Summary of NYC-Metro Physician Services PC Financial Policies

D:\_projects\parker\PJI-22-011 PAYD form updates\Financial Policy.docx

3/28/2022 3:12:00 PM

Summary of NYC-Metro Physician Services PC

Financial Poli

Thank you for choosing NYC-Metro Physician Services PC for your medical care. We appreciate that you have

entrusted us with your health care and we are committed to providing you with the best patient care possible.

Because healthcare benefits and coverage options have become increasingly complex, we have developed this

financial policy to help you better understand your responsibilities as a patient. We will do our best to assist

you

with

understanding your proposed treatment and in answering questions related to submitting your insurance

claim for reimbursement.

Your health insurance policy is a contract between you and your health insurance company or your employer.

Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need

for referrals,

pre-certifications, pre-authorizations,

limits on outpatient charges, and any requirements for specific

physicians, labs and/or hospitals to use. You should be knowledgeable of any deductibles, copayments, and/or

coinsurance. This applies to all payors regardless of whether or not our physicians participate.

If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the

details about your benefits, out-of- pocket fees, and coverage limits.

As a courtesy, we will bill your insurance, however, you (or the financially responsible party) are responsible for

any amounts that insurance does not pay.

PLEASE KEEP THESE POLICIES FOR FUTURE

REFERENCE

Insurance Coverage

Please provide us with your current insurance plan information at the time of each visit and notify us of any

changes. We will request a copy of your insurance card to copy or scan and keep on file for our records.

Please be aware of and provide any required referrals or authorizations in advance of the appointment or

service.

If you do not provide these before care is provided, you will be responsible for the cost of the care. When in

doubt, contact your plan directly for clarification.

Our doctors belong to many insurance plans but participation differs by doctor. Please contact us by telephone to

discuss the plans that our physicians participate with. Before your appointment, please be sure your doctor is in-

network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the

costs of care. If you would like a cost estimate, we would be happy to provide one. We will also help you find out

if you have out-of-network benefits. Refer to our out-of-network policy below for more details.

Please let us know at any time if you do not want us to submit a claim to your plan.

Address Change

It is important that we have your correct address information on file. Please advise us anytime there is any

change to your address, telephone or other contact information.

Co-payments/Co-insurances/Deductibles

You are expected to pay your co-payment and any co-insurance and/or deductible amounts, if known, at the time

of service.

Other Bills

You may receive services at NYC-Metro Physician Services PC such as radiology testing, laboratory testing, or

other services. These doctors provide vital services and are involved in your care even though they may not be

present at the time and you may not see them face-to-face. There may be additional charges for these services.

In addition, you may receive in-patient or out-patient hospital care at NYC-Metro Physician Services PC. If so,

you will receive a hospital bill for those services. If you have questions, you may contact the billing office at

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3/28/2022 3:12:00 PM

(718) 289-2606.

Payments

Payment is due at the time services are provided or upon receipt of a statement from our billing office. We accept

payment in the form of check or credit card (American Express, MasterCard, Visa and Discover). Returned

checks are subject to a fee of $20.00. We do not accept traveler’s checks.

As a service to our clients, we provide a courtesy calls and text messages that may be placed using a

prerecorded message. By providing your cell phone number, you consent to receiving such calls at this number.

Non-Medical Fees

Additional fees may apply to the following:



Returned Checks



Copying of medical records



Completion of disability or other forms



Unusual Travel



Home visit convenience fee for patients who

are not homebound



Visits for certain injectables

Missed Appointments

Generally, NYC-Metro Physician Services PC requires a 24 hour (1 business day) cancellation notice for most

office visits. Please note that weekends and holidays are not considered business days. If you miss your

appointment, or do not cancel with the required notice, additional fees may apply:

 New Patient Visit $100  Follow-up Visit $50

Out-of Network Providers

If the doctor is not in your insurance plan, the following apply:

• Full payment is due at the time of service for routine visits.

• Payment expected on the date of service may be an estimate of your total charges.

• You will be quoted an estimated fee before services/procedures are performed.

• A deposit is required prior to the date of service.

• Even if you have out-of-network benefits, you are ultimately responsible for the full fee charged.

• Depending on your plan, payment may be sent to you. If you receive this payment, you must reimburse

NYC-Metro Physician Services PC immediately.

Non-Covered Services

Medicare Patients. Medicare may not cover some services your doctor recommends. You will be informed

ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide

whether you want to receive services, knowing you are responsible for payment. You must read the ABN

carefully.

Non-Medicare Patients. Any service not covered by your plan are your responsibility and must be paid in full at

the time of service or upon receiving a bill.

Refunds

All credit balances will automatically be applied to any open balance on your account, including any amounts

owed to other NYC-Metro Physician Services PC providers. A refund is issued (less any outstanding balances)

when an overpayment has been identified. If you feel a refund is due and you have not received one, please

contact our billing office at (718) 289-2606.

Failure to Pay

If you do not pay your bill, your account may be sent to an outside collection agency. If your account is sent to a

collection agency, you will need to contact them directly to settle your balances.

Policy and Fee Changes

These policies and fees are subject to change. We will do our best to keep you informed of any modifications.

We know medical care can become expensive. If you have concerns about your ability to pay, you can contact

us for help in managing your account. If you have questions about these policies, feel free to ask any of our

Managers for more details or call the billing office at the number listed on your billing statement.