PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015

Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015 For 40 years, Cardiovascular Specialists of Central Maryland has been committed to providing our patients with the best in consultative and diagnostic cardiac care. If you are a new patient to our practice, we look forward to establishing a beneficial relationship as your cardiac health care provider. If you are a current patient, we look forward to continuing our relationship. In order to continue this long history of comprehensive care for our patients, our practice, like all businesses, must collect payment for our services in order to remain financially viable. Unlike other businesses, however, medical practices typically receive payment from someone other than the individuals to whom they provide services (from our patients health insurance carriers), and frequently we may not receive payment until 30 days or more after those services are provided and obviously that s not quite how it happens when you go to the grocery store or to get your car repaired. In order to continue to provide our patients with the high standards of care and expertise they have come to expect, it is important that we work together to ensure accurate billing and timely payment for the services we provide. The financial policies on the following pages outline our mutual responsibilities in this process. We know this is a lot of information to read and absorb, but we want to make sure you are fully informed about what we need from you, and what you can expect from us, concerning the financial aspects of your care. As always, we are happy to answer any questions you may have, and will continue to work with you to navigate the increasingly complex maze of insurance plan rules and requirements in order to resolve your account balance timely and accurately. PATIENT DEMOGRAPHIC AND INSURANCE INFORMATION It is critical that we have correct demographic (personal) information about you and about your health insurance coverage in order for us to bill accurately for the services we provide to you. This information includes: Your complete name, address, and phone number; The name of your insurance company, the group and subscriber number or other identifying numbers; Your insurance company s claims filing address and telephone number; A COPY of your insurance card, which also shows important information about your plan; and The name, address and phone number of the physician (usually your PCP, or Primary Care Physician) who is referring you to our office. At each visit, we will verify your demographic information and scan a copy of your driver s license (or other valid photo ID) and, for patients with insurance, your current in force insurance card for your primary and (if applicable) secondary insurance. This is to ensure accurate billing information and to protect you by confirming that we are providing services to the correct individual. This is no different than when you check into a hotel and are asked for your credit card and photo ID, or when your bank asks for your photo ID at the teller window for those transactions. Please understand that our staff will ask for this information and these documents even if you PAGE 1 OF 6

have recently been seen in our office. If you do not provide us with the needed information in a timely manner, you may be responsible for payment for services rendered. CANCELLATIONS AND MISSED APPOINTMENTS While we understand that personal circumstances sometimes make it necessary for you to cancel your office visit or testing appointment, please notify us as soon as you know you will not be able to keep your appointment. Short notice cancellations and missed appointments or no shows prevent us from offering the appointment to other patients wishing to be seen, particularly for testing slots. Appointments not cancelled at least two business days in advance (for example, by Thursday for a Monday appointment, by Monday for a Wednesday appointment, etc.) are considered late cancellations. A frequent pattern of appointment cancellations and/or visit no shows makes it impossible for our providers to provide appropriate continuity of care, and may result in a patient s discharge from our care. PLEASE NOTE: For patients scheduled for nuclear stress tests, the radioisotope for your test is ordered in advance. Although at least two business days notice is requested, if you do not cancel your nuclear stress test appointment by 12:00 noon of the business day prior to the test (meaning 12:00 noon on Friday for a Monday test date, 12:00 noon on Monday for a Tuesday test date, etc.) you will be charged for the radioisotope dose. The radioisotope is ordered specifically for each patient, and the order cannot be cancelled after this deadline or used for another patient. The radioisotope can cost several hundred dollars, with the exact cost varying depending on the dose required by the particular patient. This cost is not covered by your insurance when you cancel or are a no show for your appointment. RELEASE OF MEDICAL INFORMATION Under Federal HIPAA regulations, we will release information from your medical record to your insurance carrier if required in order to process our claim for services we provided; to your primary care physician or other referring or treating physician(s) to provide continuity of care; and in certain other circumstances specifically permitted by