Maryland Pain Specialists
410 825-6945

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an innetwork hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is "balance billing' (sometimes called "surprise billing")?

"Out-of-network" describes providers and facilities that haven't signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called "balance billing." This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

"Surprise billing" is an unexpected balance bill. This can happen when you can't control who is involved in your care-like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services -

lf you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan's in-network cost-sharing amount (such as copayments and coinsurance). You can't be balance billed for these emergency services. This includes services you may get after you're in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center -

when you get services from an in-network hospitalor ambulatory surgical center, certain providers there may be out-of-network. ln these cases, the most those providers may bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed. lf you get other services at these in-network facilities, out-of-network providers can't balance bill you, unless you give written consent and give up your protections.

You're never required to give up your protections from balance billing. You also aren't required to get care out-of-network. You can choose a provider or facility in your plan's network.

When balance billing isn't allowed, you also have the following protections:

You are only responsible for paying your share ofthe cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will payoutof- network providers and facilities directly.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

lf you believe you've been wrongly billed, you may call 1-877-696-6775,

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

FORMULARY BENEFITS DATA CONSENTS FORM

Formulary Benefits data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBM’s are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan.

By signing below I give permission for Maryland Pain Specialists to access my pharmacy benefits data electronically through RxHub. This consent will enable Maryland Pain Specialists to:

Determine the pharmacy benefits and drug copays for your health plan.

Check whether a prescribed medication is covered (in formulary) under your plan.

Display therapeutic alternatives with preference rank (if available) within a drug class for non-formulary medications.

Determine if your health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe to these pharmacies.

Download a historic list of all medications prescribed for you by any provider.

In summary, we ask your permission to obtain formulary information, and information about other prescriptions prescribed by other providers using RxHub.

I have carefully read this and have had an opportunity to ask any questions I might have had.I consent and agree that you can obtain my pharmacy information as set out above.

Please initial to indicate your agreement*

Pharmacy name

Pharmacy phone number

Street address

City

State

Zip code

FINANCIAL POLICY

Insurance Participation

We participate with most major insurance companies, including but not limited to:

AETNA

CAREFIRST BCBS

CIGNA/GREAT WEST HEALTHCARE

COVENTRY OF DELAWARE – Not the Diamond Plan

EHP

MEDICAID – Amerigroup, Maryland Physician Care, Priority Partners, University of Maryland Health Partners (Riverside), UHC Community Health Plan

MEDICARE

MEDICARE RAILROAD

PHCS or MULTIPLAN

TRICARE STANDARD HUMANA MILITARY PPO

UNITED HEALTHCARE

WORKER’S COMPENSATION

Proof of Insurance

The responsibility of providing complete and accurate insurance information to our office staff belongs to you, the patient. A current copy of your insurance card and driver’s license is required at each visit in order to verify proof of insurance. As a courtesy, we will gladly submit a claim to your insurer.

Failure to supply us with correct insurance information in a timely manner may result in being responsible for the balance of a claim. The cost for your visit will be determined based on the specifics of the care and services provided. Your insurance carrier may pay for all or part of the care provided, however, you are primarily and ultimately responsible for payment on all the services you receive.

Co-Pays, Deductibles and Coinsurance

Legally, we cannot waive co-pays, deductibles, or coinsurance amounts. Contractually, your insurance company requires us to collect the portion for which you are responsible at the time services are rendered. Payment made at the time of service allows us to keep administrative costs to a minimum.

If you are uninsured, payment is expected in full on the day of your visit.

Non-Covered Services

There are some services that may not be considered reasonable or necessary by Medicare or other insurers. You may be asked to pay for these services at the time they are rendered. In some cases, we will ask you to make a decision to receive covered services that we expect may be denied by Medicare. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. The physician will explain why he feels you should receive the service. This will be done in writing on a form called an Advance Beneficiary Notice (ABN). The ABN will also provide you the opportunity to agree or refuse the services. It also explains that we will not know if the service will be denied until Medicare processes the actual claim.

