For Patients with Insurance Coverage
A patient’s health insurance policy is a contract between the patient and their health insurance company. It is the patient’s responsibility to check that:
1. their existing health insurance plan lists LCR LLC as participating provider.
2. the LCR LLC office has received the patient’s accurate health insurance information.
3. he/she understands the terms of their own insurance coverage. This includes
but is not limited to knowing:
- if a referral is required prior to being seen by a sub-specialist
- what is the co-payment to be seen by a specialist
- what is the deductible
- what is the co-insurance
- where services can be performed
- what services are covered
At LCR LLC, all co-pays and deductibles are due at time of treatment, along with a valid referral from the patient’s primary care provider, if the insurance plan requires it. Prior to any scheduled surgery deductibles and coinsurance will be collected in full. Any outstanding balances will be billed to the patient (guarantor) after we receive an explanation of benefits (EOB) from the health insurance detailing the patient’s financial responsibility under their insurance agreement. Any billing directed to the patient will always be in accordance with the contractual agreement between the health insurance company and the provider.
Outstanding balances older than 90 days, that are determined to be the patient’s responsibility will be sent to a collections agency. If the patient requires treatment(s) that is/(are) not thought medically necessary by their health insurance, or is not a covered service with their insurance carrier, patients (or their guarantors) are responsible for payment. In the event that the patient’s insurance coverage changes to a plan where we are not participating providers, LCR LLC services will become the patient’s out-of-pocket responsibility.
What prior authorizations means?
Some insurance plans require prior authorization for certain services. Which services require authorizations vary according to an individual’s insurance policy. Even when pre-certification / predetermination authorizations are granted to perform a service, like surgery, the insurance companies assert that this does not guarantee payment to LCR LLC. It means that the insurance company finds the service medically necessary but it does not mean that it is covered by the patient’s individual policy. If, after LCR LLC care was rendered, the patient’s policy does not cover a specific service, even though it was pre-authorized, insurance payment to LCR LLC can be denied. This unfortunately makes the service the out-of-pocket responsibility of the patient.
Out of Network Insurance Plans
Patients are responsible for payment of their first office visit in full. We may consider to accept assignment of insurance benefits after the second LCR LLC visit if the terms are acceptable to us, otherwise the fees will be an out-of-pocket expense to the patient. Should LCR LLC accept assignment from the patient’s insurance company, the patient will be responsible for payment if the insurance carrier authorizes and certifies care but fails to pay as agreed upon. As a courtesy to our patients, LCR LLC will send a bill to that insurance carrier on the patient’s behalf.
Payment is expected at the time of service unless other financial arrangements have been made prior to the patient’s visit. Failure to adhere to practice policy will result in the account being sent to a collection agency. LCR LLC provides financial assistance on a sliding scale to patients who do not have insurance at family income levels up to four times the Federal Poverty Guidelines and to all patients if there are exceptional circumstances.
Eligibility for LCR LLC Financial Assistance /Charity Care:
1. Patient must be a resident of Puerto Rico.
2. Patient’s income is at or below 400% of the Federal Income Poverty Guidelines.
3. Patient must provide proof of income (income includes gross wages, rental income,
gross income from self employment, public assistance, social security, unemployment
compensation, strike benefits, alimony, child support, military family allotments,
pensions, veteran’s benefits, etc.)
4. LCR LLC determines that it is the only subspecialist trained service to manage your medical condition or that it is the most capable to offer advance care for you.
The Surgery Coordinator will request a pre-surgical deposit, the amount of which depends on the patient’s coverage and deductible amount. Typically we require 100% of any outstanding deductible prior to surgery. This payment is due no later than 3 days prior to surgery otherwise the patient’s surgery may be postponed or cancelled. The reason for this requirement is than in most occasions the physician needs to buy up-front different surgical appliances or medical implants. In circumstances of well documented financial hardship a payment plan can be instituted.
Endoscopic sinus surgery which is commonly performed by LCR LLC, does not have a post operative period as defined by Medicare and as such all services after the procedure are billed separately. Post-op visits typically have a charge for endoscopic nasal debridement (CPT code 31237) commonly for at least 2 visits.
Appointment Cancellation Fees / No Show Policy Fees
We understand that occasionally a patient may run into a situation where they can not make their appointment. We ask that the patient call to cancel their appointment at least 24 hours in advance, which allows us the ability to use that time for another patient. If authorization is required by the patient’s health insurance plan and is not provided, the patient will be asked to either reschedule their appointment or pay for their visit at the time of service.
Missed New Patient Appointments: Any new patient who fails to keep an appointment or who cancels or reschedules an appointment less than 24 hours prior to their appointment will be required to pay a fee of $50.00 in order to schedule a new office visit. For Monday appointments, cancellations must be made by noon on the preceding Friday.
Missed Follow-up Appointments: Any patient who fails to keep a follow-up appointment will be required to pay a fee of $25.00 in order to schedule a followup office visit. If there are three missed appointments, the patient may lose their ability to schedule future appointments with us.
We will do our best to give the patient a Reminder Call &/or EMAIL reminder 24 hours in advance of their scheduled appointment. Failure form our part to reach you will not exonerate the patient from a missed appointment fee. All fees are payable on or before the next office visit with the LCR LLC physician or within 30 days of receipt of a billing statement from our practice for that fee, whichever is earlier. This cancellation fee is not covered by insurance. The LCR LLC physician may waive the “no-show” fee for good cause shown.
Notice of Balance on Account
In an effort to reduce the use of paper we will notify patients of their balance due at time of service. It gives patients the opportunity to pay on the account while they are in the office. If a patient’s financial responsibility (balance) remains unpaid after 90 days, the account will be referred to a collection agency. Unfortunately, patients may be dismissed from the practice if they fail to meet their financial responsibilities. If a patient is having financial difficulty, communication is encourage as a payment plan option exists. We continue our unwavering commitment to providing each patient with the best possible care regardless of your ability to pay.
Payment & Collections
Patients may make payment to:
LA CLÍNICA DE RINOSINUSTIS LLC