Financial policy and assignment of benefits

This document explains the financial policies of our practice so that you, as a patient receiving health care services from Nevada Pain and Spine Specialists (NPSS), understand your financial responsibilities and obligations to our practice.

1. As a courtesy, Nevada Pain and Spine Specialists (NPSS) will file all claims to your insurance carrier (s) for services rendered. In order to extend this courtesy, we require a picture ID and a copy of your current insurance card. It is your responsibility to provide any changes or updates to us. If the wrong insurance company is billed, you may be responsible for payment.
2. Copays are due at time of service. B12, vaccines, and other injection fees due at time of service. Vaccines and injections may or may not be covered by your insurance. If they are denied, you will still be responsible for payment.
3. Many procedures performed by NPSS require pre-authorization from your insurance company and may take up to 2 weeks to obtain. NPSS will not schedule a procedure until authorization is obtained. If you elect to have a procedure prior to authorization or if the insurer fails to pay the claim after it is performed, you will be responsible for payment.
4. If your insurance company has not paid on your claim within 90 days of date of service, you may be billed and responsible for payment.
5. If NPSS is not contracted with your primary insurance carrier, payment in full is required at time of service. If our practice is not contracted with your secondary insurance carrier, you will be billed for the balance not paid by your secondary insurance.
6. Copays, coinsurance, and any non-covered services are the responsibility of the patient (or parent if patient is a minor). Timely payment is expected. If there are extenuating circumstances, then a payment plan should be arranged by calling our billing department at (775) 689-5410.
7. Completion of any forms by a physician requires an appointment. Charge for completing forms ranges between $25 and $200 depending on length and detail required. Payment is due at time of appointment. This is not a visit covered by your insurance.
8. If your office visit appointment is cancelled within 24 hours of the appointment you will be charged a fee of $50. Three No Show appointments will result in a discharge.
9. If your procedure visit is cancelled within 48 hours of the appointment you will be charged a fee of $100. Three No Show appointments will result in a discharge.
10. If NPSS must take adverse action (collections) against your account, you will be responsible for a $50.00 administrative fine, and a monthly assessment of 3% on your remaining balance. A $25 fee will be charged on all returned checks, regardless of the amount. If you file bankruptcy and include any NPSS balance, you will be discharged from further treatment.
11. If there is an outstanding balance on your account greater than 90 days, further treatments, and office visits (including prescriptions) will be suspended unless other payment arrangements are made prior to next service date (establishing a payment plan is an example). If an outstanding balance is present greater than 120 days and no payment has been received, then transfer of care to another practice may be initiated.

I request that payment of benefits under my Medicare or private insurance plan for services rendered by providers of Nevada Pain and Spine Specialists, be paid on my behalf to Nevada Pain & Spine Specialists. I authorize any holder of medical or other information needed to process my medical claims to release said records to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers or any other insurance company, needed for this or a related Medicare/ Other Insurance Company claim.

I understand that my signature below authorizes payment and release of medical information necessary to pay the claim. If item 9 of HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown.

In Medicare/ Other insurance assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare/ Other insurance company as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare/ Other insurance company.