implant Surgery of Western Mass, P.C., we believe that all patients deserve the best medical/dental care that can be provided. In order for us to provide you with the highest quality care and current technology, we must insure that we are able to meet the expenses necessary to operate this facility. To ensure that these expenses are met, we provide you with this agreement to acquaint you with our financial policy.
PAYMENT AT TIME OF SERVICE
In order to establish an optimal relationship with our patients and to avoid misunderstandings; our staff is trained to consistently inform you of our payment policies. Payment is required for all services at the time they are provided. Our staff will make a good faith effort to pre-verify your insurance eligibility. For those insured patients, any applicable co-payments, co-insurance and/or deductibles will be collected at the time of service. All self-pay patients, which, includes patients receiving cosmetic services, are required to pay, in full, at the time of service. For some procedures a deposit may also be required.
SUBMISSION OF CLAIMS
Medical/Dental insurance is a contractual agreement between you and your insurance carrier(s). You are responsible for knowing the specifics of what each policy covers and notifying our office of any insurance changes. Co-Payments are required to be paid at each time of service. We will submit claims to both your primary and secondary insurance plans for covered services. If no payment is received from your insurance company due to failure to provide our office with up-to-date changes or inactive coverage, you will be responsible for the full amount due.
BALANCES DUE AFTER INSURANCE PAYS
Statements will be sent to you for payment of any balance due after your insurance carrier has paid its agreed upon share.
If you do not respond to our request for payment, a final statement will be sent advising you that no further statements will be sent and your account will be sent to an outside agency for collections. At that point, the account is out of our hands. If you need to make special arrangements, it is your responsibility to contact our billing department. Payments for collection balances can be made by cash or credit card; we will not accept a personal check.
Due to the nature of our practice we require payment at the time of service. Payment arrangements are considered only in rare circumstances and require approval from the Practice Administrator or Assistant Practice Manager.
Our office accepts Visa, MasterCard, American Express, and Discover and Debit Cards. We also accept Care Credit. For information on Care Credit you may visit www.carecredit.com for details and to apply online or speak with any of our office staff.
MEDICAID (MASSHEALTH) INSURANCE PLAN MEMBERS
It is very important that you know what type of coverage you have under MassHealth, plan types changes daily. It is our policy to verify that you have active coverage on the day of your appointment. If you do not have active coverage you may keep your appointment but will be responsible for paying in full prior to treatment. If your coverage has been changed to a plan we do not accept (Network Health, Neighborhood Health, Celticare) then we will notify you and cancel your appointment (we may reschedule your appointment in the future if you contact MassHealth and choose a plan that we are in-network with).
If you have Medicare as your primary insurance carrier, but you do not have a secondary insurance, you may be responsible for the 20% coinsurance at the time of service.
MOTOR VEHICLE ACCIDENT
We do not routinely accept motor vehicle accident cases. We will typically only accept these cases if you have been treated by Baystate Medical Center while our surgeons were on-call. If your injury is due to an automobile accident, we require that you provide us with any information that will assist us in getting your medical claims paid. This information may include:
• Name and address of auto insurance, claim number and the name and direct phone number of your adjuster
• Medical/dental insurance information
Payment for any services that we provide will ultimately be your responsibility if not paid promptly by another party.
We do not routinely accept workers compensation cases. We will typically only accept these cases if you have been treated by Baystate Medical Center while our surgeons were on-call. If your injury is due to an accident in your work place, please be sure to contact your employer and inform them of your injury. We will need to receive authorization from your employer before we can process any of your medical claims. Failure to properly report this injury to your employer may result in your claims being denied. Payment for services rendered will then be your responsibility.
DISABILITY OR INSURANCE FORMS
There may be a charge for the completion of medical forms (charge is based upon number of pages and complexity of information requested). Payment is due at the time that you pick-up the forms. Please allow 7 – 10 days for the completion of these forms. If you would like the forms mailed to you or your insurance company, payment will be due prior to mailing.
We will provide you a copy of your medical records upon written request. You must complete our “Release of Oral and Maxillofacial Surgery Records” form. Please allow 7-10 days for us to copy your records. There will be a $25.00 fee for your copy. If your record is greater than 20 pages, you will be charged an additional $.50 per page.
We will provide you with a copy of your x-rays upon request. You will need to sign a letter of release at the time of pick-up. Please allow 48 hours from the time of your request. There is a $10.00 charge per x-ray, that is payable at the time of pick-up.
