Financial & Additional Policies
At Carrell Clinic, we are committed to providing you with an exceptional patient experience, from start to finish. As a part of that commitment and to help you better understand our patient policies, we have provided the following content for you to reference so you know what to expect from our practice. This information can also be found on our online patient forms.
The physicians and employees of Carrell Clinic a division of OrthoLoneStar are dedicated to providing the best possible care to you at the best possible value; therefore, we regard your understanding of our financial policies an essential element of your treatment. Our intent is to be fair, transparent, caring and accessible. If you have any questions, please discuss them with one of our staff members.
When you complete our online financial policy form, you are authorizing the following:
- I/we assign to OrthoLoneStar, PLLC (“OLS”) all insurance benefits or Medicare benefits to which it may be entitled for services rendered by its providers and authorize direct payment to the practice. This assignment includes without limitation major medical and disability insurance proceeds and benefits accruing under any settlement, structured or otherwise, or awarded in judgement for personal injury caused by a third party. I/we agree to pay practice for all charges not paid pursuant to this assignment.
- For ERISA, out-of-network, and self-funded plans, I assign and convey directly to OLS, as my designated authorized representative, all insurance reimbursement for services rendered by OLS regardless of network participation status. I authorize OLS and its authorized agents to negotiate, discuss, appeal and, in any other way, communicate with my insurance company to determine final payment for services I received. OLS has full authorization to accept or reject any proposed reimbursement proposal, and to act as necessary to accomplish the final adjudication of any claims. The results of that determination are binding upon me/us.
- Release of pertinent medical information to your insurance carrier(s).
- Administrative charges for completion of forms such as disability and FMLA forms, medical records copies, CDs of images, printed films, or similar items. Information can be found on our web site, www.carrellclinic.com under Patient Resources.
- If, after all your claims have been paid, the resulting balance is a credit of $5.00 or less, you will authorize us to write off this balance. Amounts greater than $5.00 will be refunded to you.
- I/we understand that insurance coverage and verification is not a guarantee of payment. I/we agree that I/we am/are ultimately responsible for any balance due after my insurance has paid or denied my claim(s). I/WE UNDERSTAND THAT I/WE AM/ARE RESPONSIBLE FOR ANY CHARGES IF THE INSURANCE COMPANY DENIES A CLAIM FOR ANY REASON INCLUDING STATING THAT IT IS INVESTIGATIONAL, EXPERIMENTAL, A PRE-EXISTING CONDITION, AUTO RELATED OR ACCIDENT-RELATED WHERE LIABILITY INSURANCE IS INVOLVED, OR ANY OTHER NON-COVERED SERVICE(S).
Responsibilities and acknowledgement of financial policy specifics:
- Please present your insurance card and photo ID at each appointment. Please share address, telephone number and/or insurance information updates any time a change occurs.
- Payment is due at the time of service unless other arrangements have been made in advance. For your convenience, we accept cash, check, and most major credit cards. Other financing options may be available. Please ask our staff about these programs.
- Payment of your deductible and coinsurance will be required for your calculated portion of our fees, based on your insurance contract, in advance of any scheduled surgical procedures and diagnostic testing. Any balance remaining after your health plan pays its portion for any in-office services, durable medical equipment, physical therapy services, imaging services or surgical procedures is your responsibility and payment for balance is due upon notification from our office. Any overpayment will be refunded directly to you.
- You may be asked to put a credit card on file, which will only be charged according to the terms you agree to when placing such card on file. By processing your insurance first, we will only charge you for your exact out-of-pocket responsibility. You will receive notification containing a summary of charges and an estimate of what we believe you will owe. After your insurance has processed your claim, you will receive a second notification informing you of the actual amount you owe and notifying you that your card will be charged for any in-office services, durable medical equipment, physical therapy services, imaging services or surgical procedures where there is a balance due from the patient per the patient’s insurance agreement or self-pay responsibilities. Contact the practice if you have questions once you receive this notification.
- Your insurance is an agreement between you and your insurance company. As a courtesy to you, we will file your insurance claims for you if you assign benefits to the practice. If your insurance does not pay, we will look to you for payment of your balance in full.
