Thank you for choosing Lifetime Eyecare Solutions as your eye care provider. Our practice is committed to providing the best possible treatment for our patients. Our fees are representative of the usual and customary fees in our geographic area. To help you understand patient and insurance responsibility for services rendered, we have developed this payment policy. Please read it, ask us any questions you may have, and sign in the space provided.

Our practice participates with most insurance plans, including Medicare and Medicaid. If you are covered by a medical or vision plan, it is your responsibility to know your own benefits, as we are not able to absolutely confirm each plan’s benefits for you. If it is determined, either before or after your visit, that you are not actually covered by the plan with which you believe you have benefits if you are not covered by any health plan, or if your benefits have been provided to this office in error by your insurance plan, payment in full is expected at the time of the visit. If your insurance changes, please notify us at your earliest convenience so that you can receive your maximum benefits at future visits.

Copayments & Deductibles
Copayments and deductibles are the patient’s responsibility and expected to be paid at the time of the visit, without exception.

Non-Covered Services
Your medical insurance plan may not cover all services, even though Dr. Jones determines the service(s) to be medically necessary. Examples of non-covered services include, but are not limited to, services not specified as being covered, treatment or testing frequency not authorized, or services that are specifically excluded or limited by your healthcare plan. If we expect that your plan may not cover a procedure or service we will notify you in writing prior to the procedure or service is provided. Medicare patients will be notified via an Advanced Beneficiary Notice (ABN), and for commercial payers, with a Notice of Exclusion from Health Benefit Plan (NEHBP). These documents will list the recommended procedure(s) as well as the expected out-of-pocket costs to you so that you can make an informed decision before proceeding.

Refraction Fee Policy
A refraction is the procedure performed to determine the prescription for your glasses or contact lenses and is universally considered a non-covered service by your medical insurance plan. The fee is the patient’s responsibility, generally around $35-$45. Non-medical visits, meaning visits covered by routine vision plans (ie. VSP, Eyemed, Vision Care Direct, etc.), include a refraction.

Proof of Insurance
Proof of insurance coverage requires that a copy of your valid driver’s license and insurance card be on file with our office. If you fail to provide valid current insurance information, we cannot bill your insurance. You may be asked to reschedule until the issue can be resolved, or you may be given the option of paying in full the day of your visit.

Claims Submission
We are committed to helping you receive your maximum allowable insurance benefits. As your healthcare provider, our relationship is with you, not your insurance company. Filing your claim is a courtesy we extend to our patients, but all appropriate fees are your responsibility. If your insurance company does not pay your claim within 45 days, the balance will automatically be billed to you.

Medicaid / SoonerCare Title 19
Oklahoma Medicaid (SoonerCare) guarantees coverage for basic health and long-term care services based on income and/or resources for eligible Oklahoma residents. Routine examinations, refractions (glasses prescriptions), and eyeglasses are a covered benefit only for qualified individuals 21 years of age and under. Medicaid is considered the payer of last resort, meaning any other insurance provider should be billed first. Any fees for products or services not covered by Medicaid are due at the time of visit.

Worker’s Compensation
Patients are responsible for providing our office with the employer’s authorized contact information for worker’s compensation claims. If the claim is denied, any balance for services becomes the responsibility of the patient, and payment is due upon notice to the patient. The patient may request that our office submit the claim to an appropriate insurance plan’s carrier with a copy of the worker’s compensation denial. If the claim is subsequently denied, the balance will become the patient’s responsibility.

Third-Party Billing
In the event that our office provides care for a patient due to an accident, including a motor vehicle accident, we will not bill a third party (insurance plan). Our relationship is with the patient, not the third-party liability plan. It is the patient’s responsibility to seek reimbursement from the insurance company. At the patient’s request, our office will submit a claim to a primary health plan. However, subsequent payment of medical expenses by a health plan may be contingent on the patient’s completion of an accident questionnaire. Any denial of payment is the patient’s responsibility.

Referrals and Authorizations
Some insurance plans such as HMOs (Health Maintenance Organizations) require a written referral from your primary care provider for services provided by our office. Patients should be aware of, and familiar with, such requirements. It is the patient’s responsibility to obtain a valid referral prior to treatment or service in our office. Without a valid referral from your PCP, we cannot bill your insurance plan, and you will be asked to pay in full at the time of your visit or may have to reschedule the visit after a referral is provided by your PCP.

