Patient Information and Policies

APPOINTMENTS

Providers with Gilcrease Medical Group are scheduled to see patients between 8:00 AM and 11:30 AM and from 1:30 PM until 4:15 PM each weekday. The practice uses an appointment system based upon 15 minute increments or slots. Routine appointments for established patients are usually scheduled for 15 minutes. Routine medication refills routinely up to five (5) will be scheduled for one fifteen minute appointment. The provider may ask a patient with refills or conditions exceeding five medications to schedule a second appointment on another day, as discussing refills and the monitoring of those refills may require more time to explain the use and monitoring of those medications. Additionally, follow up on x-rays, new medical conditions, well child examinations and some new patient visits will be scheduled for a 15 minute appointment as well.

Two slots (30 minutes) are reserved for new patient visits, “Welcome to Medicare” examinations, annual physicals, Medicare Wellness exams, well women nad well child examinations, follow up to ER visits, and surgical procedures only. Routinely four slots are reserved each day for patients needing ½ hour appointments consisting of two (2) in the morning and two (2) in the afternoon. Surgical procedures are usually performed at the end of the morning or the afternoon so that the patient can be monitored by our staff to safeguard the patient should they have any minor complication.

ANNUAL EXAMINATIONS AND WELL CARE VISITS

The annual check-up is scheduled with your provider to assess you present condition and any potential risk or risk avoidance measures determined from your pre physical lab work up and other diagnostic tests. This may take between 15 up to 30 minutes in duration depending upon the complexity of the of the examination and any chronic conditions. Please note: An annual examination does not include any treatments for the patient. Prescriptions, and refills of medications are considered as treatments and must be coded as an examination. Most annual physicals are paid in full by the insurance company, however treatment/exams must be coded accordingly and may require a co-pay amount to be paid when done simultaneously with the physical.

FINANCIAL STANDARDS AND GUIDELINES

In order to reduce confusion and possible misunderstandings between our patients and the practice, we have adopted the following financial policies. If you have any questions regarding these policies, please discuss them with our Practice Manager. We are dedicated to providing the optimal possible medical care and service to you and we regard your complete understanding of your financial responsibilities as an essential element in your care and treatment.

Unless other arrangements have been made in advance between you and the practice or your insurance company and the practice, full payment is due at the time of service. For your convenience we accept VISA, MasterCard, Discover, and American Express.

Your Insurance:

  • We have contractual arrangements with many insurers and health plans to accept assignment of benefits for their members. This means that we will bill those plans with whom we have an agreement and will require the authorized co-payment and/or deductible to be paid by the patient at the time of service. It is the policy of our office to collect these co-payments and deductible amounts when the patient arrives for their appointment.
  • If you have insurance coverage with a health plan with whom we do not have a written agreement, we will prepare and send the claim for the patient on an unassigned basis. This means that your insurer may send the payment directly to you. Consequently, the charges for your care and treatment are due at the time of service. In some situations, we will not be able to see a patient with a plan that we do not accept.
  • In the event that your health plan determines a service is “not covered” under your plan, you will be responsible for the complete charges payable also at the time of service. Because plans have different coverage guidelines it is not always possible to know in advance whether a particular procedure or treatment plan is covered at the time of your visit. As a courtesy to the patient we will bill your insurance for the services rendered. At times a provider may request a procedure or test to be done while you are in the office and will not inform the front office personnel prior to the patient leaving. In those situations we will bill the patient for the balance at their mailing address.
  • In order for the office to promptly bill out for services rendered to a patient, it will be the responsibility of the patient to provide current and accurate information on their address, date of birth, and phone number as well as to provide and present their current insurance card before or at the time of their appointment. Failure to show this information may result in our inability to file a valid claim which in turn may be rejected and denied by the insurance plan for not meeting their filing deadline. The patient remains responsible for the entire balance of the charges generated for the visit. A patient may be requested to reschedule their appointment if they do not provide appropriate current coverage information at the time of service.

Prompt Pay Discount for “self-pay” patients.

In the event that a new private pay (self Pay) patient presents themselves for services at our front desk, the following should be discussed with the patient. All patients are charged the same for a new patient visit. The same is true for office visits for established patients depending upon the extent of the conditions being assessed or treated. The office provides a prompt pay program which will discount that fee if the patient pays cash for the visit at the time of service. Approximately 20% will be discounted from the new patient charge if the patient pays cash at the time of their appointment. Otherwise the charge is full rate for the patient. The practice does not allow billing a “self pay” patient at their home but rather the fee for the service is due at the time of their appointment and prior to being seen.

