Medical Billing Disclosure Acknowledgment

If you are receiving massage under the referral of a doctor or another provider and requesting to have our providers bill your insurance company the following  applies without acception: (These prices include Personal Injury - PIP and MLD)

CPT CODE	Service	Cost
97010	Hot/Cold Pack	$45
97124	Massage Therapy	$45 per unit
97140	Manual Therapy Techniques	$65 per unit

Units are blocks of billable time

This is the current pricing standards outline by Medicare. Stress Knot follows this stards to maintain compliance and consitance among all policys and clients.

 

There are multiple reasons for this.

First, This is the current pricing standards outline by Medicare. Stress Knot follows this stards to maintain compliance and consitance among all policys and clients.

Second, the standards for billing insruance significantly differant than out of pocket massage therapy. With that, a significant more time is spent towards providing this type of care. 

Below are just a short list:

1. More time to do paperwork (e.g. charting, follow-ups, mailing claims, etc)
2. More time to call or accept calls from insurance and attorneys.
3. Requires pre-authorization and claim verification.
4. Requires a prescription from the primary physician.
5. Requires a part-time admin assistant to help with processing claims.
6. Working closely with other healthcare providers (e.g. MD, PT, DC, DO,
   etc)
7. Writing treatment plans

Thank you for choosing Stress Knot Mobile Massage/Stress Knot Wellness as your healthcare provider. The medical services you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive. To assist in understanding that financial responsibility, we ask that you read and sign this form. Feel free to ask if you have any questions regarding your financial responsibility. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this policy with them, as it explains our practices regarding insurance billing, copayments, and patient billing. By signing below and/or by receiving medical services from Stress Knot Mobile Massage, you agree

Financial Responsibility

• I accept that I am financially responsible for all services rendered on my behalf for which a charge may be associated. I accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by my insurance coverage, plus any collection costs for amounts personally owed by me.
• In the event that this visit is based on a Worker’s Compensation claim and my Worker’s Compensation claim is not accepted, I agree to have the fees associated with services sent to my private health insurance company.
• I acknowledge that not all services provided by the Stress Knot Mobile Massage/Stress Knot Wellness Providers are covered by my insurance plan for one or more reasons, including but not limited to exclusions from my insurance plan, my insurance plan’s designation of the Health Center as an out-of-network provider, and/or my failure to provide my insurance card. I acknowledge that not all  massage services are billed to insurance carriers and I agree to be financially responsible for those services.

All Stress Knot Mobile Massage/Stress Knot Wellness records are confidential to the extent permitted by Federal and state law. 

I understand and acknowledge that there are exceptions to the confidentiality policy, as required by law, including: 1. When I have signed a Release of Information Consent Form for specified individuals or agencies; 2. When there is a court order, signed by a duly appointed or elected judge, for release of my records;

I also understand and acknowledge that in the following two instances a report will be made to the appropriate state agency, as required by law.