OFFICE FORMS & DOCUMENTS

Insurance and Financial POLICIES

Insurance Policies

PPO, HMO, EPO Plan Participation

Our office accepts most health insurances. Here is partial list of the insurances we accept. If you do not see your insurance on this list, please contact our office.

FloridaBlue
United Healthcare
AARP Medicare Advantage
Golden Rule
Humana (All plans EXCEPT Humana Gold Plus)
Aetna
Cigna
Avmed
Medicare
Tricare
CarePlus
Ambetter by Sunshine Health
CHAMPVA
Magellan
Wellcare Health Plans
Health First
MultiPlan/PHCS
Medicaid (AmeriGroup, Simply Health, Sunshine Health, Hillsborough County Health Plan, Prestige Health Choice)

Pre-Authorization

Many insurance plans require prior authorization for hospital admissions and certain outpatient procedures or tests. In some instances, your physician may be aware of these requirements and will proceed with obtaining the proper authorization; however, it is impossible to know these requirements for all insurances and procedures. It is important that you check with your insurance carrier to verify if your procedure or test requires authorization and let your physician know. Claims denied for lack of pre-authorization may be billed to the patient.

Medicare

We are pleased to be a participating provider in the Medicare program and will file claims for Medicare beneficiaries. Patients are responsible for paying their annual deductible, if it has not yet been met. Co-insurance or non-covered services are the responsibility of the patient. If there is a supplemental coverage available, our office will file a claim to the second carrier as a courtesy; however, follow-up with the supplemental carrier, as well as amounts not paid, are the responsibility of the patient. Most supplemental and secondary insurances have a separate deductible that must be paid.

Medicare does not always cover a service. Certain types of routine care and diagnostic tests, braces, and orthotics, as stated in the Medicare benefits, may not be covered; Medicare patients should expect to be responsible for these services. Please note: this does not mean these services are not an important part of the health care being provided to you. Our office participates with most Medicare advantage plans or Medicare replacement plans. Please contact our office to verify if your Medicare Advantage plan is accepted.

Workers’ Compensation

Our office provides workers’-compensation-related services within several departments. When scheduling your appointment, please notify the receptionist that your visit is related to a work injury. In order to file your workers’ compensation claim, we are required to obtain the following information:

  • Employer name, address, phone number and an employer contact
  • Date of injury
  • Claim identification number and/or employer authorization
  • Name of workers’ compensation insurance company
  • Claim address and phone number
  • Insurance contact

This information may be obtained at the time of your visit or by phone. Attempts will be made through your employer to verify authorization for your visit. Patients seen for work-related injuries who are unable to provide the required information, or for whom the employer has not provided us with authorization, may be asked to make payment for their services.

Motor Vehicle Accident Related Services

Our office will submit a claim to your auto carrier when you provide the following information at the time of your visit:

  • Date of accident
  • Complete name and claim address of auto insurance
  • Claim number

As a further courtesy, we will allow up to 30 days for the auto carrier to make payment on your claim. At the end of the 30 days, you will be responsible for the unpaid balance. You are encouraged to remain in contact with your agent or auto insurance carrier regarding the status of your claim(s) as well as the benefits of the plan, including any deductibles, policy limits or exclusions. Patients seen for motor-vehicle-related services who do not provide us with the appropriate information to file the claim will be asked to pay for service in full at each visit.

Other Insurance

You may carry a commercial group plan that does not fall into one of the aforementioned categories. In most cases, as a service and courtesy to you, Modern Foot & Ankle will file your initial claim on your behalf.

You may be asked upon arrival to make a payment toward your anticipated out-of-pocket amounts such as deductibles or co-insurance. Any amounts unpaid by you and your insurance after the claim has been processed will be billed to you. You are encouraged to contact your insurance carrier prior to your visit to confirm your benefits.

Uninsured Patients

Our office welcomes patients without insurance coverage. To help offset the cost, we offer a Prompt-Pay Discount. Uninsured patients will be asked to pay their balance in full at each visit. Checks are not accepted for self-pay patients.

Financial Policy

Insurance Coverage

Modern Foot & Ankle is contracted with and accepts most local insurance plans, but not all. As a service to our patients, we will file eligible claims to most plans. We do not file claims to specific non-participating HMO plans or to plans outside of the U.S. Prior to your appointment, you should consult with your insurance carrier or your benefits booklet for a list of providers and benefits available to you. This will allow you to verify the services and providers you seek are covered, identify any authorization requirements or exclusions, and confirm the level of benefit available. Many plans will provide some degree of coverage to providers not listed in their network.

Coverage determinations are ultimately made by the insurance company after a claim is submitted; therefore, we are unable to guarantee their payment. It is necessary that you are aware of the details of your coverage before obtaining care as you will be held personally responsible for your account balance regardless of whether or not your insurance pays the total balance of your claims. Your insurance policy/employee benefits plan is a contract between you and your insurance company/employee benefits plan. We are not a party to that contract.

Referrals and Authorizations

We are required to follow the guidelines of your managed care plan, which may mandate that when you visit a specialist, such as us, you must first obtain a referral from your primary care physician. If a referral is required, you are financially responsible for the services received unless your referral is presented at the time of the visit. If, at the time of your visit, you do not have a referral from your primary care physician naming Dr. Adam Siegel as the referred provider, you will be financially responsible for all services received, due in full upon completion of the visit.

