Medical and surgical visits will be filed with your insurance carrier. It is your responsibility, as the patient, to verify that your physician or provider is currently under contract with your insurance plan. It is also your responsibility to provide accurate insurance (including secondary insurance) and personal information. If you belong to an insurance company that requires that you have a referral, it is your responsibility to obtain all necessary referrals before your scheduled appointment. Failure to confirm that your insurance is active, the provider is in network, and that you do not require a referral may result in your responsibility for all charges.

Recent changes in healthcare markets have altered insurance coverage to shift more of the cost of care to our patients. Many policies have higher deductibles which means, even if a procedure is covered by insurance, you may be responsible for the majority or entirety of the visit charges until your deductible is met. Because of the large shift of insurance policies to higher deductibles plans (that are not always transparent to patients and to medical offices), our office will be collecting deposits for procedures from all patients that are due at the time of service.

Our office will also be collecting deposits for any office visits for patients with high deductible plans who have not yet met their deductible. These deposits are estimated based on our best efforts; however, any differences will be billed or credited to you.

Per your contract with your insurance company, a co-payment or co-insurance may be due (in addition to the deductible as mentioned above). Like the deductible, co-payment and/or co-insurance are calculated based on our best efforts; however, any differences will be billed or credited to you. You will be responsible at the time of service for the payment of such copays or co-insurance, as well as any past due balances.

It is possible that your insurance company may not cover services or may deem services not medically necessary. If this were to occur, these charges would become your responsibility. Your insurance coverage and benefits are a contract between you and your insurance company. Therefore, all disputes must be handled between you and your insurance company. We are contracted with multiple insurers to accept assignment of benefits. If you have insurance coverage under a plan with which we do not have a contract, you will be treated as a “self-pay” patient.

If a claim is delayed due to a required Coordination of Benefits (COB), you will be responsible for payment of the office visit upon receipt of the Explanation of Benefits (EOB) indicating COB is required. Your credit card on file (see below) will be charged in this instance for the balance noted as due by the insurance company on the EOB. Once COB is completed and insurance payment is received by the office, your account will be reconciled, and any credit or balance due will be applied accordingly.

Claims not paid within 45 days by your insurance company will become your responsibility; it is your responsibility to contact your insurance company for reimbursement.

At Pacific Crest Dermatology, we maintain a credit card on file to streamline the billing process and minimize administrative tasks. This helps us ensure a smooth and efficient experience for all patients. It allows us to quickly handle balances from copays, deductibles, or services not covered by insurance, without disrupting your care. Rest assured, your information is stored securely and will only be used when necessary for any outstanding balances.

The credit card on file is required at the time of scheduling the initial appointment with our practice. If you do not provide your credit card on file 48 hours ahead of your appointment, your appointment will be rescheduled. If your card on file is no longer valid, your appointment will be rescheduled. If you decline to put a credit card on file, we will not be able to see you as a patient. If the credit card is denied, you will be subjected to a $35 service fee. If you put a debit or HSA card on file, an additional credit card will be required to be put on file as a back-up payment method. Should there be insufficient funds on your primary form of payment, your secondary form of payment will be charged. Only some exceptions may apply and will be determined by practice management.

Once your insurance processes the claim, you will receive a statement with your balance and this amount will be due in full. Any balances not paid within 2 weeks of the statement will be automatically charged to the credit card on file. Should you prefer a different form of payment, please contact the office within those 2 weeks so that other arrangements can be made. Any balances not paid within 2 weeks of the statement may be sent to collections. 

We reserve the right to charge the card on file for the amount due per your insurance, for your deductible, or for the full amount if you are a cash pay (self-pay) patient, have a high deductible, have purchased cosmetic services, have purchased any products or for any other past balances due. All self-pay and cosmetic balances are due at the time of your appointment and will be

collected at that visit in full. We will use our quote tool to give you an estimate of your balance if you have a high-deductible plan. This is not available for all insurance plans and is not a guarantee of price; you will be asked to sign your quote stating you understand this.

Pacific Crest Dermatology is not a Medicaid-participating provider and does not submit claims to Medicaid under any circumstances. This applies whether Medicaid is listed as a primary, secondary, or any other form of insurance. If you have Medicaid and choose to receive care at Pacific Crest Dermatology, you are electing to be treated as a self-pay (cash-pay) patient. Because this office is an out-of-network provider for Medicaid, services rendered are not eligible for Medicaid reimbursement, and you may not submit claims to Medicaid for payment or reimbursement.

If you have primary commercial insurance and are later identified to have additional or secondary coverage through Medicaid, you acknowledge and agree that Medicaid will not be billed or applied by this office. Any charges, balances, or patient responsibility amounts not covered by the primary insurance are then your responsibility.

