Houston IVF. Timothy N. Hickman, M.D. Medical Director. Laurie J. McKenzie, M.D. Director of Oncofertility

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1 Houston IVF Leaders in Fertility Research and Care 929 Gessner Suite 2300 Houston Texas Fannin Suite 901 Smith Tower Houston Texas Fax: Timothy N. Hickman, M.D. Medical Director Laurie J. McKenzie, M.D. Director of Oncofertility Katherine K. McKnight, M.D. Reproductive Endocrinology and Infertility Patient Financial and Insurance Guidelines and Policies To help you understand Houston IVF s financial guidelines and to anticipate any difficulties with insurance benefits you may encounter, please review this document. Houston IVF provides the medical, clinical and in vitro fertilization (IVF) laboratory services you will need for your fertility care. Insurance coverage for infertility is not as straightforward as in other medical areas. For example: Many times there is coverage for testing to determine why you are infertile, but no coverage for its treatment. Many times payment depends on why the service was performed. For instance, if we do an ultrasound of your ovaries to ensure that an ovarian cyst is shrinking, it will be paid, but if we do the ultrasound to track your response to fertility medications, it will often not be paid. Many times the information we get from your insurer over the phone is incorrect or incomplete. Insurance coverage for special procedures is determined by the employer. You may know someone who had the same insurance as you and is covered for infertility services. However, if your employer or insurer did not include infertility benefits in their insurance package, you may not be covered for infertility. Some insurers will exclude any and all expenses if the diagnosis is infertility. This may mean that initial visit or lab tests would be your responsibility to pay. To best serve you and meet Houston IVF s need for timely payment of patient accounts, we have developed the following guidelines: Determination of Insurance Benefits Currently, we participate in several insurance networks. When you become a patient at Houston IVF, we will contact your insurance to obtain information regarding the coverage you have for infertility care. We will pass this information along to you. If you think you have different coverage, or a different level of benefits, please notify us, so we may clarify the information. We suggest that you also call your insurance company directly for clarification. Unfortunately, this verification of benefits does not oblige insurers to pay. Insurance companies protect themselves by stating that verification of your insurance coverage by them is: Not a guarantee of payment, and is Not a guarantee of what is actually covered and not covered Because of this disclaimer, even when they have told you or us that a service is covered, there is no obligation for them to pay. Thus, we do require the insurance company to put any in vitro fertilization benefits in writing. The true determination as to whether a service is covered is made at the time the claim is received by the insurance company. Whether insurance will pay is dependent upon whether: The service you received is covered by your plan The reason for the service (the diagnosis) is covered by your plan The appropriate deductibles and co-pays have been met Further complicating payment is that some plans require that: You have experienced infertility for a specified amount of time before services will be covered, or The infertility is not related to prior elective sterilization, or

2 Patient Financial and Insurance Guidelines and Policies Page 2 Certain treatment steps be taken before other treatment steps will be covered. This may not always be consistent with the course of treatment that Houston IVF physicians think is best for you. For instance, some companies will pay for IVF treatment, but only after three tries of gonadotropin cycles have failed. Claims Filing and Other Payment Information For Insurance Companies/Networks With Which We Are Contracted We will file a claim for services provided that the following are verified: The insurance company and your particular plan covers the services provided. We participate in your insurance network We are unaware of any other restrictions on covered services. If you have insurance with an insurer with which we participate, but your plan does not provide benefits for your diagnosis or for the procedures/services provided, then full payment is required at each visit. We expect all balances to be settled on the day services occurs. A co-payment is a set dollar amount that the insurance company designates as your responsibility. Some insurances require percentage co-insurance based on the total charges for each date of service. Co-payment and co-insurance payments are due and will be collected at the time the services are provided. IF YOU DO NOT WISH TO HAVE ANY SERVICES FILED WITH YOUR INSURANCE COMPANY, PLEASE NOTIFY A HOUSTON IVF PATIENT FINANCE CONSULTANT IMMEDIATELY AT For Insurance Companies/Networks With Which We Are Not Contracted If we are not contracted with your health insurance company, then full payment for all services provided is required at the time of your visit. We will provide you with a statement that can be submitted to your insurance company for reimbursement directly to you. Since we do not have a contract with your insurance company, they will not pay Houston IVF. They will send your payment to you. Referrals It is your responsibility to notify your primary care provider that you have scheduled services with our offices. You may have been referred to us by a provider other than your primary care physician. It still may be necessary for your primary care physician to know you are being seen in our office as they are often the only one who can obtain a referral from the insurance carrier. You will be responsible for any services denied by your insurance company due to not having the required referral. Other Items Infertility treatment can be expensive, and we do not want to let you get over extended. Thus, we collect in full for each service as it is provided. We strive to anticipate how much each service will cost you for each (by calculating your portion of charges after insurance is applied), and expect that costs be paid at that visit. Sometimes, however, this is not possible. In some cases the actual charge can only be estimate. In other cases, we discover payment owed after a visit has occurred.