HIPAA rules, without prior written authorization from you. If you wish to have us release information from your medical record to other individuals or organizations, you will need to sign an authorization specifying the information to be released and to whom it is to be released. There may be a charge for release of information in certain circumstances; for example, for life insurance applications or legal proceedings, among other circumstances. Through our Patient Portal at https://cscmcolumbia.gemmsportal.com/, you may view and download certain documents from your own medical record directly, without completing an authorization form or contacting our office. COMPLETION OF FORMS There may also be times when you request that we complete forms of various types; examples may include medical histories for life insurance applications, disability forms, certification forms for handicapped license plates or hang tags, etc. If your provider is able to complete a short form during a scheduled office visit, there is no additional charge. However, if the form is long or complicated, will require additional time outside of the scheduled visit to complete, or if you are not being seen for a scheduled office visit, there will be a $25.00 charge, payable in advance, for completion of each form. Please understand that completion of such forms requires time by our providers and staff in order to ensure that they are completed accurately. It may also take several days before the form is available for pick up if your provider is not available for completion and/or signature at the time of your request, so please allow sufficient time before the form is needed. PAGE 2 OF 6

PATIENTS WITH INSURANCE COVERAGE Insurance Plans With Which We Participate We are participating providers with many of the major commercial and managed care insurance plans, including CareFirst BlueCross BlueShield, Aetna, Cigna, and United Healthcare, among others, and we accept many other commercial insurance plans with which we do not have a formal contract. We do participate with traditional Medicare (but NOT with any Medicare Advantage plans) and with regular Maryland Medical Assistance. We also participate with the Priority Partners Medicaid plan but not with other Medicaid managed care plans or Medical Assistance plans outside of Maryland. For questions about whether we participate with or accept your insurance plan, please contact our Business Office for assistance. HMO Plans If your insurance carrier is an HMO plan with which we do not participate, but your plan includes an out of network option, we will be happy to schedule you for a visit or diagnostic test. However, you will need to sign a waiver acknowledging that we are non participating and agreeing to be responsible for payment of amounts not paid by your plan. You may have a deductible, higher copayments and/or coinsurance meaning you have a higher amount you have to pay than if you were to see an in network provider. If we do not participate with your HMO plan and your plan does not have an out of network option, we are unfortunately not able to see you for any services in our office due to Maryland law, which prohibits us from billing you for HMO services that would be covered if we were in network. However, also in accordance with Maryland law, your plan will typically pay for emergency services rendered by our providers when you are seen in the hospital, because you did not have a choice of on call physician. Verification of Insurance Coverage We will verify your insurance coverage, including Medicare and Medical Assistance, at the time your visit or test is scheduled, and again shortly before your scheduled appointment. If your insurance coverage changes after you schedule your appointment, please notify us as soon as possible, before your visit. If we are not able to confirm active coverage, you will be considered self pay. It may be necessary to reschedule your visit or test, depending on the service requested, whether or not we are able to verify your new coverage (and whether we participate with your new carrier), and whether or not you are able to make payment at the time of the visit. [Please see the section entitled AMOUNTS DUE FROM YOU for further information and options.] REFERRALS AND PRE AUTHORIZATIONS FOR SERVICES Referrals Your insurance plan may require a referral from your primary care physician (PCP) in order for us to see you for a visit or for diagnostic test services. Under the terms of your coverage, it is your responsibility to obtain the appropriate referral prior to your visit. Some plans have an Open Access option under which you may choose to see a specialist without a referral. However, in certain plans you will have a higher copayment and/or coinsurance for an open access visit meaning you have a higher amount you have to pay than if you obtain a referral for your visit. If your plan requires referrals but does not have an Open Access option, and you do not have a valid referral at the time of your visit, we will be happy to reschedule the visit for another date so that you may obtain a referral from your PCP. In compliance with our contracts with our participating insurance carriers, we cannot obtain a referral after services have been provided. We also cannot contact your primary care physician s office to request a referral when you arrive at our office for your visit; this delays other patients who are waiting to be seen, and your PCP s office is not able to drop everything to respond to our request. Please make sure to contact your PCP in a PAGE 3 OF 6

