Dear Valued AkasaCare/Heartland Surgical Care LLC Patient,
In our continuing efforts to communicate effectively with our patients and to continue the exceptional care that our office provides, we will periodically confirm policy practices in writing to ensure patient awareness. Most of the policies you are already aware of; however a new policy regarding Balances Due on Account will become effective January 01, 2012 (Revised January 01, 2017) Please note the following policies that are in place at our office:
1. LAP BAND CONSULTATIONS: Benefits will be verified prior to your appointment and you will be required to pay your deductible, coinsurance and/or co-pays at the time of Service. Insurance will be billed. If there is any additional balance, you will be notified with a statement. Balances are due upon receipt. If there is an overpayment, the credit will be left on the account for future visits. If we cannot verify your benefits or find that you do not have Bariatric coverage for weight- loss surgery, a consultation charge of $275.00 will apply. If Dr. Lopez is out of network with your insurance company, you will be required to pay an initial deposit of $275.00.
2. GENERAL SURGERY CONSULTATIONS: Benefits will be verified prior to your appointment and you will be required to pay your deductible, coinsurance and/or co-pays at the time of service. Insurance will be billed. If there is an additional balance, you will be notified with a statement. Balances are due upon receipt. If there is an overpayment, the credit will be left on the account for future Visits. If we cannot verify your benefits or find that you do not have coverage, a consultation charge of S275.00 will apply.
3. CANCELLATIONS AND NO-SHOWS APPOINTMENTS: We would appreciate a 24 (twenty-four) business hour notification if you plan on not being here for your appointment. There is a $50.00 fee for any missed appointment that is not rescheduled by calling our office within 24 (twenty-four) business hours prior to your appointment time. This fee will have to be paid at/or before your next appointment in conjunction with that days service charges if applicable.
4. RETURN CHECKS: All checks retuned for insufficient funds will be charged a $35.00 return check fee in addition to any bank fees or charges that are assessed. These charges plus the amount due must be paid in full within 14 business days. Payments acceptable for these charges are cash or cashier’s check. Failure to reimburse these charges within 14 (fourteen) business days will result in the charges being turned over to the collection agency. Any additional payments to Heartland Surgical Care LLC must be paid by cash or cashier’s check. The charges must be paid in full prior to scheduling another appointment with Dr. Lopez.
5. BALANCES DUE ON ACCOUNT: Statements are due in full upon receipt. Interest will be charged on unpaid balances more than 30 days past due at a rate of 18%, with interest accruing from the date of the first billing statement. After 90 days, the balance will be closed with Heartland Surgical Care LLC and forwarded out of this office for collections. Balances will need to be paid in full prior to scheduling another appointment with Dr. Lopez. We collaborate with Med Loan financing should you qualify. You can apply with them here. https://www.medloanfinance.com/. (Please note that our office does not have any influence on approval of credit for Medical Loans. We can only assist you with an estimate of the amount of funds you may need to apply for. Any amount communicated for that purpose is simply an estimate. The final amount may be more or less depending on coverage and other variables etc.)
6. DISABILITY/INSURANCE FORMS/PRE-AUTHORIZATIONS FOR MEDICATIONS ETC: There is a $30.00 fee for the office to fill out any Disability/Insurance Forms or to obtain a Pre-Authorization for medication for you. These forms are filled out in the order they are received and will be sent to the patient or employer when completed. These forms will not be able to be picked up at that day’s appointment; they will be mailed or faxed to an employer, Insurance Company/Pharmacy or available for pick-up within 7 days.
7. CASH PAY POLICY FOR UNCOVERED SERVICES: Lap-Band Fills/Unfills- In certain instances where approved by Dr. Lopez you may be eligible for our Cash Pay Policy. Some examples may be but are not limited to a lack bariatric coverage or a non-insured person. These instances are reviewed and approved by Dr. Lopez singularly. Saliva Hormone Testing – Saliva testing is considered experimental by Insurance Companies and therefore is a non-covered service and we will not bill your insurance for this testing. Your HSA/FSA may cover this expense and or Insurance may reimburse you directly. The Cash Pay Policy for each of those services is attached separately.
8. INSURANCE - Failure to notify Heartland Surgical Care LLC of Insurance Changes - Failure to inform us of insurance policy changes for primary and/or secondary insurance policies that you may have could result in you being responsible for unpaid balances. A 15% of allowable Service charge will be assessed upon any Days service where insurance changed occurred where you failed to notify us prior to billing the insurance company of record on your account. In instances where you fail to update us of those insurance changes within in the window for “Timely filling” with your insurance company will result in you being charged the cash pay price for that day’s services on top of the 15% of allowable Service charge.
We pride ourselves in providing our patients with the finest care available. In order to ensure our ability to provide these services, we appreciate you taking the time to read this statement regarding our financial policies.
Thank you for your understanding and compliance in the policies of AkasaCare & Heartland Surgical Care LLC.
Dr. Jesse J. Lopez, Jr., D.O. and Staff