We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask to speak with any member of our billing team if you have any questions.
PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE PHYSICIAN. WE WILL REQUEST TO SCAN YOUR INSURANCE CARD(S) AND A PHOTO ID FOR YOUR CHART.
Current Insurance Card – A claim cannot be processed with expired insurance card information. Patients will have the opportunity to pay the total visit charge or reschedule to a date when current insurance information can be provided. We will review your insurance card(s) at every visit. All insurance changes must be given to us by the time of service. If your insurance changes and we are not notified, you will be responsible for all charges. We may not bill your insurance for any charges before the change notification.
- Copays, deductibles, and co-insurance amounts are collected at the time of service. Durable medical supplies may not included in our contract and might therefore incur an out-of-pocket expense.
- As a courtesy to you, insurance forms for services rendered will be completed by our office with your primary insurance carrier. We may file the secondary insurance, if we are given appropriate insurance information.
There are some things which for which we CANNOT accept responsibility:
- We DO NOT file Medicaid as a secondary insurance, unless Medicare is the primary insurance
- Co-insurance and deductibles: These charges are your responsibility. Due to our contractual obligations with your insurance company, we are not able to write off co-insurance or deductible amounts
- Co-payments: By law, we MUST collect your insurance carrier designated co-pay. This payment is expected at the time of service.
- Authorizations: For those patients who are members of an insurance plan that requires an authorization, it is the patient’s responsibility to get a current authorization from the primary care physician. Generally if the name of a primary care physician is listed on the insurance card, an authorization is required from that physician. Please verify with the Check-in staff before your visit that you have a current authorization. If you do not have the required authorization, you will be responsible for your charges at the time of service, or you will have to
reschedule your visit until an authorization can be obtained. - Medicare Assignment: (if applicable) I authorize any holder of medical or other information about me consent to release any information needed for this, or a related Medicare claim, to the Social Security Administration and Health Care Administration or its intermediaries or carriers. I permit a copy of the authorization to be used in place of the original request payment for medical insurance benefits to the party who may be responsible for paying treatment costs.
- Self-Pay patients: Full payment is expected at the time of service, unless financial arrangements have been made prior to your visit.
- Divorced/separated parents of a minor patient: The responsibility of payment for services rendered to any dependent patients, should parents be legally-separated or divorced, rests with the parent who seeks treatment for the patient. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of our office. Raleigh Capitol Ear, Nose, and Throat will not be involved with separation or divorce disputes.
- Supplies: Any supplies that you receive from our office must be paid for in full at the time of service. Insurance companies do not cover costs for miscellaneous supplies or administrative work.
- Outside forms: Disabilities forms, FMLA forms, Leave of Absence forms, letters regarding airline tickets or travel and/or requested correspondence that is not associated with the reimbursement of a claim may incur a charge to the patient prior to completion of the form(s). Turnaround for form completion may vary with time and volume.
- Missed or Late Cancellation of Appointment: If a patient misses an appointment without 24 hour notice of cancellation, the patient will receive a $50 missed appointment charge. If a patient misses a testing or surgery appointment without prior notice, there is a $200.00 patient charge.
- Returned Check Fee: There is a charge of $40.00 to the patient in the event of a returned check for insufficient funds.
- Statement Procedure: We will mail a statement to the address you have provided once we receive payment from your insurance carrier. In the event that a payment is not received from you within 30 days, a second pastdue statement will be mailed. If we still do not have payment within 30 days after that, we will make every effort to notify you that your account is being turned over to Equifax, which may impact your credit rating.