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Financial Policy and Procedures
Rockford Orthopedic Surgery Center

Dear Patient:

The physicians and staff at Rockford Orthopedic Surgery Center appreciate the opportunity to provide outstanding orthopedic medical care to the Northern Illinois area. It is our obligation to provide the most responsive and high quality care in a cost-effective manner. To assure continued community service, our facility strives to provide any financial resources available. As the patient, or the responsible person for medical charges, we have provided you this pamphlet to help you understand our financial policies.

Sincerely,
Rockford Orthopedic Surgery Center

If you have any questions in regards to our policies or an account, please do not hesitate to contact our office at (815) 484-6908 or (815) 381-7402. Our business hours are 7:00 a.m. - 4:00 p.m., C.S.T. Monday through Friday.

Rockford Orthopedic Surgery Center
346 Roxbury Road
Rockford, IL 61107
(815) 381-7400

Payments can be made using cash, check, money order, Visa, Master Card, or Discover. Options for any patient balance greater than $100 are described in our payment policy guidelines. Please contact our A/R department for a copy.

Patients with Employment Injuries

Rockford Orthopedic Surgery Center will bill any Workers' Compensation insurance carrier or employer providing prior authorization. We are unable to schedule patient surgeries under any of the following circumstances

• There is no prior approval from the Workers' Compensation insurance carrier or employer
• The Workers' Compensation claim is disputed or denied
• The patient is in the process of filing a Workers' Compensation claim
• The patient is considering filing a Workers' Compensation claim

Patients should notify our office to discuss setting up a surgery once a Workers' Compensation carrier has authorized payment for treatment or the issue has been determined by the Illinois Workers' Compensation Commission.

If a Workers' Compensation carrier denies further authorization for patients already undergoing treatment, it will then be the patients' responsibility to contact their health insurance carrier and receive approval for any further treatment in writing.

Falsification of information provided by patients may result in discharge from our practice.

Patients with Liability or Auto Accident Injuries

Liability insurance information must be given at the time of service. If an attorney is involved you will be responsible for providing us with their name, address, and phone number. We will bill your liability insurance carrier as the primary payer. Once the liability insurance has maxed the patients' health insurance will be billed.

As a courtesy to our patient's we will bill the Third Party Carrier, but the patient is ultimately responsible for their services.

Any balance remaining after 30 days will be the patient's responsibility.

Patients without Medical Insurance

Payment in full is expected at the time of service unless prior arrangements have been made with our financial counselor.

Patients on Medicare

All claims will be filed to Medicare and your Medicare supplement insurance. If you do not have a Medicare supplement, or your supplemental policy does not pay, any remaining balance will be your responsibility.

Patients receiving Illinois Public Aid

You are required to bring your current state issued Medicaid card at the time of service. We will then submit your medical claims. If you do not have your card or you have an unmet spend down, you will be responsible to pay for any services at the time of treatment.

It is the patient's responsibility to contact their insurance carrier to verify that Rockford Orthopedic Surgery Center is contracted with them. If a referral is required, it is your responsibility to contact your primary care physician before your appointment. We reserve the right to reschedule any surgery if all required information is not received prior to your appointment.

Patients covered under Contracted Insurance's with Rockford Orthopedic Surgery Center.

All co-pays are due the day of surgery, or your surgery may be rescheduled. If payment is not made a dated return envelope will be given to you to remit payment within 5 business days. If payment is not received within the days allowed, a $50 billing fee will be charged to your account. We will bill all services to the appropriate insurance carrier. Any co- insurance or unpaid balances are to be paid in full unless prior arrangements have been made with the billing department

Patients covered under NON-Contracted or Commercial Insurance's

We will bill all services to the appropriate insurance carrier. Any co-insurance, over usual and customary, or unpaid balances are to be paid in full unless prior arrangements have been made with the billing department.

• If an insurance company has indicated a charge is above usual customary, please understand this only means it is above their allowable rate. We want to assure you that our charges reflect the complexity of care given and the skill and expertise required for your care. We use many sources to determine the appropriateness of our charges, and cannot have insurance companies setting our fees. If you have any questions in regards to "usual and customary," please contact your insurance carrier.