If you pay cash, please ask for a receipt so that you will have a record of your payment. A detailed receipt is available upon request at the end of your visit.
If there is a remaining balance on your account after we’ve received payment from your insurance company you will receive a statement in the mail.
All Sales are Final for purchases of skincare products sold by our office. In the event of an adverse reaction, please contact our office immediately.
Refunds for cash or check payments are returned by check only. Check refunds will be mailed to you within 30 business days of the documented overpayment. We do not issue cash refunds.
The term “referral” can refer both to the act of sending you to another doctor or therapist and to the authorization put in place by your primary care physician for your visit to a specialist.
Patients are responsible for making sure a referral is in place before services are received.
OFFICE POLICIES AND PROCEDURES
APPOINTMENT CANCELLATION POLICY
Our goal is to provide quality medical/dental care in a timely manner. In order to do so we have implemented an appointment cancellation policy. This policy enables us to better utilize available appointments for our patients in need of medical/dental care.
In order to be respectful of all our patients, be courteous and call promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in need of treatment. This is how we can best serve the needs of all our patients.
If it is necessary to cancel your scheduled appointment we require that you call 24 hours prior to your appointment. Failed appointments are subject to a $50.00 charge. This fee is based on a case-by-case basis. Obvious and blatant failure to attend your scheduled surgical appointment may result in your permanent dismissal from our practice. Family emergencies or weather related delays will be handled on a case by case basis.
INITIAL CONSULTATION VISIT
Your initial appointment will consist of a consultation explaining your diagnosis and treatment options. Occasionally, surgery can be performed the same day as the consultation (local anesthesia only, procedures requiring sedation will be scheduled another day). However, a complex medical history or treatment plan will require an evaluation and a second appointment to provide treatment on another day.
Please assist us by providing the following information at the time of your consultation:
- Your surgical referral slip and any X-rays if applicable
- A list of medications you are presently taking
- Picture ID (a driver’s license, state identification card, school identification card etc.)
- All insurance cards (medical and dental)
IMPORTANT: a parent or guardian must accompany all patients under the age of 18 years of age at the consultation visit.
We cannot bill your insurance company unless you give us your current information. Your insurance policy is a contract between you and your insurance company, we are not party to that contract. Please be aware that some, and perhaps all of the services provided may be non-covered procedures and not considered reasonable and necessary under the dental and/or medical insurance. We charge the usual and customary fees, and you are responsible for payment regardless of the insurance company’s determination of usual and customary fees. We will not alter any codes or treatment dates for the purposes of obtaining payment from your insurance company.
CHILDREN UNDER 18 YEARS OF AGE
Legal documents must be presented to our office for Guardianship or Power of Attorney. All children under 18 years of age must be accompanied by a parent or legal guardian. Proof of legal guardianship is required to be submitted with all other patient documentation. A person granted the ability to make medical decisions or to consent for treatment on behalf of the patient will be required to submit a legal Power of Attorney to our office. If these documents can not be provided before the patient is treated, you may be required to reschedule the appointment. A separate policy exists for minors under the care of The Department of Children and Families.
CHILDREN ACCOMPANYING PATIENTS
While we welcome children as patients, please try to refrain from bringing non-patient children to the office. We recommend and encourage you to make arrangements to have your child or children cared for at home or in a daycare facility as a consideration to other patients.
All surgical patients planning to undergo sedation or general anesthesia must have an escort accompany them to their appointment. The escort must be present before surgery and remain in the office until the patient is discharged. The escort may not leave our office under any circumstances. The escort is the individual who will provide transportation (no motorcycles, mopeds or scooters) for the patient after surgery and be given post-op care instructions. Patients receiving local anesthetic do not require an escort.
Our practice is dedicated to maintaining the privacy of your individual health information. We are required by law to maintain the confidentiality of this health information under the Health Insurance Portability and Accountability Act (HIPAA). We cannot release or discuss personal medical information with spouses, parents of dependents who are 18 and older, or any other family member in your household. Patients who would like us discuss or disclose private information are required to sign a release form permitting such disclosure. You may request a copy of our office Notice of Privacy Practices.
DISTRIBUTION OF EXTRACTED TEETH
It is the policy of this office to treat and classify extracted teeth as a biohazardous material. That said, we will not return teeth to you (the patient). Children under the age of 10 years old will receive a “tooth fairy certificate” to leave the office with.