Minor Patients

For all services rendered to minor patients, we will look to the adult accompanying the patient for payment. The adult accompanying the patient may be required to provide a properly executed “Consent to Treat” form for the patient to be examined and/or treated.

Financial Responsibility

All professional services rendered are charged to the patient and are due at the time of service unless other arrangements have been made in advance and are documented by our business office. The practice will generate all necessary forms which shall be completed and used to file for payment with the insured’s health insurance plan. Any outstanding balances remaining after a patient’s insurance has paid or has rejected a claim are due immediately and/or prior to being seen in the office for subsequent appointments.

(See signature page Financial Obligation) I have read and understand the financial policies of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice without advance notice to our patients.

ASSIGNMENT OF BENEFITS

I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and all other health/medical plans, to issue payment or checks directly to GILCREASE MEDICAL GROUP or GARY L. GILCREASE, MD PA for medical services rendered to me and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amounts including covered as well as non-covered amounts which are to be paid by insurance. (See signature page Assignment and Release)

AUTHORIZATION TO RELEASE INFORMATION & HIPAA POLICY

I have been offered or received a copy of the explanation of Health Insurance Portability and Accountability Act as it relates to patients of this practice. I also understand that it is a HIPAA requirement to provide a picture ID at the time of service unless one is already on file that can be used for identification of the patient. (See signature page HIPAA Consent).

I hereby authorize GILCREASE MEDICAL GROUP to: 1) release any information necessary to insurance carriers regarding my illness and treatments; 2) to process insurance claims generated in the course of examination or treatment; and 3) to allow a photocopy of my signature to be used to process insurance claims from this time forward. This order will remain in effect until revoked by me in writing. (See signature page Assignment and Release)

If I have requested medical services from GILCREASE MEDICAL GROUP on behalf of myself and/or my dependent(s), I understand that by making this request, I become fully responsible financially for any and all charges incurred in the course of the releasing this information. (Ask the front office personnel for “Release of Information to Others” if releasing information to a different PCP or specialist).

I further understand that fees associated with copying services for which the practice may charge shall be paid prior to the release of the information to the requesting party.
PRESCRIPTION REFILL REQUEST PROTOCOLS
All Rx refill requests must be received via pharmacy to qualify for the protocol. This ensures adequate and consistency in providing medication names and dosages.

General Guidelines
These are guidelines for refill requests. If you have ANY questions, please clarify with a provider prior to authorizing.

  • One of the providers must have prescribed the medication in the requested dose within the last year. “A provider” shall mean a provider within the practice. A current physical shall be on file in the patient’s chart prior to refilling a prescription expeeding 12 months.
  • The diagnosed condition must be stable; verify and confirm (progress notes) there are no outstanding follow-up appointments or orders that need to be completed. If there are outstanding items to be completed, give 1 refill only and require patient follow-up.

Narcotics

  • A provider must have previously prescribed the medication and dosage.
  • All narcotic refill requests must be approved by a provider.
  • An appointment is to be scheduled every 3 months for monitoring or the use of the drug.
  • All providers are to follow the same narcotic protocol subject to a provider’s licensing restrictions.

ADHD Medications

  • A provider must have previously prescribed the medication and dosage.
  • All ADHD refill requests must be approved by a physician.
  • The office requests a 7 day window for refills on this type of medication.
  • The practice requires an office visit every 3 months for adults, and students must be seen every 3 months or at beginning of semester with a 1 month follow up. The patient must have an annual examination to continue receiving refills of ADHD medications.

Hypertension Medications

  •  A provider must have previously prescribed the medication and dosage.
  • Blood pressure must be controlled ( < 140/90 if non-DM; < 130/80 if DM)
  • Must have lab work (CBC, CMP, UA) within the last year.
  • Must have been seen in the office within the last 6 months.
  • If all of the above criteria is met; you may refill medications for one month past the due date of the next annual PE. Please notify the pt. of their PE anniversary
    month.