3 Patient Financial and Insurance Guidelines and Policies Page 3 These situations are described below, along with the way we handle them: Surgery If you are having surgery, we will calculate an estimate of the charges you would be responsible to pay based on your insurance network status and on the information the insurance company provides to us. Any patient-responsiblity payment is required prior to the surgery. We will also file the claim with your insurance company. If you are in network, you are responsible for any patient balance after insurance adjustments have been taken. If you are out of network, you will need to pre-pay for services provided, and we will give you claim forms to bill your insurance. Houston IVF does have a pre-payment, discounted surgery package price for surgeries provided in our center. Additional Services Provided Occasionally, when the doctors review results, they determine that additional testing is needed to make a complete evaluation. When this occurs, the charges for the additional test will be posted to your account at the time the test is ordered. Occasionally, our audits detect that services were incorrectly posted to your account, resulting in overcharges or undercharges. When we identify such errors, we will correct your account, resulting in a credit or a balance due. Settling of Balances As discussed above, there are times when insurance companies process a claim in a manner different than expected. In these cases, A claim may be completely denied as not covered, with no payment being made, thereby making you entirely responsible for the charge, or A claim may pay differently than was anticipated, also thereby making you responsible for a larger portion of the charge than expected. When this occurs, we will first try to understand the reason for the discrepancy. Typically an insurance company will send an EOB ( Explanation of Benefits ) that outlines what they paid and didn t pay and why. If we believe there are errors in the claim, we will resubmit it. If you receive an EOB that processed your claim differently than you expected, please call your insurance company to clarify. If the insurance company states that they processed the claim incorrectly, please obtain the name of the person you spoke with, and call us with that information so we can note this in your account. If your insurance company reprocesses the claim and you receive the corrected EOB showing payment was made to us, please call us to issue a refund to you. If, however, there are no errors, we will make the corresponding adjustments to your account, determine the portion of the charge you are responsible for and post this portion to your account. Credit Card Authorization As you may now understand, there are instances of charges being generated or recognized on days when there is no office visit scheduled. With the busy lives of our patients and the number of patients seeking care, it is difficult to reach patients to come in and pay balances as they arise. Therefore, it is our office s policy to require a credit card authorization be maintained on file so that your balances can be paid as they occur. Many of our patients prefer this strategy for convenience. We will call you before making any charge in excess of $500. We will call you before making any charge for a service provided more than 6 months ago. We will mail you a copy of your credit card receipt and your statement on the day the charge is made. A credit card authorization is attached that needs to be signed and returned to Houston IVF.

