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Notice of Financial Responsibility
Please read this financial notification carefully as pertains to your appointment and financial responsibility for your FULL EVALUATION and TREATMENT (IF YOU QUALIFY). This information is provided to you as an explanation of the ABN/ANN TESTING/TREATMENT forms that you will be required to sign.
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Midwest Dizziness and Balance Institute (MDBI) is a specialty clinic focusing only on dizziness, balance, vertigo, and lightheadedness. MDBI uses state of the art testing and treatment equipment to effectively diagnose and subsequently treat the symptoms above with an 87% success rate. The full evaluation consists of a three-hour test battery to determine if the inner ear is causing your dizziness, vertigo, lightheadedness, or imbalance. There are only 4 centers in the country that are as specialized as we are. Once the cause of the problem is identified, we have highly specialized treatment programs to assist in restoring your inner ear function.

As a courtesy, our insurance team calls your insurance for you. On this call, YOUR insurance company tells us if you have a deductible, copay, co-insurance and what they may or may not cover. This is not always an accurate representation of what they process, once the services are rendered. We do our best to provide you with the information they tell us, prior to your appointment, however they ultimately have the final decision when it comes to processing your claim. Our process is to take this information we receive; use a medical estimating tool and provide you, again as a courtesy, with an ESTIMATION of what they will charge you. You will receive an ESTIMATE before your appointment with this information. An estimate is NOT a guarantee of your insurance paying. This is just an ESTIMATE, and you may have to pay more depending on your insurance’s final decision. The estimated cost is what YOU will be required to pay AT THE TIME OF SERVICE when you check in for your appointment.

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DENIED/NON-COVERED CODES:  PLEASE SEE THE TREATMENT/THERAPY  ABN/ANN’s for a list of the codes that are not covered or may be pushed to your deductible. You will be required to sign a copy of the form.

We KNOW there are tests we administer that are deemed ‘experimental’ and are not covered by all insurance companies.  The CPT Codes that may not be covered are listed on the ABN/ANN Form you will be asked to sign. This is not an all inclusive/exhaustive list, however, these are the plans that typically do not cover the service and what your denied/non-covered charges will be. There are times other insurances, that are not listed below, will not cover these codes as well. When a charge is NOT covered or DENIED, this DOES not apply to your deductible. We put this information on your Estimate for you. If your insurance DOES cover these tests, BUT they push it towards your deductible, this will be listed on your estimate as well..

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TESTING - Denied/Non-Covered Codes - YOU WILL BE REQIRED TO SIGN A PAPER COPY OF THIS FORM.
If you qualify for TREATMENT - Denied/Non-Covered Codes -  YOU WILL BE REQIRED TO SIGN A PAPER COPY OF THIS FORM.

*When a code is listed as an unlisted code, it means there is not a code yet in the medical guidelines for the procedure. It can take up to 20 years once a test comes out for Medicare to give it a CPT code. The tests above are tests that have been administered for over 10 years that still do not have CPT codes. We will fight your insurance company for these codes and MOST of the time are successful, however, these are potential costs you may incur. Please see YOUR PERSONAL ESTIMATE as we put on your estimate if your insurance told us via phone that they will or will not cover this for you personally.

If the charges listed in the ABN/ANN forms, are covered BUT are put towards your deductible, the insurance company will assign a certain percentage of the billed rate, which is different from the charges listed. If this charge is pushed to you, by law, we MUST bill you the amount your insurance says for your deductible, as your deductible is a contract with you and your insurance company. We DO NOT decide this amount; YOUR insurance dictates this amount; it is a percentage of the billed charge. Again, we try to put this on the estimate that was sent to you for review. Please review your personal estimate for this information. Remember: This is an ESTIMATE pulled from your insurance company detailing what they expect you to be responsible for at the time of service. An estimate is NEVER a guarantee of payment by insurance nor is it always the amount your insurance deems you responsible for once they receive all our testing.

 

Please be sure that you have read our Notice of Financial Responsibility, and understand the information that we have provided to you. By signing the ABN/ANN Treatment/Therapy Form, you agree you are financially responsible for your testing/treatment, and you are aware that your ESTIMATED charge is due at the time of service when you check in at each appointment. You are also acknowledging that you understand that ultimately your insurance has the final say in the charges assessed to you. Payments at check-in can be made via check, debit card, or cash, and will not acquire transactions fees, however, if you choose to pay by credit card, there is a 3% surcharge on all credit card transactions.     

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