Cholesterol Medications

  • A provider must have previously prescribed the medication and dosage.
  • Cholesterol levels must be controlled (see problem list goal for each patient).
  • Must have lab work (CMP, Lipids) within the last 6 months.
  • Must have been seen in the office within the last 6 months unless it is a new start.
  • If new start of med, we require nml CMP, CK by 2 months of med initiation.
  • If all of the above criteria are met, you may refill medications until next lab draw.
  • Patients on cholesterol meds are required to get Lipids, CMP, CK, drawn every 6 mos.

Diabetes Medications

  • A provider must have previously prescribed the medication and dosage.
  • Diabetes must be controlled (Hgb A1C < 7).
  • Must have Hgb A1C within the last 3 months and CMP within the last 6 months.
  • We need an annual urine micro albumin on all patients. If not current, please flag chart.
  • Must have been seen in the office within the last 4 months.
  • Every patient on DM meds must have HgbA1C and CMP prior to each office visit
  • The providers would like a lipid panel with their patients.
  • If all of the above criteria met, you may refill meds until next lab/office visit is due.

Thyroid Medications

  • A provider must have previously prescribed the medication and dosage.
  • Hypothyroidism must be controlled and within normal range 0.4-4.5.
  • Must have lab work (TSH) within the 12 months.
  • Must have been seen in the office within the last 12 months.
  • Patients requiring thyroid medications must be seen in the office annually with a TSH and PE lab drawn prior to the visit. If above are met, may refill for 1 month past the anniversary date of their PE.

Depression Medications

  • A provider must have previously prescribed the medication and dosage.
  • The patient must have been seen for f/u OV after the initiation of the medication.
  • Must have completed a PE within the last year.
  • If all of the above criteria are met, may refill meds until 6 month interval appointment specific to the monitoring and use of that medication.

Insomnia Medications

  • A provider must have previously prescribed the medication and dosage.
  • Must have completed a PE (physical examination) within the last year.
  • Med cannot be a benzodiazepine. If so, follow narcotic protocol.
  • If all of the above criteria is met, you may refill medications for 1 month past the anniversary date of their PE.

Gout Medications

  • Gout is primarily treated with Allopurinol, Colchicine, and Narcotics.
  • Allopurinol is the maintenance medication for prevention and maintenance.
  • Colchicine is used during the acute phases of gout attacks.
  • Narcotics are used for pain control during gout attacks. This requires approval from a provider.
  • One of the providers must have previously prescribed the medication and dosage.
  • The patient must have lab work completed (CBC, CMP, and Uric Acid) within the last year.
  • If criteria met, may refill meds for 1 month past the anniversary date of their PE.

Allergy Medications

  • A provider must have previously prescribed the medication and dose.
  • No decongestants for patients with HTN unless approved by provider.
  • If steroids are requested, patient must schedule office visit.
  • No antihistamines with glaucoma, prostate enlargement, or urinary retention without the provider’s approval.
  • The patient must have been seen in the office within the last year.
  • If above criteria met, may refill meds for 1 month past the anniversary date of their PE.

Contraceptive Medications

  • A provider must have previously prescribed the medication and dose.
  • The patient must have had a physical or normal pap within the last year. Pap requirements are going to be different depending on age, surgical history, etc, so please review last note and pap result for follow up instructions.

Anti-Psychotic Medications

  • One of the providers must have previously prescribed the medication and dose.
  • Due to the complexity of management of these medications, please have provider review chart.

REMINDER CALLS

The practice as a courtesy provides reminder calls to patients using an outside vendor when appointments are scheduled at least 48 hours prior to the date of that appointment. This system is provided as a courtesy to our patients and is dependent upon the practice having the correct and current telephone numbers for the patient. The reminder call is made 7 days and additionally two evenings prior to the appointment. Assuming we have the cell phone number and the patient is unable to be contacted, a text message will be sent to the patient. We may at a later date insert seasonal messages regarding medical updates or reminders about seasonal vaccine shots which are oriented toward proactively keeping our patients well.

Please inform us of any feedback regarding this service as we are interested in making sure the system works for our patients.

LAB TESTING, IMAGING RESULTS AND REFERRALS

When calling into the practice to request a referral, an order for testing or a refill on a prescription, please ask for the front office Medical Assistant (MA). This is a newly created position which we hope will speed up the processing of these requests. Calling and requesting to speak with the medical assistant specifically assigned to a provider may delay the processing or create a gap in communications between the Medical Assistant specifically assigned to do these tasks and the MA working directly with the provider.

