Thank you for choosing Alpine Dermatology to meet your family’s health care needs. We are committed to providing the best care possible and appreciate your trust. Please understand that payment of your bill is considered part of your treatment. The following document is our Financial Policy. Please read it carefully.
- Alpine Dermatology will gladly submit claims to your health insurance for the services provided. However, any charges accrued on the account are your responsibility. You will be expected to follow up on any unpaid or incorrectly paid charges, regardless of insurance coverage. We will be happy to assist you in any way we can, but you are ultimately responsible for timely payment of your account.
- In divorce situations, the person bringing the child into the office is the responsible party. A divorce decree is a document that involves you, your ex-spouse and the courts. Although a divorce decree may state that an ex-spouse is responsible for medical bills, Alpine Dermatology has no authority to enforce compliance.
- You will be responsible for the charges accrued by minor children (under age 18) who come into the office unaccompanied, or in the presence of another caregiver (i.e. grandparents, baby-sitter, etc.).
- You will be responsible for charges accrued by children who have turned 18 until such time as you notify Alpine Dermatology in writing, prior to services being provided, that you no longer accept financial responsibility.
- Alpine Dermatology will charge for physician services, as well as supplies used for the care of the patient.
- Alpine Dermatology will charge for all follow-up services. The same resources (staff, room, supplies, physician time, etc.) are used for the follow-up visit, so the charges will usually be the same as the initial visit.
- Alpine Dermatology will charge for all scheduled, walk-in and after hour appointments. We will also charge for patients who are not scheduled (i.e. siblings of a scheduled patient) that the physician is asked to see.
- Occasionally a patient will be scheduled for one type of service but the physician may diagnose and treat another problem in addition to the scheduled service. When appropriate, Alpine Dermatology will charge for the additional service. Some insurance companies will not cover both services, which may result in a denial or higher co-pay.
- Alpine Dermatology reserves the right to charge for extensive phone calls, reporting, consultation, coordination of care with other providers and/or other services provided on your behalf. Your insurance may not cover these services.
- Alpine Dermatology reserves the right to charge for missed appointments when said appointment has been confirmed, including same-day appointments. These charges will not be billed to your insurance company but will be your responsibility.
Portion Due at Time of Service
- If you have insurance coverage, all co-pays, co-insurance and deductibles are due at the time of service.
- Payment in full is due from self-pay patients at the time of service. A cash discount will be given when charges are paid in full on the date of service.
- Payment in full is due at the time of service from accounts with a “bankruptcy” status.
- Alpine Dermatology reserves the right to charge a “re-billing” fee for amounts that are due, but not paid, at the time of service.
Method of Payment
Alpine Dermatology accepts the following types of payments:
- Check (including cashier’s checks and money orders. No third-party checks)
- Visa, MasterCard, and Discover credit/debit cards
- It is your responsibility to provide accurate insurance information to Alpine Dermatology at the time of service.
- Alpine Dermatology will create and submit claims to your health insurance on your behalf. However, we reserve the right to refuse insurance and collect payment in full from you (i.e. insurance information provided after claim filing deadlines, etc.).
- It is your responsibility to verify that the doctor you have chosen is a participating provider under your insurance plan, prior to receiving services. If you are a patient of Carolyn Sironen, your services will be covered under Dr. Eberting.
- It is your responsibility to verify benefits under your plan. You will be responsible for any non-covered services and services considered to be over “usual, reasonable and customary (URC)”. You will also be responsible for amounts not paid by your insurance for any reason, unless the amounts are covered under Alpine Dermatology’s contractual agreement with insurance.
- Alpine Dermatology must, under federal law, accurately report the services provided to you. Your insurance company may not pay for all services received. Alpine Dermatology cannot change the service or diagnosis codes (unless they were initially reported incorrectly) in order to make a service “fit” your insurance plan benefits. We must report the exact services provided and the exact reason for providing them.
- Alpine Dermatology has the right to release health information to insurance carriers when necessary for payment, and directs them to remit payment directly to Alpine Dermatology (assignment of benefits).
- Account statements will be sent on a monthly basis for accounts that have balances owing. Statements will show both patient (private) and insurance (suspense) amounts owing. Private balances are due by the 15th of the month.