timely manner to obtain needed referrals prior to your visit (check with them to find out how much advance notice they require to prepare the referral, and if they need to see you for a visit before they will issue a referral). Insurance Pre Authorizations In some cases an additional approval called a pre authorization or precertification is required by your insurance carrier for certain diagnostic tests. We will advise you of this requirement when you request an appointment, and will work with your PCP s office and/or your insurance carrier as needed to obtain the required pre authorization before confirming an appointment for the requested test. NON COVERED SERVICES Our providers follow current cardiology standard of care and appropriate use guidelines in ordering diagnostic tests or procedures as part of your care. Please be aware that some of the tests or diagnostic procedures recommended for you by our providers may be determined to be non covered or may be considered not medically necessary based on the benefits provided by your specific insurance plan. You will be financially responsible for the costs of non covered services and services that your insurance carrier declines to cover as not medically necessary. In the event that our information indicates that a specific service or services may not be covered by your plan, you will be asked to sign an ABN, or Advance Beneficiary Notice, outlining the services that we have determined may not be covered by your plan, and for which you agree to be responsible for payment, before we will provide those services to you. Please understand that even for insurance plans with which we participate, covered benefits may vary from one person s or employer s plan to another, and it is impossible for us to know what is covered under every plan. You are responsible for knowing the covered and non covered benefits available under your plan. If you have questions, contact your employer s personnel department or your plan directly. PAYMENT OF COPAYMENTS AND DEDUCTIBLES Copayments You are responsible for paying your copayment at the time of each office visit and diagnostic test visit. Copayments are part of your contract with your insurance carrier, and in order to keep our billing costs down, we are unable to bill you for your visit copayments in lieu of payment at the time of your visit. [It is also a violation of our contract with your insurance carrier for us to waive copayments in the absence of documented financial need.] We are aware that insurance companies sometimes do not assess a copayment, or assess a different copayment, when they process the claim. However, we must rely on the information we receive when we verify your insurance benefits, and we therefore collect the copayment amount specified by your insurance carrier s benefit verification. If you are unable to pay your copayment at the time of your visit, we will be happy to reschedule the visit for another date. Deductibles Most commercial and managed care insurance plans also include an annual deductible amount that must be paid by the patient before the plan pays any benefits, and many people now have highdeductible health plans (HDHPs), with annual deductibles that can be thousands of dollars. [Although many plan deductibles re set at the beginning of the calendar year, other plans may re set in a different month. Check with your plan to find out when your deductible year begins.] If you have not met your deductible, your insurance carrier will process the claim towards your deductible, but will not make any payment to us, and you will be responsible for payment of the contractual amount approved by your plan. PAGE 4 OF 6

We will notify you of the deductible applicable to the scheduled visit or test based on our verification of your insurance coverage (this is not necessarily the same amount as your remaining deductible), and payment will be expected at the time of service. Even if you believe you have already met your deductible as a result of medical services from other providers, those services may not yet have been processed by your insurance plan and your deductible may not yet show as having been met when we verify your coverage. If you are unable to pay your applicable deductible at the time of your visit, or to make approved payment arrangements after speaking with a Business Office representative, we will be happy to reschedule the visit for another date. AMOUNTS DUE FROM YOU We understand that paying for out of pocket medical care costs can be financially challenging. We offer several options for payment of amounts due from patients who do not have insurance ( self pay patients), as well as for those patients who may have a large self pay balance after insurance due to deductibles and/or coinsurance for which they are responsible. How to Pay Patients with self pay balances receive monthly statements, with payment due upon receipt. We accept cash, personal check, and Visa, MasterCard, Discover and American Express credit and debit cards, as well as FSA, HRA and HSA debit cards, for all patient payments (please do not send cash payments through the mail). In the event of a returned check, a $30.00 service charge will be added to your account to cover fees assessed by our bank. Discounts for Self Pay