Sample Payment Policy for Medical Practices

August 2, 2014

One way to ensure patients understand your payment requirements is to ask them to sign a payment policy. Here's a sample policy to consider adapting for your practice.

Accepting insurance at your practice and signing a contract does not mean that you've opened your arms up to assume that financial risk. It is important that patients understand this concept.

One way to ensure patients understand your requirements is to ask patients to sign a payment policy.

Here's a sample policy to consider adapting for your practice:

As a courtesy, (your practice name), verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.

It is the policy of (your practice name) that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. The office manager at your location will explain this information to you prior to your first visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.

If you are covered by health insurance with (your practice's specialty) benefits, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.

Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician's referral and our verification of your insurance benefits are not a guarantee of payment.

We highly recommend you also contact your insurance carrier and check into your coverage for (practice specialty). Do not assume that you will not owe anything if you have more than one insurance policy.