Acceptable Forms of Payment

We accept the following forms of payment:

*Cash

*Check

*Credit Card (Visa, MasterCard and Discover)

*Money Order

Payment Policy

Balances must be paid in full within 30 days of the visit. Partial payments will not be accepted unless otherwise negotiated through the Billing Department. In such cases, a minimum of thirty five percent (35%) of the balance will be due on a payment date as discussed with the Billing Department. This does not include any copay that is due at the time of visit. Appointments may be cancelled if a balance remains unpaid.

Payment plans may be available under certain circumstances; however, advance notice and pre-approval is required. Please contact our Billing Office at 410-825-8973 for more information.

Past Due Accounts

Every attempt will be made, including the services of a collection agency, to collect past due accounts. If it is necessary to utilize a collection agency you may be assessed a fee for such services up to 33% of the total owed.

Returned Checks

A fee of $35 will be assessed to your account for each personal check returned by your financial institution for “non-sufficient funds”. Furthermore, all future payments on your account must be in CASH.

Missed Appointments

We require twenty four (24) hours notice if you are unable to keep your appointment.

A fee of $25 may be charged to you and would be your responsibility. Please help us serve you better by keeping your scheduled appointment.

Medical Records

Authorized written requests for copies of medical records will be honored. Our fees are in accordance with Maryland State Law.

Forms Completion

Payment for the completion of forms must be made at the time of service. The fees are as follows:

Simple/single page forms: $10 (each form)

Complex/multi-page forms: $25 (each form)

Processing requests for medical records and forms completion requires ten (10) working days. This office does not complete disability forms. When these forms are required, it is our policy to refer patients for Functional Capacity Evaluations (FCE’s).

Motor Vehicle Accident Related Injuries

Patient must supply auto insurance carrier information (including claim number and adjustor name and contact information) as well as personal healthcare insurance information because we still need to make sure we are a participating provider. It will be necessary to confirm PIP (Personal Injury Protection) benefits prior to scheduling your appointment and if benefits are no longer available, a PIP exhaustion letter will need to be obtained. It will also be necessary for the patient to sign our MVA Release Waiver.

Self Pays

Patients without healthcare insurance will need to make arrangements with our billing office prior to appointment scheduling. The total estimated cost will need to be paid prior to that visit.

Billing Office

Representatives are available Monday through Friday, 6:30 AM - 2:30 PM at 410-825-8973 to assist you with account inquiries and the resolution of billing issues.

Payments can be mailed to the address on the statement.

I have read and fully understand the Financial Policy described above. I further understand that my signature signifies that I accept the terms as set forth in this agreement.

Please initial to indicate your agreement*

PATIENT'S AUTHORIZATION

I request that payment of authorized insurance benefits be made either to me or on my behalf to Maryland Pain Specialists. I authorize any holder of medical information about me to release to the insurance company and its agents any information needed to determine these benefits or the benefits for related services.

Please initial to indicate your agreement*

PRIVACY PRACTICES

We Care About Your Privacy

Our Pledge Regarding Medical Information

The privacy of your medical information is important to us. We respect your privacy and treat all healthcare information about our patients with care under strict policies of confidentiality that all of our staff are committed to following. This Notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

Privacy Notice is available on our website at:
https://www.marylandpainspecialists.com/webdocuments/NOTICE-OF-PRIVACY-PRACTICES-MPS-2020.pdf

Questions and Complaints

You have the right to complain to us or to the Secretary of the United States Dept. of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint with us or to the government.

Should you have any questions or complaints you may direct all inquiries to the Privacy Officer.

Privacy Practices Acknowledgement

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Please initial to indicate your agreement*

PATIENT PORTAL/TELEHEALTH/VIRTUAL CHECK-IN CONSENT

PATIENT PORTAL is a web-based system that serves as a secure, encrypted communication link between you and Maryland Pain Specialists. When you log in to the Portal with your private user name and password, you can see information that is pulled from your electronic medical record and displayed on the web page. The Patient Portal is an optional service, and we reserve the right to suspend or terminate it at any time; we will alert you to any changes as promptly as possible.

