DCG Patient Financial Responsibility Policy

We are pleased to participate in your dental care and look forward to establishing a lasting relationship as your care provider. As part of this relationship, we have outlined our expectations for your financial responsibility in our Patient Financial Responsibility Policy. Please read this document thoroughly.

Address/Phone Change

It is important that we have your correct information on file. Please advise us anytime there is any change to your address, telephone, name or other contact information.

Billing

DCG is a fee for service institution and payment is due when services are rendered. If you owe additional money after your visit, you can expect to receive a statement. Statements are mailed out on the first of each month. Payment is expected within 30 days of receipt of your statement. To make an online payment, go to augustahealth.org/dentalpay, and follow instructions.

Co-payments, Deductibles and Co-Insurance

Treatment costs for our insured patients are split between an overall estimated insurance and patient responsible portion. The estimated patient portion is due at time of service. Co-payments are collected at the time of check-in. Insurance deductibles and fees for services not covered b your insurance policy, if known, are due at the time the service is rendered. We accept cash, check, Discover, MasterCard, and Visa. We will also accept your HSA/FSA card, however please be aware that as an educational institution, as well as a healthcare provider, some HSA/FSA programs will not process payment requests from our institution. In this event you should be prepared with an alternative form of payment and to make other arrangements for reimbursement from your plan.

Deposits

For procedures requiring laboratory work, a deposit must be paid prior to the case being sent to the lab. This requirement is in place regardless of insurance coverage. Deposits may also be required for procedures that do not require labs such as surgeries. Patients should be advised of these requirements in advance. Payments apply to outstanding balances before they may be applied to required deposits.

Emergency Services

A deposit of $100 is required for services rendered in the Emergency Clinic. If you are unable to pay the full amount at the time of your appointment, a payment agreement is available. Any charges greater than the deposit will be billed to the patient.

Failure to Pay

Past Due accounts may hinder your ability to have appointments scheduled. Patients who ignore collection notices and fail to pay their balance risk dismissal from the practice and possible negative credit ratings. Should your account balance become uncollectible or if you file bankruptcy, we will continue to see you on an emergency basis for 30 days, giving you time to find a new source of dental care.

Fees

Returned checks are subject to a $30 fee and your account will be placed on a “cash-only basis.” We will accept payments only by cash or credit card until the balance is cleared. There may be additional charges applied to your account if we are asked to copy dental records per patient request or participate in a Deposition or Phone Consultation on your behalf.

Guarantor

Any patient over the age of 18, or an emancipated minor, will be held financially responsible for all charges incurred. If you have a separate or outside arrangement with another individual for payment of your services, you are still responsible for any balance on your account. You will need to negotiate repayment with them outside of our office. This policy includes individuals negotiating divorce agreements.

Insurance

It is important for you to be an informed consumer, who understands the specifications of your insurance policy (e.g.,visit coverage, referral/authorization requirements for specialty care, x-rays, and laboratory tests). Your insurance policy is a contract between you and your insurance company or employer. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals, pre-certifications, preauthorizations and limits on charges regardless of whether or not our providers participate. You m ust present a current insurance card at each visit. As a courtesy to you, we will bill your insurance company directly for services rendered. If problems arise regarding coverage issues, we will attempt to work with your insurance company to help resolve them prior to making it your responsibility. However, please be advised that you are nevertheless ultimately financially responsible for payment of services rendered by DCG. If you do not present a current insurance card, you will be responsible for payment at the time of your visit. You must furnish insurance information within 30 days of an appointment in order for DCG to file on your behalf. After this date we will provide treatment information for you to file with your insurance company. You will receive reimbursement from DCG if your insurance pays the claim at a later date. You have a responsibility to provide information to our office so that a claim can be properly submitted. If your insurance company has not paid a claim on your behalf at 90 days, the balance may be transferred to your account and you will be responsible for payment. If we receive payment from insurance at a later date, you will be reimbursed for any overpayment on your part. If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, out-of-pocket fees and coverage limits. You are responsible for payment of any service rendered which is deemed “non-covered” by your plan. Our providers belong to many insurance plans. Before your appointment, please be sure your provider is in-network and the services are covered under your plan. If your provider is out of network, you will be billed for the cost of care. If we contact your insurance carrier regarding benefits or authorization on your behalf, we are not responsible for inaccurate information provided to us by your carrier. The information about your plan that we relay to you is in good faith.

Medicaid Patients

Medicaid may not cover some of the services that your provider recommends. You will be informed of what services are not covered so that you may decide whether to receive these services. You will be responsible for payment of non-covered services.

Medicare Patients

Medicare may not cover some of the services that your provider recommends. You will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully.

Minors and Dependents

Parents and guardians are responsible for payments for their dependents at the time services are rendered. Minors and dependents must present a valid insurance card at each visit if a claim is to be filed. The accompanying parent or adult is responsible for full payment at the time of service. In case of divorce, please do not place our office in the middle of marital disputes. It is your responsibility to work out the payment of your child’s care between the custodial and noncustodial parent.

Non-Emergency Appointments

Outstanding balances or failure to pay co-payments or deposits upon check-in may require an appointment to be rescheduled. Payment for a screening appointment is required at check-in.

Payment Plans

Internal payment plans may be available for treatment that will extend beyond three months totaling up to $3,500.00. Monthly payments will be set up for the expected length of treatment or up to 12 months (whichever is shorter). Certain treatment, e.g. bleaching and x-rays are not eligible to be placed on a payment plan and must be paid in full at the time of service. Failure to stay current with payments will result in termination of plans and all amounts becoming immediately due. For those treatments totaling more than $3,500.00, or the need to extend payments beyond 12 months, patients must make other arrangements. The DCG is in partnership with Lending Club to offer alternative financing plans and can provide more detailed information upon request.

Prompt Payment

Just as we make every effort to accommodate you when you are in need of dental care, we expect that you will make every effort to pay your bill promptly. Payment is due at the time services are provided or upon receipt of a statement from our billing office.

Referrals and Authorizations

Please be aware of and provide any required referrals or authorizations in advance of the appointment of service. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt, contact your plan directly for clarification.

Refunds

A refund is issued when an overpayment has beenidentified. If you feel a refund is due, please contact the Business Office at 706-721-9447.

Self-Pay Patients

Self-pay patients should be prepared to pay at the time of each visit. Several departments have established an amount due upon check-in for self-pay patients. Additional fees over the collected amount will be billed to you and are due upon receipt.

VA Patients

DCG contracts with the VA to provide certain services to eligible beneficiaries on a referral basis. Eligibility is determined solely by the VA. Only services included on the referral will be covered by the VA. The VA will be billed directly for these services, and you will not be held financially responsible for any of these services. Patients who elect to receive services that are not covered by the VA will be financially responsible for these services.

Worker’s Compensation

The patient must provide at time of service: a claim number, name of the carrier, the date of injury, employer at time of injury and name and number of the claim adjuster. Without this information, the patient will be held responsible for all charges, and payment will be collected at time of service Patients will be held financially responsible for any services received that are not covered.

Online Bill PayClick Online Bill Pay to pay your bill online or call the Business Office:

(706) 721-2371 

(select option 3)


Printable DCG Patient Financial Responsibility Policy