Certain testing and treatment is considered investigatory and may not be covered by your insurance plan. Prior to having such testing or treatment, you will be asked to fill out and sign an ABN (Advanced Beneficiary Notice) form. The purpose of this form is to inform you that a specific test or treatment might not be covered by your insurance and you are agreeing to pay for the charges in full.

Retina Center of Vermont participates in most insurance plans offered in the region, including:

• Medicare
• CIGNA
• MVP
• Vermont Medicaid
• VMC (Vermont Managed Care)
• Blue Cross Blue Shield
• Great West
• CBA (Comprehensive Benefits Administrator)
• UHC (United HealthCare)
• Aetna

If you are not insured by a plan that we accept, or do not have any medical insurance, payment is expected in full at the time of service. If you are insured by a plan we accept, you must present a valid, up-to-date insurance card. Payment will be expected in full at the time of service unless proof of coverage can be verified. Please contact your insurance company or your employer with any questions you may have regarding your coverage.

Co-insurance, co-payments and deductibles that you are responsible for will be collected at the time of service. We will happily try to assist you in determining your co-insurance or deductible obligations. However, not all insurers provide us with that information in an expedient manner. Therefore, we strongly recommend that you address any issues with your insurer prior to your appointment. If your insurer concludes, after reviewing a claim that we submit to them on your behalf, that you owe RCV an additional balance, we will forward an invoice to you. Patients are responsible for payment within 30 days of the statement date. Any overpayments to RCV after a claim is processed will be refunded to you.

Please be aware that some (or all) of the services that you receive at RCV may be non-covered or considered not medically necessary by your insurer. We do our best to obtain information regarding which services may not be covered. However, this information may not be available until the claim has been processed by your insurer. If we know in advance that the service will not be covered by your insurance, we will notify you. You will then be responsible for payment at the time of service. Any balance on your account for non-covered services will be billed to you and must be paid within 30 days of the statement date.

If your insurance changes, please notify us before your visit so we can make appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim within 45 days, the balance will automatically be billed to you.

Monthly statements are generated only for patients whose accounts have an open balance. Payment is due within 30 days of the statement date. Please note that balances unpaid after 30 days will incur finance/service charges. If you are experiencing a financial hardship, please be sure to contact our Billing Manager to arrange a payment plan.

Payment for all services is expected on each occasion in which service is provided. If you do not have insurance, or are experiencing a financial hardship, please contact our Billing Manager.

We reserve the right to charge you for any missed appointments. All appointment cancellations and rescheduling should be done at least 24 hours in advance.

Our practice is committed to providing the best treatments, testing, and specialty care to our patients. Our prices are representative of the usual and customary charges for our specialty and locality.

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. Out-of-network providers (providers and facilities that haven’t signed a contract with your health plan to provide services) may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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—such as 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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 hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can 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. If you get other types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”). They must cover emergency services by out-of-network providers. They must 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. In addition, they must count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed and that your rights and protections from surprise medical billing has been violated, call the Federal phone number for information and complaints: 1-800-985-3059.

Visit www.cms.gov/nosurprises/consumers for more information about your rights under Federal law.