4 Patient Financial and Insurance Guidelines and Policies Page 4 Insurance Company Look Back Period Insurance companies often perform audits of paid claims. These audits can be performed up to two years after payment of the claim. If the insurance company determines a claim was paid in error when there was no benefit, they will contact Houston IVF for a refund. If this should occur we will contact you for immediate payment of these services. If Houston IVF is aware of a claim that appears to be paid in error, we will contact the insurance company before accepting the payment to verify there was a benefit. This often prevents a take back of the payment two years later. Interest on Unpaid Balances Should you have an outstanding balance on our account that is greater than 30 days old, we will assess simple interest on the unpaid balance at the rate of 1.5% per month. This represents an annual interest rate of 18%. Administrative Billing Fee When your co-pay, co-insurance or patient responsibility balance for that day s visit is not paid at the time of the service delivery, we will charge your credit card on file. If you do not have a valid, nonexpired credit card on file, we will assess a $25.00 administrative billing fee and subsequently bill you for the unpaid amount. Collection Agency Any patient balance which is more than 90 days old is reviewed for possible submission to a contracted Collection Agency. If your unpaid account is sent to a Collection Agency you will be assessed additional fees and interest per Collection Agency policies in compliance with your State s collection regulations. Patient Financial Consultants Houston IVF understands that infertility is often unexpected and difficult for patients. In addition, managing insurance benefits can be time consuming. We have Patient Financial Consultants who are trained to help you with insurance issues and payments. They can be reached at

5 Houston IVF Leaders in Fertility Research and Care 929 Gessner Suite 2300 Houston Texas Fannin Suite 901 Smith Tower Houston Texas Fax: Timothy N. Hickman, M.D. Medical Director Laurie J. McKenzie, M.D. Director of Oncofertility Katherine K. McKnight, M.D. Reproductive Endocrinology and Infertility Credit Card Authorization for Unpaid Services Houston IVF requires that all patients complete credit card authorization forms prior to initiating any treatment at Houston IVF. The forms allow Houston IVF to use your credit card on file for services/ testing which are $500 or less and are not pre-paid at the time the service/testing is provided. Information on why credit card authorization forms are required and what they will be used for is provided in detail in the attached information. In general the forms are required for: 1) Out-of-state patients and Texas patients having phone consults During treatment you may receive physician s orders from Houston IVF for blood work at a local clinic and have the results sent back to Houston IVF. Your credit card on file will be used for the cost of the lab work if it is not covered by your insurance. 2) Patients with infertility insurance coverage During treatment we will bill your insurance for covered services. Your credit card on file will be used for any deductible and other balance that the insurance companies determines as patient responsibility. 3) Patients with pregnancy insurance coverage Once you are pregnant we bill your insurance for early pregnancy ultrasounds and lab work at Houston IVF. Your credit card on file will be used for any deductible and other balance that the insurance companies determines as patient responsibility. 4) All patients actively seeking treatment. Physicians often determine additional testing may be helpful based on the initial test results. The test(s) may be added without the patient having to return to the office. Your credit card on file will be used for any additional testing. Please complete the attached credit card authorization form and return it with your new patient information. If we do not receive your form prior to your initial consult, you will be asked to complete them before any treatment begins.

6 Houston IVF Leaders in Fertility Research and Care 929 Gessner Suite 2300 Houston Texas Fannin Suite 901 Smith Tower Houston Texas Fax: Timothy N. Hickman, M.D. Medical Director Laurie J. McKenzie, M.D. Director of Oncofertility Katherine K. McKnight, M.D. Reproductive Endocrinology and Infertility Acknowledgement and Credit Card Authorization Our signatures below acknowledge that we have received and reviewed Houston IVF s information packet titled Patient Financial and Insurance Guidelines and Policies. We also acknowledge that we understand that Houston IVF has Patient Financial Consultants who can answer questions we may have about this information, and they can be reached by calling We also authorize Houston IVF to release to our insurance carrier(s) any medical or other information needed to process a claim for services provided while pursuing medical care at Houston IVF. We understand that we are financially responsible for all services received regardless of insurance payment or denial. We also understand that if we fail to obtain any required referral or authorization that we will be responsible for payment of all charges. This authorizes Houston IVF to charge the credit card listed below for any balances due on our account. We understand that we will always be advised via a printed Houston IVF statement of any charge made to our credit card via this authorization. We also acknowledge that Houston IVF will contact us by telephone if the amount to be charged exceeds $500 or if the date of service is greater than six months. Patient Name(s): Date Name printed on card: Credit Card type: MasterCard Visa AMEX Account number Expiration date: / Validation code (on back of card): Billing address for this credit card: Street address City/State Zip Cardholder s Signature Date Patient s Signature Date Complete this form and return it to Houston IVF