Insurance Verification and Identification
Patients are expected to present a valid insurance card and identification at each visit
Co-Payments and Past Due Balances
All co-payments and past due balances are due and payable at the time of service. We accept cash, personal check, VISA, MasterCard, Discover and American Express. There is a service charge of $50 for returned checks. Patients with an outstanding balance over 90 days that have not made a payment arrangement may be sent to collection, prevented from scheduling future appointments or discharged from the “Practice”. Unpaid accounts, including accounts with payment arrangements that are in arrears, will be turned over to a collection agency. If your balance is sent to collection, you will be responsible for all collection and attorney costs.
Insurance Plan Participation
We participate in most major insurance plans. A complete list is available upon request or on our website (www.wnypodiatricassociates.com). It is the patient’s responsibility to be aware of their insurance coverage, policy provisions and authorization requirements. Not all Excelsior providers participate with all insurance companies; please verify whether the physician accepts your insurance coverage when scheduling an appointment. If you provide our office with the necessary information needed to properly bill an insurance carrier that we do not participate in, we will submit a claim on your behalf. However, you are responsible for following up with your insurance carrier for unpaid claims and/or appeals. You are responsible for all deductibles, co-pays and non-covered charges.
Self-Pay
Self-pay accounts shall exist if a patient has no insurance coverage. Payment in full is expected at the time of service unless prior arrangements have been made with our Billing Department. If you need to discuss payment options, please contact our Billing Department at TBD…………, Monday-Friday, 8:00 a.m. – 4:00 p.m.
Estimated Cost Quotes
We will make every effort to estimate the cost of our services. Although we cannot possibly predict all the services that may be required for an individual being treated in our office or having surgery, we will provide to you the name, practice name, address and phone number of any provider who is scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with care to be provided in our office or care that is referred by us. It’s important to remember to contact the hospital, ambulatory surgery center, anesthesiology and any other physician offices that are involved in your care so that you understand your personal financial obligation.
High-Deductible Plans (Health Savings Accounts or Health Reimbursement Accounts)
If your insurance is a High-Deductible Plan, you will be required to pay a deposit prior to services being rendered. The deposit will be applied to your total cost. You will be billed for the balance owed or issued a refund for overpayment.
No-Fault/Workers Compensation
You are responsible for providing our office with the necessary information (insurance carrier, claim #, date of injury, etc.) needed to properly submit charges. Without this information, the fees mandated by NY State will be changed to reflect our private fees and you will be responsible for payment. Some No-Fault carriers have deductibles on medical charges, for which the patient (not the insured) is responsible. If you have private insurance, we will submit on your behalf and bill you for any unpaid balances.
Medicare Managed Care (PPOs, HMOs, etc.)
You are responsible for remitting co-pays at the time of service and, unless otherwise indicated, responsible for
obtaining the necessary referrals/authorizations your plan requires. These are the provisions you agreed to when
you contracted or signed up with your insurance plan. We will submit all charges and follow-up with your carrier for payment. You are responsible
for all deductibles, co-pays and other non-covered charges. Failure to have the necessary referrals/authorizations
your plan requires by the date and time of the appointment may result in rescheduling the appointment.
Medicare
We participate in Medicare services.” This means we must accept Medicare’s allowed charge for services rendered. Medicare will pay 80% of the approved amount. The patient is responsible for the remaining 20%, plus any out-ofpocket deductible. You will not be responsible for the difference between our full charges and what Medicare approves. If you have secondary insurance, we will submit the claim for the remaining balance after Medicare has paid. Please remember that although we accept Medicare, the patient, by federal law, must be held responsible for any portion of the approved amount not paid by Medicare or a secondary insurance company.
Medicaid Managed Care (PPOs, HMOs, etc.)
If you have a managed Medicaid plan (,, etc.) you are responsible for obtaining a referral from your primary care physician prior to services being rendered. Failing to have the necessary referrals/authorizations your plan requires by the date and time of the appointment may result in rescheduling the appointment.
Medicaid
If you see one of our providers that participates with Medicaid (not all providers do) you are responsible for providing our office with your ID (begins with 2 alpha letters, followed by numerical digits and ending with 1 alpha letter).