- All health plans are not the same and do not cover the same services. If your health plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. You are responsible for knowing and understanding your insurance benefits.
- You will be responsible for promptly responding to your insurance company to provide additional information they may request regarding your treatment, pre-existing conditions, accidents or other insurance coverage. Failure to respond in a timely manner may result in your account becoming due and payable, in full, by you.
- Self-pay patients: Payment is due at the time the service is rendered unless other arrangements have been made in advance. We accept cash, checks, VISA, MasterCard, Discover and AMEX.
- You may pay your bill on-line at www.carrellclinic.com. Payment plans are offered through our on-line payment portal, Smart Health Pay Card or Care Credit.
- Responsibility for payment for patients who are minors whose parents are divorced rests with the parent who seeks the treatment or the adult accompanying the minor for all services rendered to the minor patients regardless of any court order responsibility judgement.
- Appointment Cancellations within 24 hours of scheduled time may result in a charge in a $45.00 charge. Returned checks for any reason will results in a $35.00 charge.
- Failure to notify us 48 hours before canceling a surgery may result in a $100.00 charge.
- Some orthopedic supplies are not covered by your insurance, in which case we will require payment at time of service. A deposit will be collected upon receipt of certain Durable Medical Equipment items.
- All HMOs and some PPOs require prior authorization or referral from your primary care physician for each visit. This is your responsibility. IF YOU DO NOT HAVE THIS REFERRAL NUMBER AT THE TIME OF YOUR APPOINTMENT, YOUR BENEFITS MAY BE PAID AT A REDUCED RATE OR NOT PAID AT ALL AND YOU WILL BE RESPONSIBLE FOR THE CHARGES.
- When you are charged a “global” fee for surgery or office care of a fracture, laceration repair, excision of an ingrown toenail, or other medical procedure, that fee includes the service on the day it is performed and routine follow up care as well. The global period ranges from 10 to 90 days depending on the procedure and your health plan. Injections, X-rays, and supplies (such as casting or dressing materials, splints, braces, etc.) are not included in the “global” fee and a charge will be made for these items. Services related to complications are not included in the global fee.
- Please note there are no refunds or returns on all braces/soft goods.
- If you do not pay your balance and we are required to use a third party to collect your balance, an administrative charge of up to 25% of the balance may be added to the amount you owe.
- The Carrell Clinic Billing Coordinators are available to help you with your billing questions Monday through Thursday between 8:30am and 5:00pm by calling (214) 220-2468.
Consents and Notices
Physician's Assistant and Certified/Nurse Practitioner Consent
Carrell Clinic and its affiliates utilize Physician's Assistants and Nurse Practitioners (collectively known as “Non-Physician Practitioners”) to assist in the delivery of orthopedic medical care. A Non-Physician Practitioner is not a physician. Texas licenses Non-Physician Practitioners. Non-Physician Practitioner can, under the supervision of a physician, diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care and assist at surgery. Supervision does not require the constant physical presence of the supervising physician, but rather overseeing and accepting responsibility for the medical services provided. Carrell Clinic, its employees, and affiliates, may bill your insurer or plan administrator fiduciary separately to obtain payment for the services of Non-Physician Providers.
To serve you with the highest care quality, sometimes it is necessary to have other care providers join our team to complete or continue your medical procedures or treatment. We would like to keep you informed about any referrals to care providers who may be in or out-of-network. Should this practice or my physician refer me to a physician or non-participating provider out of the preferred provider panel, this practice or physician will disclose to me that the referral is out of the preferred provider panel and any ownership interest.
Disclosure of Physicians’ Ownership Interests
Our providers are committed to helping facilitate exceptional care at various healthcare facilities. By maintaining ownership in the facilities, our providers are able to have a voice in administrative and operational direction, resulting in a higher overall quality of care. Pursuant to Federal and Texas Law, I have been informed that either W.B. Carrell Memorial Clinic or one or more of its affiliates, physicians, or owners have a financial interest in one or more of the following organizations: North Central Surgical Center, BS & W Surgical Center at The Star, Meadow Lane Surgical Alliance, and Glen Creek Surgical Partners. After meeting with a physician, if surgery is necessary, your physician may schedule your surgery at NCSC or BS & W Surgical Center at The Star. If an MRI, CT, or other imaging service is necessary, your physician may schedule your procedure at NCSC. Because of this, your physician hereby advises you that you have the right to choose to be treated at a different facility, should you desire, and he will make such an arrangement, if possible. These facilities are separate legal entities from W.B. Carrell Memorial Clinic. You will receive separate billing from each entity. We want you to know that you do have the option to use an alternative health care provider, should you choose.
