Click here to download our Financial Policy Form. After you have completed the form, please make sure to bring it on your first visit to our office.
- The most common misconception concerning insurance is that your policy will cover the total cost of surgical fees charged. Insurance is designed to reduce your cost, but usually will not eliminate it entirely. Your estimated out-of-pocket payment is due in full for each visit at the time of service.
- The office will accept the following instruments for payment of services rendered:
Visa/ MasterCard/ Discover/Cash/ Money Order/ Cashiers Check. Unfortunately are our office does not accept personal checks or American Express. Care Credit is offered as a payment option for private pay patients only.
- Overpayment will be processed and refunded to the appropriate party promptly. Refunds due the patient and guarantor will not be processed and remitted until all active and past due, including bad debt have been paid.
- This office will not be involved with any third-party liability cases. It is the patient’s responsibility to see that this office is paid promptly.
- It is our policy to submit any insufficient funds to the appropriate legal authorities. A $30.00 charge will be added to your account for each check returned.
- The patient agrees to pay all costs of collection including attorney fees, collection fees, and contingent fees to collection agencies of not less tan 35%, such contingency fee to be added and collected by the collection agency immediately upon your default and our referral of you account to said collection agency.
- All outstanding balances unpaid after 60 days will be subject to a 1.75% monthly interest rate (21%APR).
- Insurance will not be filed for cosmetic surgery procedures. If Dr. Lee determines that your procedure is medically necessary, then we will assist you in filing the appropriate insurance paperwork. Determination of medical necessity is made by Dr. Lee.
- Insurance is filed as a courtesy to the patient and the coverage does not relieve the patient of the financial responsibility, nor suspend payments until the insurance is paid.
- Insurance will only be filed for plans that we are provided with at the time of service. We will not “Back file or retro-file” any claims. The patient must provide all insurance at the time of service. The patient is responsible for filing any claims with insurance plans we were not made aware of at the time of consultation.
- If no insurance payment has been received within 90 days of service, the patient is fully responsible for payment of the account.
- Any unpaid account not covered by your insurance must be paid in full by the responsible party no later than 60 days following surgery.
- If payment has not been paid to an account 90 days after service is rendered, and no contact or appropriate arrangements have been made, the account will be referred to the necessary legal authorities and credit bureau service. This also applies to patients with insurance.
- In cases of divorced parents, the parent bringing the child will be deemed responsible for payment.
- Insurance coverage will be verified at the time of service. All efforts are made to verify coverage prior to your initial consultation appointment. The patient must provide this office with an insurance card or proof of coverage. If coverage is unable to be verified, the patient is responsible for all charges incurred.
- Upon verification of insurance benefits, we will attempt to estimate the patient’s portion of fees due. However, this is only an estimate and neither the office nor the insurance company will guarantee this figure. The patient is responsible for any co-insurance amounts prior to surgery.
- All patients are charged the same for services rendered. This office does not accept reasonable and customary charge calculations by outside parties, unless this office is a participating provider. Any discounts/write-offs will be applied upon receipt of payments and EOBs.
- Patients, who miss a surgery or follow up appointment will be assessed a $50.00 No-show fee. This is not billed to your insurance company. All post-op appointments which are missed (no-show) will be accessed a $10.00 fee. This also is not billed to your insurance company. Late cancellation of a surgery appointment which is giving less than 48 hours notice for the cancellation or rescheduling of the surgery is also subject to the $50.00 fee and must be paid prior to the surgery being rescheduled.
- Responsible parties without insurance coverage agree to pay for services at the time of visit. All procedures must be paid in full prior to surgery. We accept Visa/ MasterCard/Discover/ Debit Card/ Cash/ Cashier’s Check/ Money Order or Care Credit.
Responsible parties with insurance coverage can either:
1) File insurance yourself and pay us in full directly the day services are rendered. We will assist you with your paperwork.
2) Have us file your insurance. We will only file with 2 insurance plans. Filing of additional plans will be your responsibility.
You must have on the day of your appointment:
- Insurance card with subscribers information
- Photo ID (We do not file any insurance without a photo ID –(Drivers License, Military ID)
- Brochure or phone number explaining your benefit, unless information was given prior to your appointment.
- The co-payment and deductible (when applicable) is due the day services are rendered. Co-payment can vary with insurance plans.
If there are any other payments made on the responsible party’s behalf by their insurance company over the charges submitted, we will promptly refund the difference. This takes approximately 30 days to process.
Cumberland Surgical Arts, PLLC files insurance as a courtesy to our patients. If you have any questions regarding your initial consultation with Dr. Lee or in regards to your insurance coverage, please do not hesitate to call your insurance company or our office during normal business hours. Monday, Wednesday, Thursday, and Friday 8:00 AM to 4:30 PM and Tuesday 9:00 AM to 4:30 PM central standard time.
At Cumberland Surgical Arts, we offer convenient financing for all of your surgical needs through Care Credit.
For all elective cosmetic procedures:
In order to schedule a procedure and to secure your desired date, we must obtain a $250.00 non-refundable deposit. The remaining balance of the fees will be due upon your preoperative visit or two weeks prior to your procedure. The deposit will be applied to your elective procedure, however, if the procedure is canceled for any reason, this balance is also non-refundable except is the case of documented emergency or medical disability. If your scheduled date is changed within 3 three weeks of your procedure, an additional $250.00 deposit is required.