Thank you for choosing us for your medical care. Our goal is to provide you with the highest quality medical care at affordable cost. To make our services available to as many patients as possible on an affordable basis, we have adopted the financial collection policy outlined below. We ask you to read the policy carefully and sign prior to any treatment.
- WE MAY ACCEPT ANY ASSIGNABLE INSURANCE WITH APPLICABLE COVERAGE.
- WE OFFER FINANCIAL ASSISTANCE (DISCOUNT, WAIVER OR REDUCTION OF DEDUCTIBLES, CO-PAYS AND CO-INSURANCE) UNDER OUR INDIGENCY POLICY TO ALL ELIGIBLE PATIENTS ON CASE-BY-CASE BASIS.
- FULL PAYMENT IS DUE AT TIME OF SERVICE UNLESS ARRANGED OTHERWISE.
- WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD, AND AMERICAN EXPRESS CARD.
- WE OFFER AN EXTENDED PAYMENT PLAN WITH PRIOR CREDIT APPROVAL.
Dishonored checks will be charged back to the patient’s account with a service fee of $25.00. Dishonored checks not redeemed within 20 working days of written notice to the maker will be referred to the prosecutor for collection.
We may accept assignment of insurance benefits at our discretion if acceptable insurance identification is provided. Acceptable insurance identification is defined as a valid insurance card, policy/plan with applicable coverage, or telephone verification. As a courtesy to our patients, verifiable and assignable insurance will be billed by this surgeon's office. However, you will be personally responsible for your account balance regardless whether or not if your insurance will pay for the total balance of your claims, unless you're eligible for discounts under our indigence policy predetermined before the services are rendered. Your insurance policy/employee benefits plan is a contract between you and your insurance company/employee benefits plan. We are not a party to that contract. In the event we do not accept assignment of benefits we require that you be pre-approved on our extended payment plan by providing a credit card or personal checking account with authorization to charge that amount for the balance due, if your insurance company/employee benefits plan has not paid your account in full within 45 days or has determined your claims to be your responsibility for the reasons of annual deductible, co-payment, non-covered services and not medically necessary
We incorporate by reference the document entitled Consent/Disclosure Form that details the Legal Assignment of Benefits and Designation of Authorized Representative. This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims. Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare and applicable federal or state laws. A photocopy of this assignment is to be considered as valid as the original.
If a patient chooses or is required to bill his/her own insurance, this office will provide an itemized statement and a HCFA-1500 Form to the patient, but will treat the account as a self-pay.
We may offer discounts, reduction or waiver of deductibles, co-insurance and co-pay to any eligible patients based on medical needs and ability to pay on a case-by-case basis under our Corporate Indigency Policy in accordance with applicable federal and state laws. You may apply for medical in digency discount assistance by asking our practice manager to determine if you are eligible.
Regarding Surgeon and Facility Charges
We will disclose to every patient our surgeon charges as clearly as practically possible before your medical or surgical procedures if it is known to us. Please feel free to ask our staff if you have any questions about charges and your payment responsibilities.
As you may be aware, your insurance company requires your doctors and surgeons to charge and bill the services separately from surgical facilities or hospitals. You shall not be surprised that you will receive separate surgeon, anesthesiologist, diagnostic labs, radiologists, pathologists, and others in addition to the surgical facility bills for your surgery. If you have any questions about your surgical facility bills, please direct your questions to that surgical center.
While we don’t anticipate any unforeseeable circumstances, we have no control over any such event(s) that may arise. Should you require additional medical or surgical care in any event of the post surgical complications and reactions, you may incur additional expenses at this facility or outside this facility, such as a hospital
The charges only include the stated date of services at this facility and do not include any other date of services from us or other providers and facilities.
Regarding PPO and HMO Network Participation
As you may know, you may have choice to choose a surgeon or surgical facilities with or without PPO or HMO participation under different insurance coverage and benefits levels. We are dedicated to providing highest quality care to every patient; however, we have no power to change your insurance coverage or network limitations. Most health care plan or insurance policies may provide surgical coverage to non-PPO providers and facilities, but at lower percentage of insurance reimbursement. Although it is your responsibility to verify your insurance coverage for non-PPO/HMO providers, we will always disclose to you as to our participation status to your insurance plan. We also provide every patient with information regarding financial assistance or discounts with high deductible plans or coinsurance per our Corporate Indigency Policy in accordance with federal and state laws.
We will verify your insurance coverage and obtain pre-certification, if applicable, for all services as a courtesy to you before your medical services. Please understand that all insurance verification is not a guarantee of insurance payment.
