Notice of Patient Financial Responsibilities

Financial Policy
Thank you for choosing the Roanoke Heart Institute. Our goal is to provide you with the highest quality care. We believe that communication with our patients regarding our financial policy is a part of providing the best service. We are committed to building a successful patient relationship. Please read this notice of patient financial responsibilities, ask us any questions you may have, and sign in the space provided. A copy will be provided to you. Please note that the Roanoke Heart Institute Billing Office telephone number is 1-855-689-8166.

Insurance Information
Your insurance policy is a contract between you and your insurance company, so please check with your insurance carrier to determine any pre-existing limitation or other benefit restrictions that you may have PRIOR to your appointment. We will file your insurance as a courtesy 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. Most insurance companies do not cover 100% of the cost of services and there is a portion that is your responsibility.
There are several patient responsibility components that may apply to an insurance payment:
Co-Pay – A set dollar amount per office visit that is the patient’s responsibility.
Co-Insurance – A percentage of the charge that is the patient’s responsibility.
Deductible – A set annual amount that the patient is responsible for paying prior to his or her insurance making a payment.
Because of the contract you have with your insurance company, we are obligated to collect payment from you for your portion of the balance. All co-payments, coinsurance, and deductibles must be paid at the time of service. Also, RHI will collect $50.00 for office visits, $100.00 for ultrasound exams and $200.00 for nuclear exams at time of service unless the patient has met their deductible for the year. If your coinsurance and/or deductibles are high, for your convenience, we can set up an automatic payment (aka recurring) plan.

Insurance Changes and Contact Information
Please note that it is your responsibility to notify our office of any patient information changes (i.e., address, name, insurance information, etc.) We ask that you provide our office with accurate demographic information (address, phone number, e-mail etc.) and proof of insurance. All patients will be required to show proof of insurance and identification.

Managed Care: All Managed Care (i.e. HMO, PPO, POS)
Co-payment, co-insurance, and deductible amounts are due at the time of check-in. If your insurance plan requires a referral authorization from a primary care or referring provider you are responsible for obtaining approval prior to treatment. If you request an office visit or procedure without a referral authorization, your insurance plan may deem this as non-covered treatment and they may not cover the costs of your care. Please remember that it is up to you to understand the requirements of your individual insurance plan and to know whether prior authorization from your insurance company is required.

Medicare
We accept assignment with Medicare. Medicare pays 80% of their allowed amount after satisfaction of the yearly deductible. You are responsible for 20% of Medicare’s allowed amount unless you have secondary insurance coverage. All co-payments, coinsurances and deductibles are due and payable at the time of service.

Secondary & Tertiary Plans with Medicare
We will bill your secondary and, if applicable, tertiary insurance as a courtesy. If you have supplemental insurance to cover the portion of the charges that Medicare or your primary insurance carrier does not pay, please provide us with a copy of this insurance card. Medicare and secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding.

Non-covered Services
Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or upon notice of insurance claim denial, depending on the nature of your insurance policy. If our office does not participate with your insurance, payment will also be due at the time of service. If your coverage is a plan that we feel may cover office visits, we may elect to take your co-pay/co-insurance at the time of service, and invoice your insurance company. You will remain responsible for the costs of care not covered by insurance.

Cash Payments
We accept a variety of payment methods including cash, check, and credit card (Visa, MasterCard, American Express and Discover.) Credit card payments are also accepted via telephone and online via our patient portal. Cash-paying patients are accepted at the discounted cash-pay rate. All uninsured patients will be required to pay in full prior to the time of treatment.

Returned Checks
A $35.00 fee will be charged for any returned checks. We will be unable to accept your checks for any services thereafter.
Nonpayment
Please be aware that patient accounts that go over 90 (ninety) days without satisfactory payment will be turned over to a collection agency.

Missed Appointments and Late Arrivals
In an effort to provide all of our patients with quality, efficient and timely care, we ask that you keep your scheduled appointments. If you are unable to keep a scheduled appointment, please reschedule it at least 24 (twenty four) hours before the scheduled time. If you do not let us know before closing time (4:30 PM) on the business day prior to your scheduled appointment, you will be charged $50.00 for each missed office visit, $100.00 for each missed ultrasound appointment, and $200.00 for a missed nuclear stress test. These fees are necessary to cover a portion of the costs of the reservation that was made to provide service to you..

Medical Records
Requests for the release of medical records will be processed upon receipt of a signed medical release form. Please be aware that billing records are also a part of your medical record and release to a third party will also require this form. We can mail or fax records. The provision of medical records is associated with a variable charge based on the volume of records requested.

Form Completion
There will be a $20 pre-payment charge for all general forms that need to be completed by the RHI staff. Due to the high volume of forms we receive please allow 7 business days to get the form back to you. If there is a need for the form sooner, there is an additional $10 “rush” surcharge. Please fill out any patient specific sections prior to submission to RHI. All forms need to include instructions as to where to send the forms once completed, along with an addressed and stamped envelope if they are to be mailed.

Account Billing Questions and Refunds
Questions or concerns regarding your account or insurance claim should be directed to our billing office staff. If you feel an error has been made in your statement or if you have any questions or concerns please contact the Roanoke Heart Institute billing office. The telephone number is: 1-855-689-8166.