- It is your responsibility to provide Alpine Dermatology with your correct address and phone number. If a statement is returned for an invalid address, your account may be turned over to an outside collection agency.
- Beginning January 1, 2010, Interest in the amount of 1.5% of your balance per month (18% APR) will accrue on accounts with private balances older than 30 days.
Payment Plan Options
- When appropriate and at Alpine Dermatology’s discretion, Alpine Dermatology will offer monthly payment plans to help you manage your health care costs.
- Payment plan duration will be no greater than 3 months unless special arrangements are made, again at Alpine Dermatology’s discretion.
- Interest will accrue on payment plan accounts, as listed above.
- Payments are due on or before the agreed upon date. If payments are late or missed your account may be turned over to an outside collection agency without further notice.
- Payment plans are intended to help bring past-due amounts current. All co-pays and deductibles are required at the time of service and will not be added to a payment plan.
- Failure to follow any or all of the payment plan requirements will render the agreement null and void.
- Any insurance credits or over-adjustments will be returned to the appropriate insurance company.
- Any patient credits or overpayments will first be used to pay past-due balances on the family ledger, including those which may have been referred to an outside collection agency.
- If patient balances have been resolved, patient credits will be returned to you (or the person/organization who paid). Please allow 2-3 weeks for processing. Smaller credits (generally under $20.00) may be left on the account to be used for future co-pays and/or deductibles.
- Your account may go to collections for the following reasons that include but are not limited to:
- Invalid patient demographic information (address, phone, etc.) which prevents us from contacting you regarding your account.
- Failure to provide timely, accurate insurance information.
- Failure to pay patient balances.
- Failure to follow through with payment plan agreements.
- Failure to follow through with statement discrepancies, insurance denials or any other items on your account.
- Failure to follow through with other correspondence from Alpine Dermatology.
- Alpine Dermatology makes every effort to work with you to keep your account out of collections. However, in the event that your account is referred to a collection agency, you will be responsible for the balance of the account in addition to a 33.3% collection fee. You will also be responsible for any interest, service fees and/or legal fees that accrue while your account is in collections.
- Checks returned unpaid by your bank, regardless of the reason, will be posted back to your account in the original amount of the check, in addition to a $20.00 return check fee. You may also be responsible for interest, costs of collection, court costs and reasonable attorney fees as allowed by law.
- Writing a bad check is a Class One Misdemeanor. Alpine Dermatology reserves the right to prosecute to the fullest extent of the law when a check is returned unpaid from the bank.
- If Alpine Dermatology receives notice of a filed Bankruptcy case on your account, we will make the necessary adjustments according to bankruptcy law.
- Your account will be placed in “bankruptcy” status, and you will be required to pay in full at the time of service, regardless of insurance coverage. We will be happy to submit a claim to your insurance on your behalf and, if your insurance pays on the claim, you will be refunded any overpayments.
- Your account will remain in a “bankruptcy” status for two (2) years from the bankruptcy file date. If there has been no collection activity (multiple statements, letters, etc.) during that time, the bankruptcy status will be removed from your account and normal payment policies will apply.
Dismissal from Practice
- Alpine Dermatology reserves the right to dismiss patients from our practice for non-payment. If you have established a history of non-payment on your account, you may be eligible for dismissal.
- Prior to dismissal, Alpine Dermatology will issue a certified letter informing you of our intent to dismiss unless payment in full is made on your account. Payment in full includes your current account balance, in addition to any amounts that have been referred to an outside collection agency.
- If payment is not made within the specified amount of time, a certified dismissal letter will be issued.
Questions or Concerns
- If you have any questions regarding your account, or need clarification on any of the items listed in this financial policy, please contact our Billing Department.
- Alpine Dermatology Billing Department Staff are available from 10:00 a.m. to 5:00 p.m. on Tuesday-Thursday. You can contact them by phone at (801) 763-7107, by email at email@example.com, or in person at our office located at 144 South Main Street, Suite 100, Alpine, UT 84004.
Thank you for choosing Alpine Dermatology for the care of your family. We are dedicated to making your experience a positive one. Please do not hesitate to contact us with any questions regarding your account, payment options or financial responsibilities.