Dean Fochios, M.D., PC, Lawrence Wiesner, D.O.
Patient Payment Policy

 

Thank you for choosing our practice!  We are committed to the success of your medical treatment and care.  Please understand that payment of your bill is part of this treatment and care. 

 

For your convenience, we have answered a variety of commonly-asked financial policy questions below.  If you need further information about any of these policies, please ask to speak with a Billing Specialist or the Practice Manager.

 

How May I Pay?

We accept payment by cash, check, debit, VISA and  Mastercard.

 

Do I Need A Referral?

If you have an HMO plan with which we are contracted, you need a referral authorization from your primary care physician.  If we have not received an authorization prior to your arrival at the office, we have a telephone available for you to call your primary care physician to obtain it.  If you are unable to obtain the referral at that time, you will be rescheduled.

 

Which Plans Do You Contract With?

Medicare, Medicaid, MVP, Excellus BC/BS, CDPHP, GHI, GHI HMO, CASEBP, United Healthcare

 

What Is My Financial Responsibility for Services?  

Your financial responsibility depends on a variety of factors, explained below.

 

Office Visits and Office Services

 

If You Have...	You Are Responsible For...	Our Staff Will...
Commercial Insurance (Also known as indemnity, “regular” insurance, or "80%/20% coverage.")	Payment of the patient responsibility for all office visit, x-ray, injection, and other charges at the time of office visit.	Call your insurance company ahead of time to determine deductibles and coinsurance.   File an insurance claim as a courtesy to you.
HMO & PPO plans with which we have a contract	If the services you receive are covered by the plan:  All applicable copays and deductibles are requested at the time of the office visit. If the services you receive are not covered by the plan: Payment in full is requested at the time of the visit.	Call your insurance company ahead of time to determine copays, deductibles, and non-covered services for you. File an insurance claim on your behalf.
HMO with which we are not contracted.	Payment in full for office visits, x-ray, injections, and other charges at the time of office visit.	Provide the necessary information for you to complete and file your claim directly with the insurance company.
Point of Service Plan or Out Of Network PPO	Payment of the patient responsibility—deductible, copay, non-covered services—at the time of the visit.	Call your insurance company ahead of time to determine out of network benefits, copays, deductibles, and non-covered services. File an insurance claim on your behalf.
Medicare	If you have Regular Medicare, and have not met your $100 deductible, we ask that it be paid at the time of service. Any services not covered by Medicare are requested at the time of the visit. If you have Regular Medicare as primary, and also have secondary insurance or Medigap: No payment is necessary at the time of the visit. If you have Regular Medicare as primary, but no secondary insurance: Payment of your 20% copay is requested at the time of the visit.	File the claim on your behalf, as well as any claims to your secondary insurance.
Medicare HMO	All applicable copays and deductibles at the time of the office visit.	File the claim on your behalf, as well as any claims to your secondary insurance.
Worker’s Compensation	If we have verified the claim with your carrier No payment is necessary at the time of the visit. If we are not able to verify your claim Payment in full is requested at the time of the visit.	Call your carrier ahead of time to verify the accident date, claim number, primary care physician, employer information, and referral procedures.
Worker’s Compensation (Out of State)	Payment in full is requested at the time of the visit.	Provide you a receipt so you can file the claim with your carrier.
Occupational Injury	Payment in full is requested at the time of the visit.	Provide you a receipt so you can file the claim with your carrier.
No Insurance	Payment in full at the time of the visit.	Work with you to settle your account.  Please ask to speak with our staff if you need assistance.

 

Surgery

If your physician recommends surgery, you will be escorted to his Surgery Coordinator. She will answer specific questions about the surgery scheduling process, discuss the paperwork and tests involved, and complete all pre-certification/authorization if your insurance company requires it. 

 

The Surgery Coordinator will request a pre-surgical deposit if you are uninsured.

 

What if My Child Needs to See the Physician?

A parent or legal guardian must accompany patients who are minors on the patient’s first visit.  This accompanying adult is responsible for payment of the account, according to the policy outlined on the previous pages. 

 

 

 

I have read, understand, and agree to the above Financial Policy.  I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility. 

 

I authorize my insurance benefits be paid directly to (name of your practice).

 

I authorize Dean Fochios, MD, PC  to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.

 

 

 

_________ Date

________________________ Signature

________________________ Printed Name