Calls for results of lab tests will continue to be sent to the MA assigned to the provider.

Lab tests

Lab testing for patients within our office is routinely directed next door to CPL (Clinical Pathology Labs) in Suite 103, unless the patient alerts our medical assistant in advance that their insurance plan requires the testing to completed through another lab drawing station or service. If the patient is required to have lab testing completed at another lab by their employer or insurance carrier and we are not made aware of that requirement, it could result in the patient not receiving immediate feedback and the patient having to pay out of pocket for these results. The results of your lab tests routinely take a minimum of two days to turnaround to the office and then must be reviewed by the ordering provider prior to contacting you or the patient with the results. If you have not been called, please wait 72 after your lab work is drawn to call about the results unless it was ordered as a “stat” lab test. In the case of “stat” lab orders, we will call the patient as quickly as possible to minimize any anxiety with the patient.

X-ray examination/MRI scans and other Imaging Services

Routinely this practice sends patients to Austin Radiology Associates (ARA) in either Kyle, San Marcos or Austin based upon the proximity of that location to where the patient works or lives. Results of imaging procedures are routinely sent back to our office and then are reviewed by the ordering provider. Your imaging service will inform you as to when you can expect to receive those results from us.

ARA has a patient portal which can be accessed “online” which will indicate if the results of the procedure are available. Please check with the imaging service to determine how this system works. You are entitled to use another imaging service if that appears more convenient to you.

Referrals

When it is determined that a patient needs to be examined or treated by a specialist, a referral to that specialist may be needed. Your insurance company determines when a referral is needed and authorized which may require the patient to be seen immediately prior to the referral being generated. Routinely, however we ask that you allow five (5) business days for the medical assistants in our office to receive approval from your health plan and then communicate the appropriate referral information to your specialist.

Referrals for Tricare covered patients for behavioral health issues, depression, and anxiety or for ADHD related diagnoses must be generated by our staff prior to the patient being treated by the a primary care provider or specialist for the service to be covered by Tricare.

MEDICARE PATIENTS and MEDICARE ADVANTAGE (REPLACEMENT) ENROLLEES

Medicare has changed many of its requirements in recent years which differentiates itself from what patients have been exposed to under commercial insurance programs when the patient becomes eligible for Medicare or a Medicare Advantage (replacement) Program. We will try to list the most frequent issues which the patient can expect when they first become covered by the Medicare Program.

First, within the first twelve months of eligibility with Medicare or Medical replacement a patient is expected to have a “Welcome to Medicare” examination, which is at no cost to the patient. This shall not be for the treatment of a medical condition or prescription renewal. This examination tries to identify any issues the patient may be dealing with or which the provider determines might be pertinent to the patient within the next twelve months. It does not require the patient to be ill or sick at the time of the examination but is more for medical planning purposes so your provider can anticipate any medical issues which may be present in the near future. Lab work will many times be ordered quite possibly with other diagnostic testing to establish base line information for the provider.

After that initial visit the patient is expected to schedule appointments as needed for medical conditions affecting their daily living as needed. There are many diagnoses or conditions which will prompt the provider to have a discussion with the patient and which initially will be monitored by the Medicare Program to ensure the patient follows the standards typically set for patients with chronic conditions. The practice as of 2015 is now going to be paid based upon what is referred to as a “value based treatment plan”. “Value based” in this sense refers to the quality indicators based upon results of compliance associated with patient having periodic testing, lab studies, imaging and consumption of prescribed medications. Patients who are not in compliance with the established standards identified by Medicare for patients with similar diagnosis may cause the practice to incur a reduction in payments for unmet actions plans by the patient. Continued resistence to or avoidance from not complying with the specific care plans may necessitate the practice terminating its relationship with non compliant patients. The practice will begin a program in the near future which we will use to remind patients of some of these designated services and the time requirements for the steps in the process. The patient may also be asked specifically before having an exam if certain testing has been completed which may delay the patient being seen for non emergency visits.