This form is intended to give you the facts and risks surrounding the use of the web portal. By signing this document, you confirm that you have read, understand, and agree to comply with our procedures and guidelines for using the Patient Portal. You also agree not to hold Maryland Pain Specialists or any of their staff liable for network infractions beyond their control.

The Patient Portal has a secure tunnel connection with our office that uses encryption to keep unauthorized persons from being able to access and read your health information or your communications with us. To help insure that the tunnel remains secure, we need to have your current (private) email address and be informed if it ever changes. Keep your Portal User ID and password secure so only you can gain access to patient information. If you think someone has learned your password, immediately go to the portal site and change it. We will protect your email address as we do your medical and other personal information.

TO REQUEST ACCESS TO THE PATIENT PORTAL:

Read and sign the Consent at the end of this document.
Send, fax, or deliver this document to Maryland Pain Specialists
Once we receive this consent, we can authorize you as a user and you will receive a welcome email with your login and temporary password. We do NOT keep a record of this information.
The welcome email will contain a link to our portal.
Please review the Patient Portal Instructions found on the site.

Do not use email to communicate if there is an emergency or urgent need for communication—call 911

Proper Subject Matter : Lab results, referral requests or billing questions
Sensitive subject matter: (HIV, mental health, work excuses, etc) is not permitted

We do not refill medications through the PORTAL - please contact the office 410.825.6945

Email address you would like to use for Patient Portal*:

TELEHEALTH/VIRTUAL CHECK-IN - You are consenting to receive care through the use of telemedicine/virtual check-in (non-face to face treatment/exchange of medical information in response to patient message received via any modality). These modalities enable health care providers at different locations to provide safe, effective, and convenient care through the use of technology. As with any health care service, there are risks associated with the use of technology, including equipment failure, poor image resolution and information security issues.

Patient Agreement

I have read and fully understand the Patient Portal/Telehealth/Virtual Check-In Consent described above.

Please initial to indicate your agreement*

GENERAL CONSENT TO TREATMENT AND RIGHT TO REFUSE TREATMENT

When a drug or device is approved for medical use by the Food and Drug Administration (FDA), the manufacturer produces a “label” to explain its use. Once a device or medication is approved by the FDA, physicians may use it “off-label” for other purposes if they are well-informed about the product, base its use on firm scientific method and sound medical evidence, and maintain records of its use and effects. Many commonly used pain treatments fall into this category.

General Consent to Treatment: Having come to MARYLAND PAIN SPECIALISTS for evaluation and/or treatment, by signing below, I, (or my authorized representative on my behalf) authorize MARYLAND PAIN SPECIALISTS and their staff to conduct any diagnostic examinations, tests and procedures and to provide any medications, treatment or therapy necessary to effectively assess and maintain my health, and to assess, diagnose and treat my illness or injuries. I understand that these treatments may be “off-label.” It is the responsibility of my individual treating healthcare providers to explain to me the reasons for any particular examination, test or procedure, the available treatment options, common risks, anticipated burdens and benefits associated with these options as well as alternative courses of treatment. It is also my responsibility to ask questions about my treatment plan when I have them.

Right to Refuse Treatment: In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, therapy or medication (label and off label) recommended or deemed medically necessary by my individual treating health care providers.

I understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of my evaluation and/or treatment.

Please initial to indicate your agreement*

Patient Agreement and Signature

I have read and fully understand the agreements described above. I further understand that my signature signifies that I accept the terms as set forth in these agreements.

Printed name of patient (or financially responsible person)

Patient Signature

Reset Signature

Date:

Your Rights and Protections Against Surprise Medical Bills

PATIENT PREFERRED CONTACT INFORMATION

FORMULARY BENEFITS DATA CONSENTS FORM

FINANCIAL POLICY

PATIENT'S AUTHORIZATION

PRIVACY PRACTICES

PATIENT PORTAL/TELEHEALTH/VIRTUAL CHECK-IN CONSENT

Patient Agreement

GENERAL CONSENT TO TREATMENT AND RIGHT TO REFUSE TREATMENT

Patient Agreement and Signature