By signing this financial policy and maintaining a card on file, you authorize Pacific CrestDermatology to charge the card on file for all patient-responsibility balances. As noted above, this office utilizes a quote tool to provide the best estimation of balances due at the time of service; as such, all balances (including the estimated quote) are due at the time of service unless other arrangements have been made in advance.

We want you to clearly understand your bills and payments. To support this, we review your insurance benefits prior to your appointment and make every effort to provide the most accurate cost estimates possible. Even with these processes in place, questions or misunderstandings may occasionally occur. If you have any questions about a balance due or a charge to your credit card on file, please contact our office directly so we can review and resolve the issue with you.

Please be aware that if you initiate a dispute with your credit card company, the practice incurs a chargeback fee regardless of the outcome of the dispute. If a chargeback is filed, a $40 fee will be added to your account to cover the credit card company’s chargeback fee and the administrative costs associated with managing the dispute. To avoid this fee, we encourage you to contact our office first so we can address your concerns and attempt to resolve the matter without involving the credit card company.

To make sure we are taking care of all patients in a timely manner, we do have a 15-minute no-show policy. If you are running late, please give our office a call to ensure that the practice is still able to see you. We understand that unexpected events occur. When this happens, please call our office as soon as possible to inform us of such issues.

Missed appointments for routine office visits are subject to a $75 no-show fee if not canceled 24 hours prior to your appointment. Missed appointments for surgical or cosmetic visits are subject to a $150 no-show fee if not canceled 24 hours prior to your appointment.

At times certified mail may be sent out to patients that can’t be reached for reasons such as outstanding skin cancers, insurance changes within the office, patients in a pre-collection status, etc. A $20.00 charge will be applied to the card on file in the event that a certified letter must be mailed.

By definition, cosmetic services and procedures are not covered by insurance companies, and this office does not submit claims on their behalf. A deposit will be taken when a cosmetic appointment is scheduled. A cosmetic consultation costs $250 and will be collected at the time of scheduling. Of the $250 collected, $150 may be applied toward the balance due for any cosmetic treatments received or cosmetic products purchased within three (3) months of the consultation. The remaining $100 represents the consultation fee. If you fail to keep your cosmetic appointment and do not cancel at least 24 hours in advance, $150.00 of the deposit will be forfeited, as outlined in the late cancellation and no-show section of this policy.

If you are scheduled for a medical visit and choose to discuss cosmetic concerns, recommendations, or treatment options during that visit, the visit will include a cosmetic consultation. This cosmetic consultation is not billable to insurance, and a cosmetic consultation fee of $250 will be added to your visit and charged to the card on file at the time of service. This fee is in addition to any co-pays or fees due for the medical visit, as outlined above.

All cosmetic services and products must be paid in full at the time of service.

Biopsies are sent to an outside pathology lab. You will receive a separate bill from the pathology lab. Microbiology and other laboratory tests are performed by a separate lab that will bill you separately. We are not able to assist with these bills. Please contact the laboratory directly for questions regarding pathology or laboratory bills.

As a courtesy, Pacific Crest Dermatology will submit prescriptions to your pharmacy of choice. Coverage and payment for prescription medications are determined by your insurance plan and the dispensing pharmacy. Any questions or concerns regarding prescription costs should be addressed to the pharmacy or the insurance company directly.

Please note that Pacific Crest Dermatology is not a Medicaid-participating provider. As a result, prescription medications prescribed by our providers may not be covered by Medicaid, even if Medicaid is listed as primary, secondary, or additional insurance. In these cases, you may be required to pay out of pocket for prescription medications, or work with your pharmacy to identify alternative payment options.

Our practice utilizes an electronic medical record system which has a secure online patient portal available to you at no charge. Printed copies of your medical records are available at a fee of $0.60 cents per page plus the cost of postage. Medical records may be sent to another medical provider at no charge but do require a signed medical release form.

Pacific Crest Dermatology accepts the following forms of payment: Cash, Personal Check with proper identification (valid Driver’s license or photo ID), Visa, Mastercard, American Express and Discover. A $35.00 overdraft charge will be added to the insufficient funds amount of any returned checks. A $35 fee will also be applied to any denied credit cards on file that are being charged to cover outstanding balances.

Any outstanding balance after 60 days from the date of service may be subject to a $40 administrative fee to cover the cost of staff time and resources spent attempting to collect the balance. If payment is not received after these efforts, accounts may be referred to an outside collection agency, at which time an additional fee may be applied by the agency. Patients with unpaid accounts or accounts which have been sent to collections may be discharged from our practice.

Your signature acknowledges receipt and understanding of these policies.