Critical Application Assignment

1. Financial Policies 1
Financial Policies Final Project
Jennifer Reynolds
March 17, 2013
University of Phoenix
HCR/230
Jetonga Keel

2. Financial Policies 2
Smooth Waters Psychiatry
(123)-456-7890
101112 West Business Lane
Suite ABC
Forever Calm, Texas 12345
Thank you for choosing Smooth Waters Psychiatry for your care needs. We
understand that it can be rough choosing the best provider for a specific patient’s
needs and are proud to be the practice chosen to provide our patients with our
unique style of quality therapeutic services.
In order to provide the best possible quality service to our clients, we
adhere to a strict financial policy. Additionally, we follow a stringent schedule
policy to minimize our patient wait time and to allow for periodic emergency same
day scheduling. Therefore, as a courtesy to our clients we are providing a written
notice of Smooth Waters Psychiatry’s Financial Policy requirements.
Please initial or sign each highlighted area below to acknowledge receipt of Smooth Waters
Psychiatry’s financial policies and procedures.
Scheduling of Appointments:
______ Smooth Waters Psychiatry reserves the right to charge a $25.00 fee for
each “No Show” missed appointment.
In order to cancel an appointment, and not be responsible for this fee the patient
must call a minimum of 24 hours in advance to allow time for our office to
reschedule another patient or fill that appointment.
The 24 hour notice does NOT include weekends, holidays and non-business
hours; we ask the patient call the on last business day before the appointment.
Follow up Appointments:
______ Smooth Waters Psychiatry cares for a relatively high volume of patients,
please schedule all follow up appointments before leaving our office at the check-out
desk.
(Please note, new patients can have a wait for up to several months to schedule
an appointment); and this is the only assurance the patient will see the doctor
before prescription medications run-out.
Medication Refill:
______ Smooth Waters Psychiatry recognizes the potential of abuse with
psychiatric medicines and follows strict prescription policies. Medications are only
refilled at the time of the patient’s appointment. Should the patient miss an
appointment, we will not be able to refill their medications. The patient will need
to visit the nearest emergency room or schedule for the next available
appointment in order to refill medications due to a skipped office visit.
After Hours Physician Page:
______We understand some emergencies may occur at any time of day;
however Smooth Waters Psychiatry advises all patients to visit the nearest

3. Financial Policies 3
hospital or psychiatric emergency room and list us as your specialty provider of
psychiatric services.
______If we participate in care at the hospital the patient has chosen, we will
make rounds and treat the patient during their stay in the hospital.
In the event a patient places a phone call to the answering service and it results
in an after-hours physician page - for any reason, the patient will be charged a
$50.00 after- hours consult fee.
*The physician will NOT provide refills or call in any new prescriptions at this
time.
I acknowledge receipt of Smooth Waters Psychiatry’s Prescription, Appointment
and Scheduling Policies and fees associated therein and I hereby certify that I
understand these policies.
Any questions have already been explained. I am aware that these policies are
subject to change at any time.
Patient Signature:
X_________________________________
Smooth Waters Psychiatry
Insurance, Billing, and Collection Patient Information Agreement
As a service to our patients, we routinely bill insurance companies for our
services.
Should the patient have any questions, our staff is available to answer them
during normal business hours at: (123)-456-7890. For the convenience of our
patients we allow select credit worthy patients to make their co-pay at the end of
the business week, to accommodate for pay days of the patient. We welcome
cash, check, and all major credit cards.
Insurance Acceptance:
Please be advised, Smooth Waters Psychiatry is in a relationship with the
patient, not the insurance company. It is the responsibility of the patient to
contact the insurance provider and establish the amount or benefit of co-pay if
any, and what mental health benefits the insurance provider covers. (The
Woodlands Ob/Gyn Associates, 2012)
We submit insurance claims electronically on behalf of the patient to the
insurance company; however, it is solely the responsibility of the patient to
provide accurate information on the very first visit, before any services are
rendered.
Smooth Waters Psychiatry is committed to helping our patients get the
most out of their insurance benefits. “However, due to the fact that insurance
policies vary, we can only estimate the patient’s coverage in good faith. We are
unable to provide any guarantee of coverage due to the complexities of

4. Financial Policies 4
insurance contracts” (The Woodlands Ob/Gyn Associates, 2012). Therefore, the
estimated patient portion is always due and must be paid at the time any service
rendered.
*Patients receive monthly billing statements for any unpaid balances, co-insurances or charges
assessed as non-covered under the patient’s insurance policy.
Patient Signature: X
_________________________________
Types of Insurance Providers Accepted:
We accept many different insurance providers; if a particular carrier is not listed
below please contact our office at (123)-456-7890 for further confirmation.
Medicaid
Medicare
Aetna
Blue Cross Blue Shield,
Humana,
TRICARE
CHAMPVA
Cigna
United
Kaiser
Care First
(U.S. News, 2011)
Returned Checks:
______ When a patient’s check is returned for insufficient funds or stopped
payment, the patient’s account is placed in “negative status” a will be charged a
$35.00 returned check fee.
* In the event this occurs, the patient will be required to pay cash for all future visits.
Co-payment:
______ Smooth Waters Psychiatry collects all co-pays during the check in
process. This occurs before any services are rendered.
______ Smooth Waters Psychiatry understands that times are tough, in the event
a patient is unable to make their co-pay; they are asked to contact the Business
Office at (123)-456-7890 at least 24 hours in advance of the scheduled
appointment time to make financial arrangements.
(Care Credit may be available to those patients that qualify)
______A $15.00 fee will be applied to all accounts over due 30 days or more.
______All billing disputes that carry a balance due must made within 30 days of
the original billing date to be considered valid.
No Insurance/Non-Covered Services:
______In the event a patient is uninsured or their insurance provider offers no
mental health coverage cash payments are due in advance at the time services
are rendered. If finances are a problem, please consult our financial advisor in
the business office.

