TRIFECTA PRIMARY CARE

Your insurance coverage is a contract between you and your insurance company. We are not a party to that contract. If you have insurance, we will help you receive maximum benefits. If we accept your insurance, you must pay any co-payments and/or deductibles allowed, at the time of service.

• In the event we accept assignment of benefits, the patient is still ultimately responsible for all charges. If your insurance company has not paid your account in full within 45 days, the balance is due in full from the patient and/or guarantor.

• If we accept your insurance, we are legally required to bill your insurance company (i.e. you cannot choose to be self-pay to get the prompt pay discount)

Our practice is committed to providing the best treatment for patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. We file claims as a courtesy to our patients. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, etc., other than to provide factual information as necessary. You are responsible for the timely payment of your account.

Payment is due at the time service is rendered unless other arrangements have been made in advance. This includes co-payments, co-insurances, deductibles, and non-covered services per your contractual obligations with your insurance company. This policy is in effect regardless of who brings the patient in for the appointment, even if he or she is not the account guarantor. We are legally prohibited from writing off patient responsibility amounts.

Trifecta Pediatrics & Primary Care is contractually obligated by your insurance company to collect your co-payment at the time of each visit. The cost of billing co-payments often exceeds the actual co-payment amount. Therefore, our policy will be to add $10.00 processing fee if you are unable to make your payment at the time of service.

Primary and secondary insurances are filled by our office, through our Electronic Medical Record and Revenue Practice Management Service, Charm Health and ClaimMD, on your behalf. Billing statements will be mailed out by our billing service and are due upon receipt. If you are unable to pay your bill in full when you receive it, please call our office to set up a payment plan.

In the event of untimely payments, late fees will be assessed an outside collection agency may be utilized to secure payment. There will be a $5.00 late fee charged to any account that is 31-60 days past due. There will be a $10.00 late fee charged to any account that is 60-90 days past due. After 90 days, late accounts will be released to our collection agency. No appointments will be made until the balance is paid in full, unless a payment plan has been approved and set up by management.

In the event the patients’ insurance company requires referrals to other physicians or outside tests, your Primary Care Provider must approve those referrals. Please call at least three (3) business days in advance of the appointment with another provider because your provider may need to evaluate the need of your request with an office visit and some insurance companies request at least 3 days to complete a referral.

Due to the recent increase in high deductible plans, Trifecta Pediatrics & Primary Care requires a $50.00 pre-payment for any visit scheduled that is not for preventive care. Preventive care services include well visits, immunizations, and yearly wellness visits. Charges for all visits will be charged to your designated insurance carrier/provider for services rendered. The $50.00 pre-payment will be applied to the account and any remaining balances, as determined by the insurance carrier will be billed to the responsible party on the account.

Patients who do not have insurance or utilize a health sharing service with a self- pay model, are considered “self-pay”. All charges are to be paid for on the visit date. A prompt payment discount may be applied.

Please cancel or reschedule scheduled appointments at least 24-hours prior to the appointment. Failure to cancel or reschedule an appointment at least 24-hours prior to scheduled appointment will be recorded as a “no-show”. Please note, after 3 no-shows, the patient may be dismissed from Trifecta Pediatrics & Primary Care.

Many insurance companies are now paying for phone calls resulting in many practices charging for every after-hour call. We do not currently charge for routine after-hours calls. Rather, we utilize an annual administrative practice fee (see below) to offset these costs. However, we do reserve the right to bill your insurance for “consultative” or “complex” type calls requiring extensive time and charting. If your insurance does not pay, you will be responsible for the charges.

To help offset costs to the practice primarily due to administrative procedures such as filling out school or FMLA forms, after-hours calls, and denied insurance claims, Trifecta Pediatrics & Primary Care bills $ 36 per patient at the first appointment of the year for 2 or fewer patients per family or $100 per family each year for 3 or more patients. This fee is eligible for a financial hardship discount. This fee eliminates the need to charge for routine after-hours calls and filling out forms that many other practices now charge.

Trifecta Pediatrics & Primary Care uses a sliding-fee-scale to determine Annual Administrative Practice Fee discounts based on your family or individual’s income and family size:

Federal Poverty Guidelines (FPG)

≤ 175% & Medicaid -> Group A = 100% Discount

≤ 176% to 250% -> Group B = 50% Discount

≤ 251% to 300% -> Group C = 25% Discount

> 300% -> Group D = 0% Discount

Eligibility for the financial hardship discount is continuously assessed and determined for all patients, even those who have health insurance. However, you must show proof of income to be eligible for Groups A, B, or C. The following items are proof of income that Trifecta Medical Group can accept. Choose one of these items to bring in prior to your child(ren)’s first appointment of each year to obtain the discount.

• Current pay stubs for the most recent one month of work of everyone working in your household.

• 4 pay stubs if paid weekly, or 2 pay stubs if paid every other week. This can include unemployment pay-stubs.

• Letter from an organization that helps you, like a Church, stating your situation related to your income. Letters must be on letterhead, signed, with the name and telephone number of the person writing the letter.

• Letter from your employer that provides your income amount. Letters can be on letterhead or handwritten, they must be signed, with the name and telephone number of the person writing the letter. The letter must include your pay rate and the number of hours worked each week.

• Letter for Social Security, SSI, Disability, Unemployment, Food Stamps or other public assistance that shows your income. Only 1 letter is needed.

• Most recent income tax filed or W2 from your employer.

• Medicaid Card

  If you do not bring in proof of income, you are automatically assigned to Group D. You may update your proof of income at any time, however, discounts are not retroactive.

Trifecta Pediatrics provides patients and families an opportunity to reduce their out-of-pocket costs through a Prompt Payment Discount.

For those patients who do not have insurance or who utilize health sharing services with a self-pay model, Trifecta Medical Group offers a discount on the total medical charge (does not include the Annual Administrative Practice fee, if applicable), if full payment is made the day of service. This discount is 40%.

We aim to be transparent with our pricing. You will find a list of many of our services and fees on our website (this list is not comprehensive). If you would like an estimate for a future appointment, please call our office at least 3 business days prior to the scheduled appointment. However, please note some diagnoses may not be covered by insurance companies like obesity, dental caries, and behavioral issues. Furthermore, your insurance may withhold a co-payments for various reasons.

Our providers’ charges may not be covered 100% by your insurance. Our providers will do their best to explain their plan of treatment before services are rendered but they cannot tell you whether your insurance will cover all of their services. Unfortunately, it’s not until the service is processed by your insurance that patient financial responsibility may result. It’s best that you contact your health insurance carrier for questions on covered services before scheduling appointments.

There is an additional $25 fee for appointments on late evenings, weekends and holidays that may or may not be covered by your insurance.

Newborn babies need to be added to your insurance plan within 30 days of birth to ensure coverage. We understand that it takes time to get new additions added to the plan and receive an insurance card. We will collect applicable co-pays, co- insurance or deductible amounts without an insurance card for up to eight weeks after your baby is born. You should receive your card as confirmation of coverage prior to your baby’s two-month appointment. If you have not received this card within a week before the appointment, please call your insurance company and ask them to send the card immediately. If we do not have insurance information, your account will be treated as a self-pay account by our office and full amount will be collected at the visit. If our office is not contracted with your insurance we cannot file your insurance claims. Your account will be treated as a self pay account and you will receive a receipt with all pertinent information to submit to your insurance company for reimbursement. Self-pay accounts are required to pay in full at the time of service.

Cosmetic procedures such as ear piercing are NOT billed to your insurance company. These charges must be paid in full at the time of service and are NOT eligible for the Prompt Payment Discount.