We are delighted that you have entrusted your care to Dr. Cook and the staff at Midland Plastic Surgery Center (AKA MPSC). We look forward to helping you reach your healthcare goals. Our practice believes that a good physician/patient relationship is based upon understanding and open communication. To that end, the policies outlined below are intended to provide understanding of our mutual expectations regarding the financial guidelines of MPSC. We hope you will find this information helpful.
Overview of our Respective Financial Responsibilities
• MPSC’s Responsibility – To post charges and payments accurately. To prove claims and statements to the responsible party based on the best information available to us. This includes direct insurance billing and patient billing for remaining balances. To provide accurate financial counsel to patients who contact our billing department.
• Patient’s Responsibility – To assure that MPSC is provided with the most current insurance information known. To provide timely payment to MPSC for all balances to be the responsibility of the patient (whether co-pay at the time of service or balances due following insurance payments applies i.e., deductibles and coinsurance). Delays in communicating changes in your insurance coverage may result in the balance being uncollectible from the insurance company and the full responsibility for payment falling on the patient.
The total patient balance due is required to be paid at the time services are provided. For your convenience we accept cash, checks, Visa, Mastercard, Discover, American Express, CareCredit, Alpaeon, and United Medical Credit. Our office participates with a variety of insurance plans. It is your responsibility to:
• Bring your insurance card at every visit. If you do not have your insurance card, you may be asked to pay at the time of the service and sign a waiver of responsibility;
• Be prepared to pay your co-payment and or co-insurance at each visit;
• For medical care not covered, deemed medically unnecessary or deemed cosmetic by your insurance company, payment in full is due at the time of the visit. If unable to do so, please contact our Billing Department at 432-618-6772 ext. 110.
You are responsible for any balance your insurance does not cover. We will file your insurance claim and allow forty-five (45) days to render payment. After forty-five (45) days, if we have not had a response from your insurance company, you will be responsible for the entire balance. We do file secondary insurance claims for your payment to our office. If you have insurance that is considered “out of network” we will bill them as a courtesy to you but any amounts unpaid by your plan will be your responsibility.
Medicare and Medicaid:
Medicare – Please be aware that some office visits and/or procedures are not covered by Medicare on an annual basis. Please check with your local Medicare carrier for specific benefit guidelines. We do accept assignment from Medicare. For services/procedures not covered by Medicare you will be asked to complete and in an ABN form. For Surgical Procedures – We will require a deposit of $500.00 which will be due ten (10) business days prior to your surgery date. Medicaid – We do accept assignment from Medicaid.
Children of Divorced Parents:
Responsibility for payment for treatment of minor children, whose parents are divorced, rest with the patient who seeks the treatment. Any court ordered responsibility judgement must be determined between the individual involved, without the inclusion of Midland Plastic Surgery Center PA.
Please be advised that patients may receive sperate bills for any lab tests, cultures and biopsies, as they may be sent to outside sources for analysis. Any inquiries regarding their charges should be made directly to that facility’s business office.
Medical Records Fee – If you are waiting medical records for your personal use there is a $25.00 charge for the first twenty (20) pages and $.50 for each page thereafter. There will need to be a Medical Release Form completed and signed. Please allow fifteen (15) days for the records to be processed.
Return Check Fee – If a check does not clear the first time our bank will automatically run the check through a second time of processing. Checks that are returned to our office will carry a $25.00 return check handling fee. It is expected that the patients will pay the amount of the returned check and the fee wit with cash or credit card as soon as the situation is brought to their attention.
No Show Appointment Fee – If we do not receive a 24-hour notice to cancel or reschedule an appointment,
there will be a $25.00 charge added to your account.
Surgical Fees – Midland Plastic Surgery Center provides only surgical services. Other services are necessary to complete your surgical treatment i.e., anesthesia, radiology and pathology, to name a few. There is a possibility that “out of network” providers may provide all, or part of the covered services related to your surgical care.
Cosmetic Procedures: During the scheduling process, our Surgery Coordinator will estimate the “out-of-pocket” cost of your scheduled procedure. A deposit of $500.00 will be collected at the time your surgery is scheduled along with a cancellation fee of $500.00*; total of $1,000.00. The remaining balance must be paid ten (10) business days prior to your surgery. If you cancel within five to ten (5-10) business days prior to your surgery date, one-half of your deposit will be refunded. If less than five (5) business days, there will be no refund.
Non-Cosmetic Procedures: During the scheduling process, our Surgery Coordinator will estimate the “out-of-pocket” cost of the scheduled procedure. This estimated cost will be collected when the
surgery is schedule.
Form Completion – If you have the following forms that will need to be completed there is a $25.00 fee per
• Short Term Disability;
• Long Term Disability; or
• Verification of Wellness Examination
Please note, these forms will be completed within ten (10) business days after being submitted. If you would like them in a timely manner, bring them to your Pre-Operative appointment with our Surgery Coordinator. Thank you for taking the time to review and understand our financial policies and the reason behind them. If you have any questions or concerns about the financial aspects of your relationship with us, please feel free to contact our Billing Department at 432-618-6772 ext. 110.
Important Numbers to Know:
Appointments 432-618-6772 ext. 101
Billing Department 432-618-6772 ext. 110
Nurse 432-618-6772 ext. 103
Medical Assistant 432-618-6772 ext. 102
Practice Manager 432-618-6772 ext. 108
Surgery Coordinator 432-618-6772 ext. 107