5. Financial Policies 5
______Insurance providers do not always pay for every medical service, even
those that would be beneficial to the patient. In some cases, it may be lack of
pre-authorization. At any rate, should the situation arise that a service is not
covered by the patient’s insurance policy; unfortunately, the patient is then
responsible for footing the bill out of pocket.
Established Patient Change of Insurance Policy:
______ It is the responsibility of the patient to notify our office at least 24 hours in
advance of their next scheduled appointment if their insurance provider or policy
has changed. This advance notice is required because most insurance carriers
require the physician obtain pre-authorization to treat the patient.
In the event the patients neglects to notify the insurance change with in the 24
hour period, the end result will leave the patient paying in cash for that days visit.
*Please note Smooth Waters Psychiatry starts patient visit charges at $250.00 per hour and up. Therefore, any
delay in the office receiving the new insurance information, will cause delay in payment from the insurance
provider. Which could result in a denial of coverage and non-payment.
Past due Accounts:
______ If at any time under the care of Smooth Waters Psychiatry the patient’s
account becomes delinquently past due “we will take all necessary steps in order
to collect this debt” (Coastal Kids Dental, 2012). If the patient is non-compliant in
reimbursement for services rendered Smooth Waters Psychiatry will peruse
collection actions further. (Lexington, 2006).
______ Smooth Waters Psychiatry employs the use of a collection agency to
collect any and all unpaid debts which may adversely impact the credit record of
the patient.
______ Patients who have had their past due accounts turned over to our
collection agency will also be discharged as a patient from Smooth Waters
Psychiatry.
A representative in our business office is available to answer any questions you may have regarding patient
accounts or payment arrangements at (123)-456-7890.
I have read and understand the Financial Policies of Smooth Waters Psychiatry
and consent to treatment and billing of my insurance agent.
Patient Signature: X____________________________
Patient Printed Name: ____________________________
Date of Acknowledgement: ___/___/______

6. Financial Policies 6
Reference
Coastal Kids Dental. (2012). Coastal Kids Dental Financial Policies. Retrieved from
http://www.coastalkidsdental.com/policies.html
Lexington (2006). Office Information. Retrieved November 27, 2009, from
http://www.lexobgynnyc.com/office-fin.html
The Woodlands Ob/Gyn Associates . (2012). Woodlands Ob/Gyn Associates. Retrieved
from http://www.woodlandsobgynassociates.com/OurOffice/OfficePolicies.aspx
U.S. News. (2011). The Top 25 Health Insurance Companies. Retrieved from
http://health.usnews.com/health-plans/national-insurance-companies

7. Financial Policies 7
Part B
In the medical field many physicians’ offices train their staff on policies and
procedures through verbal instruction from one staff member to another. This process
lacks stability and causes the practice to function much less efficiently. “Inevitably,
important elements of policies are lost in translation. Creating written financial and office
policies and procedures help staff learn their jobs faster, with greater accuracy, and
relieves physician and manager frustration” (California Medical Association, 2013).
This policy is written for a larger psychiatric practice; however, these policies
could be implemented in almost any private practice setting. This policy uses clear
straight to the point language in order to inform both patients and staff of what to expect
from one another in the financial billing process. This financial policy notifies the patient
that any changes should be reported directly to the office in a timely manner. The patient
is also informed they are responsible for notifying staff of pertinent changes to their
information.
The financial policy further advises patients of their financial obligations and to
remit their insurance co-payments or deductibles at the time of their appointment with the
doctor and that, should their insurance company require a preauthorization or referral,
they have to obtain this on their own prior to scheduling a visit with the provider. The
patient is made aware that the staff is more than happy to bill their insurance provider on
their behalf; however, the patient must provide the insurance company any additional
required data.

8. Financial Policies 8
The financial policy contains supplementary information such as, the forms of
payment that the office accepts, non-covered services, returned checks, minimal office
penalty fees, payment plans, and the collection process for past-due accounts.
Implementation of a sound financial policy counsels the patients and the staff of their
responsibilities. The financial policy thwarts unanswered questions and disputes as to
whose responsibility each portion belongs to.
Although, significant problems can arise when a patient or an office staff does not
pursue the official financial policy. For instance, let us assume a patient does not acquire
the referral necessary for their insurance company to provide coverage prior to their visit;
they will not be able to see the doctor. When the patient is allowed to see the physician
without the referral, the patient will then be required to pay the full amount of their
appointment at that time.
Having a firm financial policy in any medical practice prevents confusion on
behalf of the patients and the staff. Patients are held responsible for their financial
obligations and staff mistakes occur much less often. The communication between the
patients and the staff is vastly enhanced and miscommunications decline simply by
maintaining a clear financial policy. This enables the practice to become much more
productive, profitable and to perform more efficiently when there is clear communication
between the patients and staff as to what is expected of them.

9. Financial Policies 9
Reference
California Medical Association. (2013). Creating and Implementing Financial and
Office Policies . Retrieved from http://www.cmanet.org/events/detail/?
event=creating-and-implementing-financial-and-office

10. Financial Policies 9
Reference
California Medical Association. (2013). Creating and Implementing Financial and
Office Policies . Retrieved from http://www.cmanet.org/events/detail/?
event=creating-and-implementing-financial-and-office