POLICIES AND PROCEDURES
We welcome you to
CAROLINA
PARTNERS IN MENTAL HEALTHCARE, P.L.L.C. We prepared the following information so that
you may have a clear understanding of our policies and procedures concerning
fees, insurance, and confidentiality.
Referrals: Carolina
Partners is a group practice. You may be referred within the group to an
appropriate health care provider according to your needs.
Fee Schedule:
The Clinician’s fee will vary depending on the service rendered, the specific
provider involved, and the terms of particular insurance plans. However, each
provider has a “standard fee” for a 45 minute individual, couple, or family
session. Longer or shorter sessions are prorated from this basic fee. Please
ask about our fees and we would be happy to describe them in detail for you.
*Ms. Boorman, Ms. Buhrman, Mr. Csarny, Ms.
Frazier, Ms. Howe, Mr. Lawson, Ms. McEntire, Mr. McGloin, Ms. Miller, Ms.
Navascues, Ms. Stillman, Ms. Telli, Mr. Zeger, and Dr. Ranes charge a standard
fee of $100.00 for a 45-50 minute therapy session. The fee for the initial
interview is $175.00. Please ask in advance about the fees for any other
services.
*Ms. Bruce, Ms.
Hartsell, and Drs. McAllister, Mickiewicz, and Monroe charge a standard fee of
$150 per 45 minute individual, couple, or family session. Initial
evaluations, which involve more administrative time, are $225. Prior
authorization and claims for the Nurse Practitioners Ms. Bruce, Ms. Hartsell,
and Ms. Leif are filed under Dr. Yvonne Monroe’s name.
*Drs. Headen, Holmes,
Shin and Ware; and Mr. Dominguez charge a standard fee of $200 per 45 minute
individual, couple, or family session. Initial evaluations, which involve
more administrative time are $250. Prior authorization and claims for the
Nurse Practitioner Mr. Dominguez is filed under Dr. John Shin’s name.
*Drs. Barker,
Miller, Prinzhorn, and Roos charge a standard fee of $120 per 45 minute
individual, couple, or family session. Initial evaluations, which involve
more administrative time, are $180.
Telephone Calls:
Clients in psychotherapy may occasionally have the need for crisis
intervention by telephone. Telephone charges are based upon the provider’s
standard fee per 45 minutes and prorated per minute. There is no charge for
calls under 5 minutes concerning side effects of medications that you have
been prescribed by a Carolina Partners provider. However, if the medication
call involves phoning in a medication or if the call is over 5 minutes, you
will be charged. After
5 PM
and after noon on Fridays until Monday at 8AM, there may be a $25.00 charge
for calling in a refill or writing a prescription to be picked up. The
on-call clinician will only provide enough medication through your regular
clinician’s next business day.
Appointments:
No one is guaranteed an appointment with a clinician at Carolina Partners but
we accept most insurance and managed care plans and will do our best to
accommodate you. If you are unable to keep an appointment, please notify our
office immediately. This time is reserved exclusively for you. If an
appointment is cancelled or missed without 24 hours notice, you may be billed
for the session. Some appointments are scheduled over the phone, and not
in person. Our Assistant may call with your appointment date and time
as a reminder, and may leave a message on your answering machine, or with a
responsible party in your household, unless you specifically request us
not to do so. With or without an answering machine or other party telephone
reminder, you are still responsible for canceling with 24 hours notice, or
you will be billed for the session as above.
Payment:
As a courtesy to you, Carolina Partners will normally accept assignment of any
insurance benefits you may have and file health care claims directly to your
insurance company. However, payment of all applicable copays and
deductibles (or any other amount not covered by your primary insurer) is
required at the time services are rendered. Payment may be made by
cash, check, credit or debit card. Every client is asked to sign a “Financial
Acceptance” agreement that is appended to this document. If you are unable to
pay your obligation at the time of service, we may ask you to authorize
Carolina Partners to charge your credit card for any balance due more than 60
days old. Please note that we will not charge your credit card if there is no
balance due more than 60 days old. There will be a $25 service charge for
returned checks. Notwithstanding the former, Carolina Partners reserves the
right to demand full payment for services rendered at the time of service. If
you are covered by more than one insurance company and we receive prompt
payment from your primary insurer, Carolina Partners will normally file claims
to your secondary insurer as a courtesy to you. However, pending payment by
your primary insurer, you may be asked to make payment at the time services
are rendered of any amounts covered by your secondary insurer.
Carolina Partners will
not be able to file claims to your insurance company unless you provide us
with accurate and complete information about your insurance plan.
Accordingly, we ask you to review your policy carefully and to be aware of any
limitations on your benefits. You must also promptly inform us of any changes
in your insurance coverage or we will not be able to file your claims.
Similarly, many insurance companies are now managing their mental health
benefits. This means you must consult your insurance booklet to see if your
insurance must approve sessions before they occur. If this approval is not
obtained, your insurance will not cover the sessions. If you are not sure,
please ask Carolina Partners to help you with these prior authorizations.