Patients For patients without insurance who elect to make payment at the time of service, we are able to offer a significant prompt pay discount. This discount applies only to patients without insurance, is only for services provided in our office (not available for hospital services), and is only available if the discounted amount is paid in full at the time of the office visit or diagnostic test. The discounted payment for a self pay new patient visit (including EKG if ordered by your provider) is $150.00, and for a self pay follow up patient visit (also including EKG if ordered by your provider) is $75.00, if paid in full at the time of service. Please contact our Business Office for information on prompt pay discounts and payment amounts for other services. [Please note that for those patients who take advantage of our prompt pay discount, your account will reflect our full standard charge for the actual service(s) provided, and the discount will be applied to those services to reflect the discounted amount paid at time of service.] Partial Payments and Payment Plans In certain circumstances, we are able to approve a partial payment at time of service and set up a payment plan for the balance. This may be offered in those situations where the total self pay portion is particularly high and where your account is otherwise in good standing with a record of keeping payment promises. Because of the high cost of carrying and billing unpaid accounts, we are unable to offer payment plans of longer than 6 months. Please contact our Business Office for further information. Reductions Due to Financial Need You may be eligible for a reduction in your self pay balance, including self pay balances after insurance, in cases of documented financial need. Our guidelines provide from as little as a 20% reduction up to a 100% reduction. Because we must document all reductions to our billed charges, you will need to complete a Financial Assistance Application and provide requested documentation of your income and expenses in order for us to determine your eligibility for financial assistance. Patients who are not eligible for financial assistance in the form of a reduction to their self pay balance may still be eligible for a payment plan. Please contact our Business Office if you would like us to send you a Financial Assistance Application. PAGE 5 OF 6

Self Pay Balances After Insurance If you have insurance but have a balance remaining after your insurance carrier processes the claim (due to copayments not identified through insurance verification, unmet deductibles, coinsurance and/or non covered services), you will receive a statement from our office showing itemized charges, insurance payments and adjustments, any patient payments, and remaining balance due. Payment is due upon receipt, and may be made by personal check or credit card as listed above (please do not send cash through the mail.) If you have a large balance after insurance that you are unable to pay in full, please contact our Business Office so we can work with you to set up a short term payment plan based on your account balance. Refunds In the event a patient payment results in an overpayment or credit balance on your account, the overpayment will be refunded to the patient as soon as all payments posted to the account have been verified and any unpaid dates of service have been resolved. NON PAYMENT / DELINQUENT ACCOUNTS Please contact us if you find that you are having difficulty meeting your payment obligations. If you do not communicate with us, we cannot work with you to determine potential eligibility for a reduction in your account balance and/or to establish a reasonable payment agreement. If the self pay balance on your account is 60 days or more past due, if you do not contact us about your balance or respond to our efforts to contact you, and/or if you do not make agreed upon payments when we have approved a short term payment plan, your account balance will be subject to placement for outside collection. [Please note that accounts placed for outside collection are no longer eligible to apply for a reduction based on financial need.] If your account balance is placed for outside collection, the unpaid amount will be reported to credit bureaus by our contracted collection agency. You will be responsible for all reasonable collection and attorney fees and filing and processing costs. In extreme circumstances, an unpaid account balance may result in a patient s discharge from our care. FOR FURTHER INFORMATION AND ASSISTANCE Our providers strive to provide you with the best in cardiac care but their knowledge and expertise is about your medical needs, not about insurance and billing, and they will direct to you our Business Office with your billing questions. Our Business Office billing and financial counseling staff are experienced and dedicated to ensuring that the charges for your medical care are billed promptly and accurately. If you need assistance or have further questions, please contact our Business Office Financial Coordinator at (443) 276 9049 between 8:30 am and 4:30 pm Monday through Friday, or send us a message through our Patient Portal, which is a secure, HIPAA compliant method to communicate with our office, at https://cscm columbia.gemmsportal.com/ at any time. We will make every effort to resolve your questions. Thank you. Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PAGE 6 OF 6