The following guidelines are intended for your safety and efficiently meeting your medication needs.
- Take medication only as prescribed
- We do not prescribe long term medications, patients requiring long term pain medication will be referred to a pain management specialist.
- Call your pharmacy directly for medication refills
- Instruct pharmacy to fax all request to 214-750-1982
- Choose only one pharmacy for all of your medications
- Allow three business days for medication refills
- Early refills will not be honored for any reason
To protect your health: Notify our office of all medication changes by other physicians, as this can be a potentially dangerous situation. Lost, stolen, or misplaced medications are replaced only with a clinic visit.
Formulary Benefits Data Consent Form
Formulary Benefits data are maintained for health insurance providers by organizations knowns as Pharmacy Benefits Managers (PBM). PBM's are third-party administrators of prescription drug programs whose primary responsibility is processing and paying prescriptions drug claims. They also develop and maintain formularies, which are a list of dispensable drugs covered by a particular drug benefit plan. We may need access to your data as maintained by PBM's to know what medications have been prescribed to you in the past and to know which drugs are covered by your insurance plan. This consent will enable W.B. Carrell Clinic to:
- Determine the pharmacy benefits and drug copays for a patient's health plan.
- Check whether a prescribed medication is covered (in the formulary) under a patient's plan.
- Display therapeutic alternatives with a preference rank (if available) within drug class for non-formulary medications.
- Determine if a patient's health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe to these pharmacies.
- Download a historical list of all medications prescribed for a patient by another provider.
Opioid (Narcotic) Prescription Policy
We understand that physical pain is interpreted differently among all of us and we are sensitive to the fact that many of our patients present to us with physically painful conditions. However, it is also our duty as physicians to minimize harm to patients. Narcotic addiction is a national epidemic. Physicians have been placed on the front line of managing this epidemic and are held accountable. In order to protect our patients and maintain our professional standing, Carrell Clinic a division of OrthoLoneStar, PLLC and its wholly owned subsidiaries and affiliates have an established policy for prescribing narcotics.
- Narcotics will not be prescribed for chronic pain conditions; however, they can be prescribed for acute conditions at the discretion of the treating physician.
- If you are under the care of a pain management physician, we expect you to disclose this information on your first visit. Failure to do so would violate your contract with your pain management physician.
- Narcotics will be prescribed post-operatively for a maximum of six to eight weeks depending on the type of surgical procedure performed.
- Prescriptions for narcotics will be dispensed in accordance with the Texas Prescription Monitoring Program. They may not be “called in” to your pharmacy.
- Your prescription history will be reviewed prior to the prescribing of any narcotic medication, pursuant to the Texas Prescription Monitoring Program.
- If you are taking narcotics prescribed by a pain management physician, you will need to receive your post-operative pain medicine from that physician.
- Long-term pain medication needs will require a referral to another physician, such as a pain management physician or primary care provider.
- Refills may take up to three days to process, so you must call well in advance. No refills will be authorized after hours or on weekends. NO EXCEPTIONS. On-call physicians are not authorized to refill narcotic pain medication. You may be asked to come to the office to be reevaluated prior to receiving a refill.
- Lost, damaged or stolen prescriptions will NOT be replaced.
- All medications are to be used as prescribed. Adjustments or increases in the amount of medication should not be done without discussion with the prescribing provider.
- Adverse reactions are to be reported to the physician’s office immediately.
- Combining narcotic pain medications may have unrecognized or unpredictable interactions with other pain medications.
- Operating heavy equipment or driving is not permitted when using narcotic pain medications.
We have created this policy to ensure the health and safety of our patients. We appreciate your cooperation.