Claim Submission

As a courtesy service to you, we will submit your insurance claim for in-network services rendered in our office and assist you in any way we reasonably can to help get your claim paid. Please be aware that the balance of your claim is your responsibility, whether or not your insurance company pays for it. Your insurance benefit is a contract between you and your insurance company.

Insurance Follow-Up

Modern Foot & Ankle strives to provide accurate and timely billing to insurance companies and patients. In most cases, claims are filed and processed by the insurance company within 30 days of receipt. Any unpaid balances are billed to the patient within 60 days from the date of service. On occasion, a carrier may not respond immediately, and further attempts to obtain payment from your insurance company may be required. In such instances, payment from the carrier may take longer than usual, and you may be billed for amounts not covered by the plan at a later date.

Our office generally makes two or more attempts for payment from the group carrier. Occasionally, a claim may remain unpaid by insurance even after repeated efforts by our billing office to resolve it. In such cases, the unpaid balance may then be billed to you with an indication to contact your carrier regarding questions about the payment of your claim. This is not our preferred method of billing; however, we have found that with the assistance of the patient in these instances, the claim is often resolved fairly quickly by insurance. If not resolved by insurance, then the claim will become the responsibility of the patient.

Non-Covered Services

Depending upon the insurance carrier, some medical procedures are considered “non-covered” and are the full responsibility of the patient. Common examples (note: this is NOT an exhaustive list) include routine foot care, orthotics, certain wound supplies, certain amniotic membrane injections, cosmetic procedures, certain surgical procedures, and over-the-counter products. Ultimately, it is your responsibility to determine what your policy covers. Any non-covered services will be the full responsibility the patient.

Account Balances

Co-payments, payments for cash products, and payments for non-covered services are due in full on the day of your appointment. Account balances, pre-payment for estimated deductibles, and co-insurance amounts may also be requested when you check in or check out. Any amounts not covered by your plan and not collected on the day of service will be billed to you and are due in full upon the receipt of your statement. Any overpayment will be refunded to you in the form of check or credit. Patients will receive a billing statement each month for balances that are due from them. The bill is itemized and will reflect the cost of service. Payment is due in full by the date indicated on the statement. Questions about this amount may be obtained by contacting Modern Foot & Ankle.

Payment options

Account payments can be made at the time of check-in or at any time in person at our location, through the mail, or over the phone. Payments can also be made online at ModernFootAnkle.com, through onpatient.com., or via the onpatient iPhone app. Unfortunately, we are unable to accept checks from our self-pay patients. There will be a $30.00 returned-check fee assessed when applicable.

Payment methods include:

  • Check
  • Cash
  • Credit/Debit Cards
  • CareCredit
  • HRA, HSA, FSA cards

Cancellations

Cancellations for scheduled surgery must be received at least 5 days prior to the scheduled surgery date. Patients who fail to cancel a scheduled surgery within the allotted time frame will be charged a $100.00 no-show fee.

Delinquent Accounts

Accounts that remain unpaid after 60 days will be treated as delinquent and efforts will be made to collect the unpaid balance. These efforts may include phone calls, letters, and possible referrals to an outside collection agency. It is our sincere desire to avoid outside collection agencies. As such, a notice will be mailed to the last known address on the account prior to any referral. Patients are strongly encouraged to work with our business office on suitable payment arrangements to avoid placement of their account with an outside agency.

Patient Cooperation

If we accept your insurance assignment as a payment from your insurance reimbursement, you agree to a timely cooperation with your insurance company or health plan in the course of the insurance claim processing, such as insurance inquiries, requests for additional information, claims status verification, or any inquiries for the purpose of your claim processing. You also agree to notify us immediately of any insurance inquiry or request for additional information and provide us with a copy of any documentation received from the insurance company or submitted to insurance company from you.

In an event that you do receive insurance payment checks for your surgeries rendered by Dr. Adam Siegel, you agree to submit such insurance reimburse check to our office within five (5) business days after your receipt of insurance checks. In a failure or refusal to forward or send us the insurance reimbursement checks for the medical services from this provider, all of your discount arrangements will be voided, and the total balance is due immediately, as there is no justification for you to hinder the insurance payment for our services as you have promised to pay for our services. You further agree to compensate us for any legal fees should we retain any legal services to collect past dues.

Office Forms and Documents

Insurance and Financial Policy

If you wish to download our Insurance & Financial Policy, you my do so here.

Breaking In Your Orthotics & Shoes

We have produced detailed instructions for breaking in therapeutic shoes and custom-molded inserts

Supplier Standards

We are compliant with all the rules and regulations of the Medicare program. Please feel free to download the list of the Durable Medical Equipment (DME) Supplier Standards.

Notice of Patient Rights

We want you to fully understand your rights and responsibilities when you visit our office. Please feel free to download this file and keep for your records.

Authorization to Disclose Health Information

Use this form if you wish to have Modern Foot & Ankle share your health information with another party.

HIPAA Data Use Agreement

This form explains how and when we use your personal health information.

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