Compliance & Disclosure under Texas Occupation Code - Section 102.006
In compliance with Section 102.006 of Texas Occupations Code in connection with my informed consent and personal choice of doctors and facility solely based on the quality and safety of care, reputation of patient satisfaction, and my knowledge in my decision-making in exercising my rights with respect to the in-network or out-of-network coverage and cost sharing, my attending doctor(s) and/or clinic (facility) have disclosed to me at the time of initial contact and at the time of referral with respect to the choice of a doctor or facility solely in the interest of my healthcare quality and safety, as a result of my informed consent and personal choice of doctor(s) and/or facility: (A) his/her affiliation, if any, with the doctor or facility for whom the patient is referred and (B) that he/she will receive, directly or indirectly, remuneration for referring upon my such request and exercising my rights of freedom of choice for the provider(s) and facility under the in-network or out-of-network coverage as provided by my health plan, in compliance with all applicable federal and state laws, Medicare, ERISA, PPACA and the Section 102.006 of Texas Occupations Code.
Town Park Surgery Center, Oprex, Altus HMS, Altus DME (Group Care), ASC Houston Management, Altus Houston Hospital, Altus Pharmacy (Altus Rx), Oak Pharmacy, Custom Rx, Altus Pharmacy Management, Clarus Imaging Center, Westside Surgical Hospital, and Zerenity Sleep Center are all entities owned by local area physicians. As such, Drs. Pasha and Matorin may have an affiliation and receive remuneration in these entities.
As an alternative to receiving your treatment at/by Town Park Surgery Center, Town Park Surgery Center, Oprex, Altus HMS, Altus DME (Group Care), ASC Houston Management, Altus Houston Hospital, Altus Pharmacy (Altus Rx), Oak Pharmacy, Custom Rx, Altus Pharmacy Management, Clarus Imaging Center, Westside Surgical Hospital, and Zerenity Sleep Center, you may choose another facility or health care service provider.
You have free choice to obtain medical services elsewhere and you will not be treated differently by your physician if you choose a health care facility or service provider other than those entities.
If you have any questions, you may contact Manny Gerardo at (281) 920-5558.
Your responsibility for Cooperation
If we accept your insurance assignment as a payment from your insurance reimbursement, you agree to timely cooperate with your insurance company or health plan in the course of insurance claim processing, such as insurance inquiries, requests for additional information, claims status verification or any inquiries for the purpose of your claim processing. You also agree to notify us immediately of any insurance inquiry or request for additional information and provide us with a copy of any documentation received from the insurance company or submitted to insurance company from you.
In an event that you do receive insurance payment checks for your surgeries rendered by this doctor, you agree to submit such insurance reimburse check to our office with five (5) business days after your receipt of insurance checks. In a failure or refusal to forward or send us the insurance reimbursement checks for the medical services from this provider, all of your discount arrangement will be voided, and the total balance is due immediately, as there is no justification for you to keep the insurance payment for our services as you promised to pay for our services. You further agree to compensate us for any legal fees if we have to retain any legal services to collect balances.
Indigency Policy and Agreement
As fully explained in our Corporate Indigency Policy, indigency discount is no different than all PPO discounts from BCBS or all other commercial insurers in compliance with all applicable federal and state laws with respect to indigency assistance without any routine waiver or cost sharing, advertising, or solicitation, for underinsured or uninsured patients. Once indigence is determined, collection is no longer undertaken with regard to the patient for the forgiven amount without waiving any patient financial and legal obligation or responsibility to the provider’s actual total charges AND patient’s right and eligibility, assigned to the provider, to claim for the reimbursement, under the health plan coverage, based on the provider’s actual total and reasonable charges in accordance with Provider’s Corporate Indigency Policy, as the Indigence determination itself is a good effort to collect, and hospitals or doctors are NOT required under any federal or state laws, Medicare, ERISA & PPACA, to take low-income, medically indigent, uninsured or underinsured patients to court, garnish their wages, or seize their homes, or send claims out to a collection agency when those patients don’t or can’t pay their hospital or doctor bills.
It would be possible to receive a discount based on being medically indigent, if you declare that without following indigent assistance, seeking for and continuing with medically appropriate and important health care would be impossible for you to or make you indigent if you were forced to pay full charges for your medically necessary care expenses. You would be required to request for such indigent assistance only after you are fully informed of the important medical treatment options and necessity solely based on your particular medical needs and availability of this provider's Indigency policy.
"Nothing in the Centers for Medicare & Medicaid Services" (CMS') regulations, Provider Reimbursement Manual, or Program Instructions prohibit a healthcare provider from waiving collection of charges to any patients, Medicare or non-Medicare, including income, uninsured or medically indigent individuals, if it is done as part of the healthcare provider's Indigency policy."
"By "Indigency policy" we mean a policy developed and utilized by a healthcare provider to determine patient’s financial ability to pay for services. By "medically indigent," we mean patients whose health insurance coverage, if any, does not provide full coverage for all of their medical expenses, relationship to their income, would make them indigent if they were forced to pay in full charges for their medical expenses."
We are committed to serving you with the highest quality care possible at affordable cost. Every staff member at our office is ready to help you at all times.
If you have any questions regarding our financial policies, please do not hesitate to ask us at any time. We thank you for your cooperation.
I have read the Financial Policy. I understand and fully agree to this Financial Policy.