Nexgen Oncology Financial Policy

download the .pdf form here

Thank you for choosing us as your healthcare provider. We are committed to providing you with high quality and affordable care. Please read this financial policy, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

1. Proof of insurance: All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid health insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

2. Coverage changes: If your health insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. Further, all bills for patient balances are mailed to the address of record. Therefore it is imperative that you update us with any and all changes to your account whether it is a change of address, phone number, insurance etc.

3. Health Insurance: We participate in most health insurance plans, including Medicare. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. If you are insured by a plan we are contracted with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage.

If you insured by a plan that we are not contracted with or are uninsured, payment in full is expected at each visit. Payment arrangements must be made prior to service. If you first saw the physician in the hospital, payment arrangements must be made immediately after hospital discharge.

4. Co-payments and deductibles: All copayments, coinsurance and deductibles must be paid at the time of service unless arrangements have been made in advance by you or your insurance carrier. We accept personal checks and credit cards (Visa, MasterCard and Discover). In order to limit the amount of cash we have at our facility, we typically prefer not to accept cash. However, we will accept cash if necessary.

Your health insurance benefit is a contract between you and your insurance company; we are not party to that contract. "Your insurance company requires that we collect your copayment." We cannot waive any copayments, coinsurance and/or deductible. Failure on our part to collect copayments, coinsurance and deductibles from patients can be considered insurance fraud. Please help us in upholding the law by paying your co-payment at each visit. Further, mailing statements increases the office’s costs associated with billing.

5. Claims submission: As a service to you, we will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not


your insurance company pays your claim. Should the service provided go beyond the amount covered by your insurance, we will need payment paid in full. However, if this is not feasible, we do offer some payment options. We can work with you to create a payment schedule. This will be based on each patient’s individual bill and amount they are able to pay. However, we prefer that all payments be paid in full within a 3-month period.

6. Non-covered services: Please be aware that some of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

7. Nonpayment: If your account is over 90 days past due, you will receive a letter stating that you have 10 days to pay your account in full. Please do not ignore these statements. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency.

8. Missed appointments or late cancellations: Missed appointments or late cancellations represent a cost to us and to other patients who could have been seen in the time that was scheduled for your visit. We request that you cancel appointments 24 hours prior to the appointment. Our policy is to charge $30 for missed appointments not canceled within 24 hours. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointments.

9. Referrals and Pre-Certifications: Your insurance company may require a referral from a primary care physician (PCP) in order for you to see a specialist. Your insurance may also require pre-certification of office or outpatient services. As a courtesy, our office will make every reasonable effort to obtain these referrals and pre-certifications for you. If a referral or pre-certification cannot be obtained prior to the date of your visit, your appointment may have

to be rescheduled. Referrals and/or pre-certifications are sometimes required for CT scans, X-rays and other diagnostic tests. Some managed care contracts specify the location for

these services.

Our practice is committed to providing the best treatment to our patients. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I have read and understand the payment policy and agree to abide by its guidelines. I hereby assign, transfer and set over to Nexgen Oncology my assignment of benefits for reimbursement of services rendered.

This consent will remain in effect until revoked by me in writing. A photocopy of this assignment will be considered as valid as an original. I understand that I’m financially responsible for any charges not paid by my insurance carrier(s).