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Author Topic: Has anyone had to sign a document like this???????????  (Read 1396 times)

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Offline Cinammo

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Has anyone had to sign a document like this???????????
« on: October 31, 2006, 05:47:44 PM »
Our Insurance is the Federal Government(Tricare Prime)and one of the things that reads in our insurance is that if after a fee has been contracted with the provider we are not responsible for any costs other than that.  I know the total cost of this surgery to be right around $23000.  I know Tricare won't pay even half of this, although they are approving a procedure.  What do you all think of this document?






Notice and Acknowledgement of Financial Obligation

Cartilage Transplantation/Carticel is an innovative, unique and potentially non-covered surgical procedure.  As a result, you may be responsible for the cost of the procedure in the eventuality it is denied by your insurance carrier.
   
We will submit your insurance claim to your carrier with the expectation that they will provide full reimbursement for these procedures. However, there is no guarantee that they will provide any level of reimbursement even though they may initially authorize the procedure.

The fee for this procedure is $12,000 for the primary surgeon and $3,600 for the assistant surgeon.  In the event that your insurance company does not cover or denies payment for this service, you will be financially responsible for this amount.  Additional charges may also be incurred depending on additional surgical procedures that are required.

To ensure that Midwest Orthopaedics at Rush (MOR) is reimbursed for the services we render, a valid credit card is required prior to the date of your procedure. If your insurance carrier denies payment or coverage for this service, we will charge your credit card for the above quoted amount(s).

Please note that there may be up to three components of your bill to you and/or the insurance company: the hospital, the anesthesiologist, and Midwest Orthopaedics at Rush. Thus, charges in addition to the surgical procedure(s) should be expected.

Your signature below acknowledges that you fully understand this policy and agree to the terms.  This form must be signed prior to undergoing your surgical procedure.   Please return this form to Michelle Karlin by mail: 1725 W. Harrison St. Suite 1063, Chicago, IL 60612 or fax: 312-563-0579. If you have any further questions you may also contact her at 312-432-2381 or our billing department directly at 708-236-2600.

Card Type:              

Credit Card#                             

Exp. Date:             Security# (3 digits)           


_____________________________                                   __________________
Patient or Responsible Party Signature                                 Date

         
______________________________
Patient Name Printed
My 17 year old son had the OATS procedure on November 29th, 2006.  He has two previous scopes on the right knee and one on the left.

Offline Cinammo

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Re: Has anyone had to sign a document like this???????????
« Reply #1 on: October 31, 2006, 08:40:00 PM »
Well I received the answer to my question.  Dr. Cole's office stated that since this is a military insurance he will accept whatever Tricare pays.  But I guess for all other insurances policies this is in place now for his office, which is kinda sad.  A lot of people who need this treatment are not going to be able to afford this.  I guess his office instituted this policy 6 months ago due to insurance companies approving the procedure but not payng on it.  The state of health care in America is in sad shape.  Wonder what the answer is to straighten it out.
My 17 year old son had the OATS procedure on November 29th, 2006.  He has two previous scopes on the right knee and one on the left.