Financial Policy

Your medical insurance plan is a contract between you and the insurance carrier. MVSA is not a party to that contract. Your coverage and benefits, requirements for co-payments, deductible and co-insurance are all defined in your policy. As a courtesy, MVSA strives to verify insurance benefits and coverage before your new patient appointment. If an issue with coordination of benefits were to arise, it is the responsibility of the policy holder/subscriber to supply MVSA a coordination of benefits obtained from each insurance party. If we find that MVSA is out of network, we will contact you before your scheduled appointment. MVSA will make every effort to ensure that our providers are in network with your insurance carrier, however, it is the patient’s responsibility to confirm our providers are in network with your plan. If you choose to bill your own insurance or MVSA is out of network, payment in full is due at the time of service.

You are responsible for supplying accurate and complete insurance information to the practice. Including but not limited to:

• Current insurance card: primary, secondary and tertiary (if applicable)
• Government issued identification
• If required, referral from your primary care physician or referring provider.

Referral Policy:
Some insurance plans require you to obtain a referral from your Primary Care Physician. Without an insurance required referral, the insurance company will deny payment for services. If you are unable to obtain a referral prior to being seen in our office, you will be rescheduled or asked to pay for the visit in advance.

We will be happy to assist you with good faith estimate for professional services rendered by MVSA. You may receive bills from entities separate from MVSA who provide services to or for you, including but not limited to facility charges (for example, hospital or ambulatory surgery center), anesthesiologist, radiologist, pathology, outside surgical assistants and/or lab services. MVSA encourages patients to confirm their benefits with their insurance carrier before rendering a service. In the event you need surgery, a pre-surgical deposit may be required.

All co-payments, deductibles, co-insurance and fees for non-covered services are due at the time of service. Payment arrangements can be made in advance of your appointment by request. If you arrive without proper payment, we may ask you to reschedule. MVSA cannot waive any copays, deductibles or co-insurance amounts defined as a patient responsibility under the terms of OUR contract with your insurance carrier.

You are responsible for all charges rendered in our office or hospital setting. As a courtesy, MVSA will bill your health insurance carrier directly for medical services rendered to you. As determined by an explanation of benefits (EOB) provided by your insurance carrier, any remaining patient portion; copay, deductible and/or co-insurance, will be transferred to patient responsibility and a statement will be generated. Payment arrangements on any patient liability must be addressed within 120 days of your first statement and can be subject to collections. If an account is delinquent, written-off to bad debt, or in collections status, the outstanding balance must be paid in full before an appointment is scheduled with MVSA.

Note regarding patients under the age of 18:

The parent or guardian who brings the child to the office for care is responsible for payment at the time of service no matter if the account is self-pay, participating insurance, or nonparticipating insurance. The practice does not honor divorce specifics (e.g., percentage of financial responsibility), and will not bill a divorced spouse for the patient’s services. If the child has coverage with a participating insurance plan and the proper insurance identification is present at the time of service, the practice will bill that insurance company. Applicable co-payments, coinsurance and/or deductibles are due at the time of service, unless arrangements have been made with the office prior to arrival.

The practice understands personal circumstances make it necessary for you to cancel or reschedule your appointment. We request at least 48-hour advance notice be given to the office if you are unable to keep your scheduled appointment. This allows us to release your appointment time to another patient. We charge an administrative fee of $50.00 for “no shows” and appointments canceled without the required 48-hour notice. This fee will not be covered by your insurance and payment is the patient’s responsibility. Patients who repeatedly “no show” for appointments may be dismissed from the practice.

Late policy:

If you are greater than 15 minutes late to your scheduled appointment, you may be asked to reschedule.

A $35 fee is required for the completion and release of the following forms:

• Disability
• Life insurance
• Workman’s compensation
• Short Term Disability (STD)
• Family and Medical Leave Act (FMLA)
• Other as requested

For timely completion, please include payment along with the necessary forms to MVSA. A turnaround time of 10 business days is required for form completion. FMLA forms will be provided post-surgery.

Acceptable forms of payment are cash, check, Visa, MasterCard, Discover and American Express.

In the event MVSA has collected more than the determined patient responsibility, you can expect a prompt refund based on the form of original payment.

Self-Pay or uninsured are classified as:

• Patient does not have health insurance coverage.
• Patient is covered by an insurance plan that our providers do not participate in.
• Patient does not have a current, valid insurance referral on file, if required.
• Patient declines to provide proper identification.

Click Here for Self-pay prices of common services.

The full payment due will be collected at the time of check-in. For services outside of the face-to-face encounter with the provider, an estimate will be discussed prior to receiving additional services. Payment plans are not offered for self-pay rates.

Your surgeon may require a surgical assistant on many cases, even if your insurance company does not recognize this as medically necessary. As part of the healthcare team, surgical assistants are specialized professionals with advanced education and are privileged to operate under the supervision and direction of your surgeon.

If you are seeking financial assistance, please refer to the U.S. Federal Poverty Guidelines to learn about specific qualification requirements.