** Please note that
you are ultimately responsible for all charges incurred for your treatment or
the treatment of those for whom you are responsible. If for any reason your
insurance company, or other third party payer (such as a divorced spouse or
lawyer), does not promptly reimburse Carolina Partners for services rendered,
you will be responsible for those charges
(subject to any applicable law or the terms of any contract we may have with
your insurer).
Statements:
Unless you specifically request not to receive a statement, you will be billed
on a monthly basis for any past due balance you may owe. Payment of all
services is expected within 30 days of the date they were rendered. Processing
past due accounts is expensive and Carolina Partners reserves the right to add
a finance charge to any past due balance accrued. This charge shall not
exceed 1 1/2% per month (an annual percentage rate of 18%). Accounts with
balances more than three months old may be referred to a collection agency for
processing.
Your Satisfaction:
Carolina
Partners must show insurance and managed care companies and your employer that
the treatment you receive is effective and provided in a satisfying manner.
As a client you must agree to complete a Client Satisfaction Questionnaire at
3 times: 6 weeks, 6 months, and 1 year after you complete a course of therapy
and/or medication treatment.
Confidentiality:
Any
confidential information you disclose to us during treatment, or any other
confidential information we obtain while attending to you professionally,
shall be held in confidence unless you permit us to disclose such information
or where we are required to disclose such information by law.
By signing this
contract, you are agreeing to the disclosure of confidential information where
such disclosure is necessary to obtain certification, authorization, or
payment for your treatment, or where we are required to disclose information
by the terms of our contract with your insurer or managed care company. For
example, in order for your insurance company to cover your treatment, we may
be required to periodically communicate details of your condition and
treatment with them or with your managed care case manager. You are also
expressly authorizing your provider to pursue appeals and grievances with
insurers or managed care companies when those appeals are necessary to obtain
payment for one of your insurance claims or when your provider believes an
appeal of denial of care by your insurer is appropriate or necessary.
By signing this
contract, you are agreeing to the disclosure of confidential information to
other physicians or therapists familiar with your case, where your provider
decides it is clinically necessary or appropriate to do so. For example, if a
physician or psychotherapist referred you to us for evaluation and treatment,
your Carolina Partners provider may communicate with that professional about
your condition and treatment. Please tell us in advance if you want certain
information withheld. Similarly, if we refer you to another physician or
therapist within Carolina Partners for treatment, that provider will have
access to your records and may communicate with your prior provider(s).
Forensic Matters:
Carolina
Partners may be required by law to disclose confidential information in
certain cases. The following are examples:
1. If we assess that
you are a clear and imminent danger to yourself
or another person,
appropriate others may be notified to prevent that occurrence.
2. If there is reason
to suspect that child or elder abuse has occurred, the law requires that it
be reported to the proper authorities.
3. In a legal
proceeding, the Judge may order disclosure of information s/he feels would be
necessary for the proper administration of justice.
Court Appearances:
In certain cases, a Carolina Partners clinician may be willing to act as an
Expert Witness in a court action involving a client. If you wish to engage
the services of a clinician as an Expert Witness, you must read and sign a
Carolina Partners Expert Witness Agreement that binds you to payment for the
clinician’s time in preparing for court, appearing in court, preparing
reports, communicating with attorneys, etc. Please discuss the possibility of
court appearances with your doctor or therapist as far in advance as
possible.
In the event that a Carolina
Partners clinician is subpoenaed to appear in a court action involving the
care that was delivered to you or to a family member, you will be charged that
clinician’s standard fee for court appearances, etc. even in the absence of a
signed Expert Witness agreement. Even if the subpoena is not issued by your
attorney, but rather by an adverse party, you will be charged for and expected
to pay the clinician’s fees for these services.
On Call:
Several providers
share a rotating on-call schedule, starting Fridays at noon until Monday
morning. Please call (919) 403-2122 to obtain the name and number of the
on-call clinician. If you think you or your family may require
hospitalization, please call the Response Service at Holly Hill / Charter
Hospital at 1-800-447-1800 for a free consultation 24 hours a day.
For
medication emergencies call 911.
Grievances:
Anyone who has a grievance about any aspect of the services received from
Carolina Partner may submit a grievance. You may call us with your concerns
or submit them in writing. The addresses for complaints about clinical
services are:
Yvonne Monroe, MD,
Managing Partner
Carolina Partners in
Mental HealthCare, PLLC
1502 W. Highway 54,
Suite
Durham, NC
27707
or
Brad Prinzhorn, PsyD
Carolina Partners in Mental HealthCare, PLLC
10003 Main St, Suite 102
Chapel Hill NC 27516
The address for
complaints about any other matter is:
Carolina Partners in
Mental HealthCare, PLLC
Executive Director
1502 West Highway 54,
Suite 103
Durham, NC 27707
We appreciate the
opportunity you have provided for us to be of service to you. CAROLINA
PARTNERS IN MENTAL HEALTHCARE, P.L.L.C. is committed to providing you with
the best possible psychiatric care. If you have any questions, concerns or
suggestions regarding any aspect of our group practice please feel free to
discuss them with us.