Insurance & Billing

Billing Information

ITEM I: You were seen by your physician, Dr. Momin, Dr. Haueisen, or Dr. Braun, of Susquehanna Valley Pain Management for evaluation of your medical condition. Your physician has recommended a surgical procedure at Harrisburg Interventional Pain Management Center. Please be advised that Dr. Momin, Dr. Haueisen and Dr. Braun own interest in Harrisburg Interventional Pain Management Center.

Harrisburg Interventional Pain Management Center is a Medicare-approved facility and is licensed by the Commonwealth of Pennsylvania to provide ambulatory/outpatient surgery in its location at 825 Sir Thomas Court, Harrisburg, PA. Harrisburg Interventional Pain Management Center is accredited by the American Association for Ambulatory Health Care, Inc. (AAAHC), the renowned Chicago-based accrediting organization that operates in this capacity.

Both entities, Susquehanna Valley Pain Management and Harrisburg Interventional Pain Management Center are located in the same building at 825 Sir Thomas Court, Harrisburg, PA. Each of the aforementioned entities is a separate and distinct business.

ITEM II:
If you have decided to have your surgical procedure at Harrisburg Interventional Pain Management Center, there will be two separate charges:

1. A charge from Susquehanna Valley Pain Management for your surgeon’s    fee. This charge is what your physician charges for performing a surgical procedure.
2. A charge from Harrisburg Interventional Pain Management Center for a facility fee. This charge covers the use of the operating and recovery rooms, sedation/analgesia (if used), equipment, supplies and medications necessary to perform your surgical procedure. It also covers the services of the clinical staff.

Both you and your insurance carrier will receive a separate bill for each of these services. Your surgeon and the facility are two separate entities and are required to bill separately for these services. Regardless of where you have your surgical procedure performed, you will receive two separate bills. (This billing method is standard and required by all insurance carriers.)

CONSENT TO TREATMENT AND FINANCIAL RESPONSIBILITY

I desire to be treated at Harrisburg Interventional Pain Management Center. I understand that I may discontinue treatment at any time.

1. I consent to the rendering of medical care.
2. I hereby authorize all professional staff to release any information acquired in the course of the examination and treatment to referring physician, insurance company, workers compensation carrier, the center’s attorneys and consultants in accordance with the privacy laws.
3. As part of the medical procedures or tests, I understand that I may be tested for H.I.V. infection and/or hepatitis, or any other blood- borne infectious disease if the doctor orders the test for diagnostic purposes.
4. Guarantee of Payment: I agree to be responsible to the center for charges resulting from services and supplies rendered at the prevailing rates unless I qualify for discount. I agree all bills are due in full upon demand. Should I fail to honor this agreement I agree to pay any collection cost or attorney fees resulting from the collection of my account.
5. Pre- Certification Requirements: If my insurance company or third –party requires pre-certification, then I understand that it is my responsibility to contact them to obtain such certification. Exception: Medicare.
6. Assignment of  Benefits (other than Medicare and Medicaid): I hereby assign all rights and privileges and authorize payment directly to the center for any claim filed on my behalf or on the behalf of the person for whom I am duly authorized to sign for insurance benefits. I also understand that I am financially responsible to the center for co-pays, deductibles, co insurances and charges not covered by this assignment or by my insurance plan.
7. Assignment of Benefits (Medicare and Medicaid): I request that payment of authorized Medicare and/or Medicaid benefits to be made to the center or on my behalf for any services or supplies furnished by the center, including physician services. I authorize any holder of medical or other information about me to release it to the center for Medicare and Medicaid services and its agents, as appropriate, any information needed to determine these benefits for related services. I understand that I am responsible for any coinsurance, unmet deductibles and services not covered by Medicare and/or Medicaid.
8. Grievance Appeal Consent: I hereby authorize Harrisburg Interventional Pain Management Center to act on my behalf in requesting a reconsideration of medical determination made by my managed care plan or utilization review entity regarding my medical care.
9. It is the policy of the physicians and staff of the Facility to honor Advance Directives presented to them by their patients. However, should an untoward event happen to a patient while he or she is in our Facility, it is our policy to stabilize the patient and transport him or her to the hospital of his or her choice with a copy of the Advance Directive (if available).
10. Complaints, concerns, grievances regarding treatment, service, damaged or lost articles or billing should be directed to the Director of Nursing/Administrator for investigation and appropriate response.