Self-pay Accounts
“Self-pay” accounts describe patients without insurance coverage, coverage by a plan with whom we do not participate, patients who cannot provide a valid insurance card, and liability cases. We do not accept letters from attorneys in lieu of payment or contingency payments. We do offer a “prompt pay” or “same-day payment” discount for non-insured patients if the fees are paid in full at the time of service. If payment is not made in full at the time of service, the discount is removed and payment in full is be expected before future visits.

TeleMed Services
Telemedicine services are virtual office visits initiated by the patient and replace in-office visits. Few eye-related issues can be managed in this manner, but there are some for which this service may be appropriate. These visits include the use of audio/visual, email, emailed photos, telephone calls, or remote monitoring.

TeleMed E-Visit (Online Patient Portal or Email) – Fees range from $55 – $78

TeleMed (Phone call only) – Fees range from $75 – $155 (depending on the duration of the call)

TeleHealth Services
TeleHealth services are visits between doctor and patient conducted by telephone or other audio/visual means. Phone calls or video chats are examples. These visits are covered by your medical plan and replace in-office visits. Co-pays, coinsurance, and deductibles are applicable the same as in-office visits. Phone conversations between doctor and patient for the purpose of advising on matters of eye health will be subject to TeleHealth fees.

Fees for TeleHealth visits range from $75 – $190, depending on the time involved.

Payment for Services Rendered
Payment is due at the time services are provided. Any charges for uninsured patients, appropriate copayments and deductibles, co-insurance amounts, or non-covered services, are expected to be paid in full at the time of the visit. Acceptable forms of payment are cash, personal check, money order, major credit card (VISA, MasterCard, AMEX, Discover), or Care Credit.

Account Balances
If you have a balance on your account and you are not enrolled in a payment plan, your balance must be paid in full upon receipt of notice from this office. The balance must be paid before you are eligible for future non-emergency services.

Patient refunds are processed within 45 days of the notice of overpayment. Refunds will be sent to the address on file, or you can request the overpayment be credit back to a credit card used for the initial payment. Refunds amounts of less than $10 will be left on your account as a credit.

Returned Checks
Our office will charge a fee of $35 for a returned check, payable only by cash or money order. You will have 30 days to pay the account in full. If not paid in 30 days, your account will be submitted to the District Attorney’s Bogus Restitution Program, which may result in criminal charges.

Accounts with outstanding balances 90 days past due will receive a letter offering 30 days for full payment. Partial payments will not be accepted without agreed-upon payment arrangements. If not paid within 30 days, the account will be turned to a collection agency, which may affect the account holder’s credit report. If sent to collections, it is our policy to consider discharging the patient from our practice. A patient who communicates with our billing office in order to make payment arrangements, and keeps up with the agreed-upon payment arrangements, will not typically be discharged.

Patient Discharge
Any patient discharged from our practice for any reason will be notified by certified mail of our intention to provide emergency care only for 30 days, after which the patient will need to seek medical or routine eye care elsewhere.

Missed Appointments
Please notify our office within 24-48 hours if you are unable to keep your scheduled appointment. Failure to cancel may result in a $45 missed appointment fee. This fee will be bill directly to the patient and is not covered by insurance.

Late Arrivals
If you arrive more than 15 minutes late for an appointment, your visit will be handled as a “walk-in” and every effort will be made to work you into the schedule. However, scheduled appointments will not be made to wait due to your tardy arrival, and other patients’ scheduled visits will be given priority. In some cases, it may be necessary to reschedule your visit.

Fees for Duplication of Medical Records (Paper)
Duplication fees apply for attorneys, insurance companies, etc. are:

Administrative Fee = $10

Duplication Fee = $0.50 / page

Image Fee (if applicable) = $5 / page

Postage Fee = Cost of postage

Electric / Digital Records = $0.30 / page + Transmittal/Delivery fee of up to $200

Fees for duplication of records for patients or authorized patient representatives (ie. family) are waived.

Family Medical Leave Act (FMLA) & Other Forms
The completion by our office for any forms NOT for the express purpose of insurance claims management are subject to a $25 fee for the first four (4) pages, and $5 per page thereafter. Allow up to five (5) business days for forms to be completed.