Welcome and thank you for choosing Mann Ear Nose and Throat Clinic for your medical care. We are committed to providing you with the highest quality medical care possible in a cost effective manner. Our professional fees have been determined through careful consideration in addition to being reasonable and customary within our geographical area. We are pleased to discuss with you any questions you may have concerning a bill.
We are networked with most insurance companies and all copays are due at time of visit. As a courtesy to our patients, we accept cash, personal check, money order, Visa, MasterCard, Discover, and American Express.
We also provide our patients the ability to pay for their accounts over the phone at:
919-859-4744; Ext 26.
In order to achieve our goal of providing you with the best care possible, we need your assistance and your understanding of our financial policy:
Our Office Hours are:
Cary Office
Mon-Fri: 8:30-5:30
(Closed Mon/Tues/Thu/Fri 12:30-1:30 & Closed Wednesday 12-2)
Clayton Office
Monday: 2pm - 4pm
Tuesday: 9:40am -11:10am & 1:40pm - 3:10pm
(First Wednesday of each month: 9:40am -11:10am)
Thursday: 2pm - 4pm | Friday: 1pm - 3pm
Answering service for after hour emergencies is available.
Items to bring with you to EACH appointment:
Health Insurance Card
Drivers License
Method of Payment
Appointments:
Please arrive for your appointment 10 minutes early.
If more than 20 minutes late for your appointment, there is a possibility you will be marked as a No Show and will need to reschedule your appointment at another time.
It is your responsibility to verify that the physician is currently under contract with your insurance plan and that you have obtained all necessary referrals BEFORE your scheduled appointment. (Failure to confirm this will result in your responsibility for any and all charges.)
Please inform the receptionist of any demographic changes (phone number, address, insurance information, etc.). Failure to notify us immediately of changes in demographic information, financial status and/or insurance coverage will result in you being responsible for any services not covered by your insurance carrier.
Missed or Cancelled Appointments and other fees:
There will be a charge for appointments cancelled with less then 48 hour notice and for ALL No Show appointments. Our No Show fees are as follows.
New Patient and Follow Up: $50.00
CT Scan: $50.00
Procedure: $75.00
Surgery: $100.00
(cancelling surgery requires a 72 hour notice for cancellation)
If one must reschedule surgery within 72 hours, there will be a $50 rescheduling fee.
There will be a fee of $30 for any returned checks to our office.
All balances are due prior to any further service provided by our office unless other arrangements have been made.
“In Network” vs. “Out Of Network” Insurance
Your insurance coverage and benefits are a contract between you and your insurance company and, therefore all disputes must be handled between you and your insurance company.
We are contracted with multiple insurers to accept assignment of benefits.
If you have insurance coverage under a plan with which we do not have a contract, you will be treated as a “self pay” patient and will be provided documentation to assist you in filing your own claim.
We are required to file with your primary insurance carrier only. As courtesy to our patients we file your secondary insurance, unless otherwise stated on your insurance card.
I understand my signature requests that payment be made to Mann Ear Nose and Throat Clinic and authorizes release of medical information necessary to pay the claim. If item 9 of the CMS 1500 claim form is completed, my signature authorizes release of the information to the insurer or agency shown. In Medicare assigned cases, Mann ENT agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charged determination of the Insurance carrier.
Payment in full is due at the time services are rendered:
Co-Pays and Co-Insurance amounts, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due during the check-in process. Failure to produce payment at check-in will result in your appointment being rescheduled. There will be a fee of $15 if unable to pay your copay at time of service, which will be added to your account.
If you receive more than one type of service on the same day, you may be responsible for more than one co-pay.
Any amount not covered by the insured/patient’s insurance is due within 30 days of the time of service and prior to any further services being rendered. 07/01/2010
As a courtesy to our patients, we gladly accept cash, check, money order, Visa, or Master Card.
Failure to pay balance will result in your account being sent to a collection agency.
“Self Pay” Patients
We offer a reasonable discount for our self paying patients. We will give you an estimate of what will be due at the time of service and payment in full for services is due at check out. Please feel free to ask our front desk for a copy of our office policy.
Payment in full is due at the time the services are rendered.
Medicare/Medicaid/TriCare Prime/Aetna HMO Patients
Please make sure you have a full understanding of your benefits and what might be your responsibility if not covered by your insurance plan.
Medicare requires that we provide patients with a written notification whenever it is likely that you will be responsible for a bill.
Medicaid/Carolina Access and Aetna HMO patients are required to have a referral from their primary care physician at time of visit.
TriCare Prime patients require authorization from TriCare, which is generated by your primary care physician prior to appointment.
Minor Patients:
The parent(s) or guardian(s) accompanying a minor are responsible for providing current insurance information for the minor as well as any out of pocket expense, i.e., copay, deductable or outstanding balance.
Parent(s) or guardian(s) must have an Authorization for Medical Treatment form signed for a minor being unaccompanied for an appointment.
In compliance with HIPAA regulations, we are unable to discuss any details of services rendered or to produce an itemized bill for any parties that are not the patient, unless otherwise documented.
Additional Paperwork:
Any paperwork needed to be filled out by the physician will result in a fee; (i.e., disability forms, life insurance, etc.)
A minimum of 72 business hours is required for all paperwork.
Auto Accidents/Workers’ Compensation:
Our office will send appropriate workers’ compensation claim forms for services rendered on your behalf as a courtesy to you. If and when a claim is denied, we will expect full payment from you within 30 days of receipt of our bill (a good faith deposit of 25% is required for a longer term of repayment).
It is the patient’s responsibility to bring all forms required by the insurance company and proof of coverage. 07/01/2010
Lab/Hospital Charges:
Any service(s) provided by a lab, hospital or any other ancillary provider is a contract between you and that provider. Any dispute with that provider should be handled with them and can not be the responsibility of our practice.
It is your responsibility to know which procedures your insurance will and will not cover at these facilities and to request an Explanation of Benefits (EOB) from your insurance carrier.
Collections and Outstanding Balances:
If you neglect to pay your outstanding balance your account will be turned over to a collection agency. A $15 fee will also apply to any delinquent account turned over to the collection agency.
Our office will be happy to work with you in order to pay any balance due to our practice.
Please allow 5 mailing days prior to each due date for each payment to be received by our practice.
Please mail all payments to our office or call Morgan at ext 26:
601 Keisler Drive; Suite 200, Cary, NC 27518 919-859-4744
PLEASE NOTE! YOU WILL BE RESPONSIBLE FOR ANY CHARGES CONSIDERED “NON-COVERED” BY YOUR INSURANCE, IN ADDITION TO YOUR CO-PAYS, DEDUCTIBLES OR PERCENTAGE, STATED IN YOUR INSURANCE CONTRACT.
Refunds:
Refunds are issued to the appropriate party.
Patient refunds will not be processed until all active or past due charges are paid in full.
Medical Records:
All requests for medical records must be in writing.
We ask that you allow 7-10 business days to process your request.
Records will be faxed to your physicians as a courtesy with no charge.
There is a fee for any legal statements generated.
Medical records are available for personal use, but incur a $10.00 charge for the first 13 pages and $.75 per additional page.
(jb:07/01/2010)
Thank you for reading our financial policies. For any questions, please call the office at 919.859.4744. If you would like to register online for your previously reserved appointment, please continue to
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