Referrals/Authorizations
You are responsible for obtaining the necessary referrals/authorizations your plan requires. We must receive a referral 3 days prior to the date of service. Failing to have the necessary referrals/authorizations your plan requires by the date and time of the appointment may result in rescheduling the appointment. If you do not provide the required referral or prior authorization and elect in writing to proceed with the appointment, the service or procedure you receive will be a Non-Covered Service under your plan, your visit for that date of service will be processed as self-pay and payment will be due on that date.
Liability
Carriers usually remit payment to the patient or the patient’s attorney if one has been retained. OUR POLICY DOES NOT ALLOW US TO HOLD ACCOUNTS WHICH ARE PENDING RESOLUTION OF ANY LIABILITY OR LITIGATION ISSUES. WE DO NOT, UNDER ANY CIRCUMSTANCES, BILL ATTORNEYS. If you provide a letter from the liability carrier indicating, they accept full responsibility and will remit payment, we will submit claims for our charges on your behalf. Otherwise, you may either have charges submitted to your private carrier or pay for services and obtain reimbursement upon resolution/settlement.
Custodial Parent Responsibilities
The custodial parent is responsible for payment at the time of service whether the account is considered self-pay, participating insurance, or nonparticipating insurance. The office does not get involved with divorce specifics, e.g., one parent pays 80% and the other 20%. It is the parents’ obligation to work out an agreement themselves or through the court system.
Cancellation Fee
A fee of $50 may be charged for any missed appointments or not cancelled 24 hours before the scheduled visit. It is the patient’s responsibility to notify the physician’s office when an appointment needs to be cancelled or rescheduled.
Records Fee
Copies of medical records are available on request. A fee of 75 cents per page will be charged for medical records.
Forms Fee
A $25.00 fee is charged PRIOR to completion of disability forms. The $25.00 per form is applied to all disability forms with the exception of NYS Workers’ Compensation and No-Fault Insurance Carrier Forms. This fee is not covered by your insurance. You are responsible for payment. Failure to pay will result in the disability form not being filled out.
Surgery Re-Scheduling Fee
A fee of $50.00 may be charged for elective rescheduling of surgery unrelated to medical reasons.
Durable Medical Equipment
For your convenience, we offer braces, splints and other devices on site. Durable Medical Equipment’s financial
policies will be discussed with you should you require those services.
Financial Hardship Policy
Patients experiencing financial hardship may apply for a discount or waiver of the patient’s financial responsibility.
Whether such a discount is granted shall be based on an individual assessment of the patient’s financial
circumstances. For a complete understanding of our Hardship Policy, please contact our Billing Department at 716-
656-0078, Monday-Friday, 8:00 a.m. – 4:00
p.m.
CONSENT/AUTHORIZATION FOR TREATMENT AND TO RELEASE/DISCLOSE PROTECTED HEALTH INFORMATION
I hereby agree that WNY Podiatric Associates, PLLC, may perform care and treatment, and may conduct such
examinations, laboratory tests and procedures as may be directed by my physician or treating practitioner.
I hereby consent to the use and disclosure of my Protected Health Information by WNY Podiatric Associates, PLLC
for purposes of treatment, payment and health care operations. For example, my physician or treating practitioner
at WNY Podiatric Associates, may furnish Protected Health Information maintained in the course of my care and
treatment. Any release of my medical records and Protected Health Information will be made according to state and
federal regulations. I understand that Excelsior may release medical information to any third party that may be
responsible for payment of my medical expenses.
ASSIGNMENT OF BENEFITS; INSURANCE PROCEEDS, SETTLEMENTS
If I am entitled to health care services under any insurance policy from any person or organization that may become
liable to me to provide such benefits, I assign such benefits to WNY Podiatric Associates, PLLC. I further authorize
payment directly to WNY Podiatric Associates, PLLC and such physicians of all such insurance benefits payable to
me. Such insurance may include, but is not limited to, private commercial insurance, auto liability insurance, worker’s
compensation and government programs such as Medicare and Medicaid. I further assign to WNY Podiatric
Associates, PLLC any payments for medical benefits payable to me as a result of any settlement or judgment in a
lawsuit. I certify that the information given regarding my insurance is accurate and current to the best of my
knowledge.