Financial Information

Basic Policy:  Payment for services rendered is due in full at the time of service.  Our office accepts cash, personal checks (with valid drivers license), credit cards and several financing companies.  We process our checks through Telecheck.  These checks are processed electronically and withdrawn from your bank.  There is a $50.00 returned check fee due, and payable from you for each check payment returned to Telecheck by your bank.

If for some reason your account should become delinquent, you agree to pay for all re-billing charges, interest charges, collections (33.3% of unpaid balance of accounts less than 1 year old) and attorney's fees if necessary. 

For Patients with Insurance:  As a service to our patients, we will accept “assignment of benefits” and will bill your insurance carrier, provided proper paperwork is provided to us.  We will also assist you in billing your secondary insurance carrier, if applicable, and in researching unpaid claims.  Every effort will be made to estimate your co-payments and deductible which are due at the time of service, but the ultimate responsibility for any unpaid balance rests on you.  Please understand that insurance is a contract between you and your insurance company. If an insurance carrier has not paid within 60 days of billing, any unpaid professional fees are due and payable in full from you.

Managed Care Participants  Some benefit plans require pre-authorization and specialists referral forms from your primary physician.  Please provide the proper insurance plan identification and forms necessary prior to your visit.

Surgery Fees:  All co-payments, deductibles and payments for non-covered surgical procedures are due prior to your surgery.  Prior authorization is required by your insurance carrier.  The tentative treatment plan represents an estimate of charges based on the findings of actual treatments.  You may receive a revised list of charges at the time of or following treatment.  INSURANCE COVERAGE IS ESTIMATED. You, the patient are responsible for all financial obligations for your health care services.  You will be charged a service charge each month for unpaid balances.  If for some reason your account should become delinquent, you agree to pay for all rebilling charges, interest charges, collection fees and attorney costs, if necessary.  A surgery deposit is required to schedule surgery.  The amount will be specified when the treatment plan is established.

Non-Covered Charges:  Any charges not paid by your insurance carrier will require payment in full at the time of service or services are provided or upon notice of insurance claim denial.  To assist our patients, we offer financial arrangements and/or alternative financing sources.  Please ask our billing personnel for additional information.

Minor Patients:  The adult accompanying a minor is responsible for the full payment.  We accept pre-arranged payment over the phone with a major credit card (American Express, MasterCard, Visa) and debit cards or cash/check when patient is accompanied by an adult who is not the parent or guardian.

Workers Compensation/Personal Injury:  If the injury is work-related, we require the necessary insurance billing information and employer authorization form prior to your office visit or treatment.  This office does not bill for lawsuit related cases.  The patient is responsible for services provided at the time of service. We do not wait for payment pending suit settlement. 

FAMILY MEDICAL LEAVE ACT/ WORKERS COMP. FORMS: KOMSA will complete all leave papers after a $ 20.00 administration fee is paid.  We will complete the papers and mail/fax to the appropriate department.  We will complete the forms within 2 business days. These will not be filled out  until surgery has been completed.