Advanced Benficiary Notifications (ABN)

Medicare patients who have scheduled appointments for services or products not covered by the traditional Medicare program are required to sign an ABN form notifying them that the service or request will not be provided by Medicare. The ABN will indicate that the patient will have three options which they have to choose from to complete the form. The form must also have the specific service which is not being paid by Medicare and the the patient’s out of pocket cost associated with the service. This ABN is a governmental generated form and must be completed and signed prior to the patient seeing a provider for the services being rendered. As stated on the form if this information is not conveyed to the patient in advance the practice may be required to return any out of pockets payments made to the practice for the specific services.

Medicare as Primary Insurance

When a patient is covered by Medicare or a Medicare Advantage Program (Medicare replacement) the practice shall assume that Medicare or the Medicare Advantage Program is primary. The patient will be asked which is primary but in only a few situations will Medicare/Medicare Advantage not be primary. Some patients have a secondary insurance which is considered a supplement which will be billed for claims after Medicare has processed their claims as the primary insurer.

MEDICARE ADVANTAGE PROGRAMS (Medicare Replacement)

CMS (Medicare) has contracted with several major insurance companies (United Healthcare, Humana, AETNA, CIGNA, Blue Cross) to provide the same or similar medical services to patients eligible for Medicare benefits. When a person signs up to participate in one of these plans they are waiving their ability to use Medicare for medical services and agree contractually to follow the guidelines outlined by the private insurance carrier. In most cases there is no difference between these private plans and Medicare and some include participation in not only Part B Medicare but Part D plans for patient prescriptions. The patient’s private insurance card is required to be presented to the front office at the time of service. Under these plans, even though a patient may have received a Medicare Card indicating eligibility for Medicare, the Medicare card is not sufficient for the practice’s purposes when registering a patient.

NON PARTICIPATION IN CERTAIN HEALTH PLANS

The practice participates in over 200 plans but limits itself to certain panel sizes within some of those plans. Because of the plans have a history of reimbursement being significantly lower than the norm in this area we have chosen to either not participate or not to accept any new patients in those plans. The practice does not participate in the Medicaid plan or any of the Managed Medicaid Programs which typically utilize the name “Star” within the title of the plan. Likewise we no longer accept new patients under the “Texas or Seton Chip” programs although we continue to see our existing patients who participate in those programs until they no longer are not longer eligible.

As a precautionary measure when the patient is changing to a different insurance plan it is always a good idea to call our office to see if we are participating in that specific program. In some cases the practice may have temporarily closed our panel to some of the Affordable Care Act Plans (ACA or Obamacare plans) even though the insurance carrier may indicate that we are participating. It is again a wise idea to call the practice first before enrolling in the program if you are an existing patient. We have had several patients who have been with the practice for many years who have had to change to a different Primary Care Physician (PCP) as a result of signing up for one of these plans first before calling us.

MOTOR VEHICLE ACCIDENTS AND CLAIMS

The practice will not participate in any action related to liability insurance regardless of whether the patient states that they are covered or not. Most health insurance companies upon finding out that a member was injured in a motor vehicle accident which includes legal claims for benefits proven by auto insurance liability claims, will invalidate and not cover the health care claim. This practice does not accept treating patients injured in a motor vehicle accident unless they are billed at the time of service as a “self pay” patient.” The practice will not code or create a bill to be sent to an insurance company. If the patient is be required to secure a statement which they in turn can present to the participating insurance companies for payment, we shall provide one to them.

ANNUAL PHYSICAL EXAMINATION

Patients scheduled to have an annual examination should note that an annual physical examination is an assessment of their physical condition to detect any medical conditions which may need to be addressed or to have preventive testing completed to be proactive in screening for common health risks based upon the patient’s age, family and personal history and any known chronic conditions. The annual exam does not include treatment for any medical condition nor does it include refills for any medications as this is considered treatment. In many cases the annual physical examination is paid in full or fully covered by the insurance plan, excluding any lab work being ordered. A refill cannot be authorized for a prescription over 12 months if at least a current physical assessment (physical) is on file.

Please note, the practice adhers to Federal, state and insurance guidelines for coding and billing for services. Any treatment processes are not considered part of a physical examination and are required to be coded as either an examination, treatment or procedure and are billed separately. If treatment is rendered at the same time as an annual physical exam, a copay may be required by your insurance plan even though your physical could be covered in full or at no cost to the member. Any discussion about a medical condition and/or a prescription being ordered are considered as treatments and are taken into consideration when the provider codes for an examination.

Download the admitting consent and acknowledgement page here.