NOTICE – Right to Receive a Good Faith Estimate of Expected Charges

Effective Date – January 1, 2022

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, healthcare providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical services. 

• You have right to receive a Good Faith Estimate for the total expected cost of any non-emergency item or services. This includes related medical test, prescription drugs, equipment, and facility fees.
• Make sure your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before your medical and/or other related services. 
• Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Self- Pay Patient Policy

In order to make our services accessible to patients lacking health care coverage, we offer a significant discount for *Self-Pay Patients and will consistently apply a method of discounting, billing and collecting from a Self-Pay Patient.

*A Self-Pay Patient is defined as a patient who: 

• Has no health insurance coverage of any kind, including (i) federal and state healthcare programs, including but not limited to Medicare, Medicaid, Tri-Care, or Federal Employees Health Benefits plan, or (ii) other commercial or private health insurance coverage from any source.  
• Has health insurance coverage but informs us that he or she will not submit their claim to his or her health insurance.
• Patient does not claim any third-party liability for their healthcare treatment.
• Patient is not eligible for worker’s compensation coverage or auto/accident coverage; and has no other responsible party covering the expenses associated with the care received from our office. 

NOTE: Patients with a “high deductible” (HDHP) health insurance plan, or with health insurance coverage by a commercial insurance plan in which our practice does not participate, will not be considered Self-Pay Patients.   You can however, set up a payment plan with the billing office for the expected expenses from non-participating providers or balance from a high deductible health plan.

Nephrology Associates offers a flat-rate discount for self-pay office patients as well as a percentage option to pay at time of service when the full fee is undetermined.  Patients are required to pay at least a portion at time of service and made aware of the possible balance that will be billed to them.

Immunizations or other injectable drugs for self-pay patients are not available, and the patient should seek these services from their primary care or the local pharmacy/walk-in clinic. 

Patients without insurance coverage that have a large balance from a hospital stay, and in extreme hardship can inquire with the billing office to complete a financial application for further reduction or forgiveness of debt.

Fee Schedule – The simplified fee schedule in the table below is based on the Medicare Allowable Fee Schedule. The estimated costs are valid for 12 months from the date of the good faith estimate, and are subject to changes.  The estimated payment is rounded to the nearest whole dollar.  We accept Check/Money Order or Credit Card.

Good Faith Estimate Disclaimers:

This good faith estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. 

The good faith estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your good faith estimate for that provider or facility, federal law allows you to dispute the bill. 

This good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate. 

If you are billed for more than this good faith estimate, you may have the right to dispute the bill. 

You may contact the health care provider or facility listed to let them know the billed charges are higher than the good faith estimate. You can ask them to update the bill to match the good faith estimate, ask to negotiate the bill, or ask if there is financial assistance available. 

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. 

If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill. 

There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this good faith estimate, reduced by the $25 fee. If the SDR entity disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. 

For questions or more information about your right to a good faith estimate or the dispute process, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

Updated October 1, 2022