Plymouth Psych Group has updated our billing practice regarding receiving patient payments. You will be required to have an active credit, debit, or HSA card on file to pay any balance due. For insured clients, the outstanding balances are determined by the insurance company contract.

For self-pay clients, a $250.00 deposit will be required prior to being seen. Your balance due will simply be calculated after each visit.

All copays, co-insurance amounts, and estimated deductibles, per our fee schedule with your insurance company are due at the time of service. This card will be used to charge these balances due. Other charges you may incur but not limited to no-show fees, returned check fees, interest charges for overdue balances, payment plan installments and other fees listed in the Plymouth Psych Group Consent for Treatment.

Your ability to dispute a charge or question your insurance company’s determination of payment will remain unchanged

TERMS OF CREDIT CARD ON FILE:

Your credit card information is not kept on file in this office. It is kept securely offsite by our Payment Gateway and our office does not have access to the full credit card number once it is entered into our system.

1. I understand I must keep this card information current in this office. Cards denying could incur additional fees.

2. I understand that once my insurance has paid their portion for the medical care we received at Plymouth Psych Group the remaining balance is my responsibility as shown on my Explanation of Benefits (EOB) from my insurance company.

3. I understand that Plymouth Psych Group will charge my payment card on file for the estimated patient responsibility and any balance difference due once the EOB is received.

4. If I have more than one type of payment card on file, Plymouth Psych Group will process my Health Savings card - before charging my credit card for the remaining balance.

5. If I am self-paying my payment card will be charged at the time of service or within 3 days.

6. If the payment card is declined for any reason, I may be charged an additional fee of $35.00 to my account (same as a returned check fee).

7. If your HSA card declined, you will receive a phone call and be given the opportunity to give us another card to use.

If you have any questions or concerns, our staff is happy to speak with you about your account at any time.

By signing this form, you agree to: *

I authorize Plymouth Psych Group to charge co-pays and any other outstanding balances on your account to the card provided, per the terms as stated in this agreement.

If the credit card or debit card that I give today changes, expires, or is denied for any reason, I agree to immediately give Plymouth Psych Group a new, valid credit or debit card which I will allow them to charge. I agree that the new card number that is provided may be used with the same original authorization above.

ADDITIONAL INFORMATION

Plymouth Psych Group has updated our billing practice regarding receiving patient payments. You will be required to have an active credit, debit, and/or HSA card on file to pay any balance due. For insured clients, the patient balances are determined by the insurance company contract. For self-pay clients, a $250.00 deposit will be required prior to being seen. Your balance due will simply be calculated after each visit.

Why the change? There are several reasons for this change. With the changing environment in healthcare, more responsibility of payment is being placed on the patient. We need to be sure that patient balances are paid in a timely manner. To do this, we need to ensure we have a guarantee of payment on file in our office.

What is a Deductible and How Does It Affect Me? An annual deductible is the dollar amount you must pay out of pocket during the year for medical expenses before your insurance coverage begins to pay. For example, if your policy has a $2,000 deductible, you must pay the first $2,000 of medical expenses before the insurance company begins to pay for any services. This works just like the deductible for your car insurance or homeowner’s insurance policy does. Deductibles begin at the start of your plan year. Some begin either Jan. 1st or July 1st but can start on any date. Most plans also have co-pays and/or coinsurance which is patient responsibility.

But I always pay my bills, why me? We must be fair and apply the policy to all patients. This includes patients with Medicare and/or Medicaid plans. We have wonderful patients, and we know that most of you pay your balances. Unfortunately, this is not always the case.

When do I have to pay for services? Any time you receive services, you will be expected to pay for your services whether this is a co-pay, co-insurance and/or deductible. This amount will be charged the day of, or within 3 days the service is rendered. If you have a very large deductible, called a high-deductible insurance plan, you will be charged an estimated amount for your deductible based on your insurance plan. The exact amount will be determined when the office receives your EOB.

How will I know when my deductible has been met? You can call your insurance company at any time to check on how much of your deductible has been met and some insurance companies have this information available online. Every time you receive medical services, you will receive notification from your insurance company (either by mail or online) by way of an Explanation of Benefits (EOB). This will show with how much they paid or did not pay, if the amount went to your deductible or coinsurance, and what your responsibility to pay.

How will I know how much you are going to charge me? You will receive a letter in the mail (or e-mail) from your insurance carrier that explains how much of your office visit they paid and how much you are responsible for. This is called an Explanation of Benefits (EOB.) We receive the same Explanation of Benefits (EOB) that you do. Most Insurances will send your EOB to you first prior to us receiving our copy. It arrives about 10-20 days after your appointment has been billed. We look at each EOB carefully and determine what your insurance has determined as patient responsibility.

When will you charge my credit card? If you have a standard office visit copay, we will charge the day of, or within 3 days of service rendered. Once we receive the insurance EOB for your visit, we will apply the patient responsibility to your account. We will charge the credit card on file the exact amount as per the EOB that is stated to be patient responsibility. Your copy of the EOB will be your pre-notification. Once we receive the EOB on your visit, we will charge your credit card if the patient’s responsibility is higher than the original estimated amount collected at the time of service, or you will have a credit on your account if your patient responsibility is lower than the original amount collected.

But wait, I’m nervous about leaving you my credit card. We do not store your sensitive credit card information in our office. We store it on a secure website called a gateway. The gateway we use is a secure clearinghouse that meets the industry standards set forth from the Payment Card Industry Data Security Standard (PCI-DSS) and is certified at the highest level attainable. Once we enter your information through this gateway, your information is securely encrypted, and we do not have access to view or edit the information. This gateway is only used to process your payment and email you a receipt once payment is processed.

What is PCI-DSS? Payment Card Industry (PCI) Security Standards Council offers robust and comprehensive standards to enhance payment card data security and reduce exposure to credit card fraud. PCI Data Security Standard (DSS) provides an actionable framework for developing a robust payment card data security process, including prevention, detection, and appropriate reaction to security incidents.

When do I give you my credit card? We will be sent a secure link for you to enter your credit card information prior to your scheduled appointment. You can also provide your credit card information over the phone to our staff or by mail.

My High-Deductible Health Plan has a Health Savings Account (HSA) Card. Can I keep my HSA card on file? Yes, you can keep your HSA card on file, however, since HSA funds are limited, we may require an additional card to be kept on file should the funds in your HSA account become insufficient.

What if I need to dispute my bill? We will always work with you to understand if there has been a mistake. We will refund your credit card if we or if your insurance company has made a billing error. We will only charge the amount that we are instructed to by your insurance carrier, in the EOB they send to us, in the same way that we normally determine how much to send you a bill for in the mail.