Madison Street Patient Billing Practices
Thank you for choosing Madison Street Surgery Center as your provider. Madison Street Surgery Center is committed to providing you with quality and affordable care. Madison Street Surgery Center is a private organization that relies on income from patients and their insurers. In order to provide the best possible medical care at the lowest possible cost, we need your assistance and agreement to our payment policies. As the patient or the person with legal authority to sign on the patient’s behalf, you understand and agree to the following:
You agree to pay any required co-payments, co-insurance and deductibles, as well as charges for services not covered by insurance, outstanding balances and delinquent accounts at or before the time of service. For your convenience, we accept cash, checks and credit cards. CareCredit may also be available.
1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the entire balance.
2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Furthermore, if you are treated without making applicable co-payment and deductible payments at the time of service, we retain the right to levy an administrative charge of $10 to your account in order to defray the cost of securing the co-payment or deductible payment.
3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient’s contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient (e.g., refraction) and treatment or tests not authorized by the health care service plan.
4. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. Madison Street Surgery Center may use and disclose your information, and provide information to health insurers, programs, third party administrators, vendors, other providers, and health care facilities, as is allowed by federal and state laws and regulations. You authorize Madison Street Surgery Center to disclose all information as needed to ensure proper claims payment. You agree to assign to Madison Street Surgery Center any and all health care benefits to which you are entitled under any policy of insurance or benefit plan and authorize, to the extent permitted by law, payment of benefits directly to Madison Street Surgery Center.
5. Referrals/Pre-authorizations. If your insurance plan requires a referral or other pre-authorization, it must be presented before seeing the physician. If you do not have the required referral or pre-authorization, we reserve the right to reschedule your appointment or you will have to be willing to be responsible for the entire cost of the examination.
6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, to the extent permitted by law, the balance will automatically be billed to you. Please direct questions regarding non-payment by your insurer to the insurer, not to Madison Street Surgery Center.
7. Nonpayment. Our Billing Department will send a statement to the patient noting balances owed, 30, 60 and 90 days out from the date of service. If your account is over 90 days past due, you will receive a letter stating that you have 10 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency, and you and your immediate family members may be discharged from this practice. If this situation occurs, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our staff will only be able to treat you on an emergency basis. Any balance that is under $100.00 and older than a year from the date of service will be recorded as Self Pay Bad Debt. If your account is delinquent, you may be charged interest at the lesser of: (1) 1.5% per month (18% per year); or (2) the greatest amount allowable by applicable law. If a delinquent account is sent to collections, the patient shall be responsible for collection expenses, including but not limited to reasonable attorney’s fees and cost costs as applicable.
8. Insufficient Funds. Any payment made by check that does not clear your bank account will result in a fee for insufficient funds. Our fee for insufficient funds is $25 and will be added to your account for each bounced check.
9. No-Shows & Cancellations. If you need to cancel or reschedule an appointment, you must provide no less than 24 hours’ notice prior to the scheduled appointment time. You may contact Madison Street Surgery Center 24 hours a day, 7 days a week at: https://www.omnieye.com/contact-us/
Should your need to cancel arise after regular business hours, you may leave a message or navigate to https://www.omnieye.com/contact-us/. If you fail to provide such notice, our practice will bill you $35.00 per missed appointment. These charges will be your responsibility and billed directly to you. Any such charges must be paid in full before your next appointment. Please help us to serve you better by keeping your regularly scheduled appointment. If you fail to present for your appointments three or more times, you may face dismissal from the practice.
10. Medical Records. If you request that a copy of your medical records be sent directly to you or another third party, the practice will charge a per page fee, payable in advance. However, where your medical record is to be sent to a collaborating physician (primary care or specialist) to assist in your care, there is no charge. A schedule of Medical Records Request Fees is available upon request.
11. Conflicts. In the event of a conflict between this policy and any other information you receive, the information contained in this document shall apply.
Madison Street Surgery Center is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.
Thank you for understanding our Patient Billing Practices. Please let us know if you have any questions or concerns. A copy of this document will be provided to you upon request.
Flexibility to pay online means it’s easier to focus on what matters most: your health and wellness. Find multiple options to make your payments here. All you need is your account number (see your recent statement) and your preferred method of payment.
To use Quick Pay, please have your patient account number, credit or debit card or checking account ready. Your patient account number is required, please see your recent statement.