FINANCIAL AGREEMENT & CONSENT
Billing Services + Out-of-Network Care
1) CONSENT FOR USE & DISCLOSURE OF HEALTH INFORMATION
I authorize the midwife named above (“Provider”) to share information needed for billing and insurance purposes with Lyons Medical Billing LLC (“Lyons Medical Billing”). I also authorize Lyons Medical Billing and the Provider to submit necessary information to my insurance company to support claim processing.
2) PRIVACY NOTICE
Lyons Medical Billing LLC follows all applicable HIPAA requirements and maintains a Business Associate Agreement with the Provider. My information will only be shared with the Provider and my insurance company as needed for billing purposes. I acknowledge that I have received a copy of the Provider’s Privacy Policy.
3) INSURANCE PAYMENTS & PATIENT COOPERATION
I understand and agree that:
Claims may be billed at the full amount.
My insurance may be billed for covered services at the Provider’s full charge, regardless of what I have paid the Provider.
Insurance may pay me directly.
If my insurance pays me directly, I agree to notify Lyons Medical Billing and/or the Provider and provide an Explanation of Benefits (EOB) or payment information as requested.
Reimbursement calculations.
Lyons Medical Billing may help calculate reimbursements due to me based on my insurance benefits, what I have paid to the Provider, and the Provider’s charges listed in the Provider Financial Agreement. If it is determined that insurance payment should be forwarded to the Provider, I agree to cooperate and send payments accordingly.
4) REIMBURSEMENT FOR CHANGES IN CARE / BILLING NEEDS
If I transfer out of care:
Before 36 weeks of pregnancy: I will receive a $90 refund for reduced billing services.
After 36 weeks of pregnancy: No refund will be issued.
It is my responsibility to notify Lyons Medical Billing if I transfer out of care.
5) SCOPE OF BILLING SERVICES & LIMITS OF RESPONSIBILITY
Lyons Medical Billing LLC is committed to submitting claims accurately and according to billing guidelines. I understand and agree to the following:
A. Claim Preparation & Submission
Lyons Medical Billing is responsible for:
coding medical services based on documentation provided by the Provider, and
submitting claims according to national billing guidelines and the selected care model (e.g., global maternity, itemized care, bundled services).
Proper coding and submission does not guarantee insurance payment, and I remain responsible for the Provider’s full fee.
B. Follow-Up Support (2 Follow-Ups Included)
Billing services include up to two (2) follow-up actions after the claim(s) have been submitted.
Follow-up actions may include:
claim status checks,
correction and resubmission of claims (when appropriate), and
communication needed to confirm claim receipt or processing.
Once two follow-up actions have been completed, additional follow-up support is not included unless separately arranged.
Important: Follow-up actions are counted per patient billing service order, not per individual claim line.
C. Claim Corrections
If a claim is denied due to a billing error made by Lyons Medical Billing (such as a coding or submission error), Lyons Medical Billing will correct and resubmit the claim.
D. Appeals and Disputes
Lyons Medical Billing does not handle insurance appeals for denied, reduced, or incorrectly processed claims beyond the follow-up support described above.
All formal appeals are the responsibility of me, the patient, and must be handled directly with my insurance company.
Lyons Medical Billing may provide general guidance or documentation upon request but does not guarantee outcomes.
E. No Guarantee of Coverage or Payment
Lyons Medical Billing is not responsible for:
changes in my insurance coverage,
misquoted or incorrect benefits,
decisions made by my insurance company,
claim denials, reduced payments, or processing errors.
Lyons Medical Billing does not guarantee:
what my insurance will cover,
how claims will be processed,
what benefits my insurance plan includes, or
the amount of reimbursement I may receive.
Insurance coverage is determined solely by the insurance company.
6) OUT-OF-NETWORK STATUS, INSURANCE COVERAGE & BALANCE BILLING AGREEMENT
All Providers in this practice are Out-of-Network with all insurance companies. Lyons Medical Billing may assist with claim submission and may request a “Gap Exception” when appropriate. However:
these steps do not change the Provider’s Out-of-Network status,
these steps do not limit the Provider’s right to collect their full fee, and
these steps do not guarantee insurance payment.
LIMITATION OF PROVIDER RESPONSIBILITY
I understand and agree that the Provider is not responsible for insurance benefit determinations, claim outcomes, reimbursement amounts, denials, delays, or decisions made by the insurance company. The Provider does not guarantee reimbursement. Any disputes regarding insurance coverage or claim processing must be addressed directly between the patient and the insurance company. The provider is not responsible for sending any medical records or documents needed for the claims to process to insurance, although they may do this if they want to. I can attain any documents needed for processing of my claims from the provider and submit them to insurance myself.
By signing this agreement, I understand and agree:
A. Financial Responsibility
Regardless of what insurance pays—or if it pays nothing—I am responsible for the Provider’s full Midwifery Fee as listed in the Provider Financial Agreement.
If I have not signed the Provider Financial Agreement, I agree that this document serves as my agreement to those financial terms.
B. Balance Billing
Because my Provider is Out-of-Network, I may be billed for the difference between the Provider’s fee and the amount reimbursed by insurance. I understand and agree to pay any remaining balance according to the Provider’s Financial Agreement.
C. Insurance Payment Is Not Guaranteed
Insurance companies may deny claims, reduce payments, or apply benefits differently than expected. Any disputes regarding insurance payment are between me and my insurance company. If insurance makes a payment and later determines that it was paid incorrectly, I am responsible for making
D. Gap Exceptions
If my insurance approves a Gap Exception, it does not:
make my Provider in-network,
change the Provider’s fees, or
guarantee payment from insurance.
I remain responsible for paying the Provider’s full fee.
E. Payment Timeline
My financial responsibility does not depend on how long insurance takes to process claims.
INSURANCE OVERPAYMENTS & RECOUPMENTS
I understand that insurance companies may issue payments and later determine that they overpaid, incorrectly processed a claim, applied benefits incorrectly, or paid in error. In these situations, an insurance company may request repayment (“recoupment”) from the Provider, the patient, or both, even after reimbursement has already been issued.
If the Provider has reimbursed me based on insurance payments received and my insurance later requests repayment, reverses payment, withdraws funds, or otherwise determines that an overpayment occurred, I agree that:
The Provider is not responsible for absorbing insurance recoupments.
I remain financially responsible for any recouped amounts that relate to insurance reimbursement that I previously received or benefited from.
I will repay the Provider within 30 days of notification for any amounts the Provider is required to return to the insurance company that correspond to reimbursements previously paid to me.
This applies regardless of the reason for recoupment, including claim processing errors, benefit changes, audits, retroactive denials, coordination of benefits issues, or insurer administrative error.
7) TRANSFER OF CARE
If I transfer to an in-network facility or another provider—whether due to medical necessity, patient choice, or any other reason—this Financial Agreement and the Provider’s financial agreement remain in full force and effect.
I understand that fees charged by the receiving facility or provider are separate and not included in the Provider’s Midwifery Fee.
8) UNDERSTANDING & AGREEMENT
These policies have been explained to me in clear language. I understand them and agree to the financial responsibilities described in this document.
9) STATE-SPECIFIC ADDENDUMS (CA, WI, MN, TX)
California (CA)
California consumer protection laws (including surprise billing rules) generally apply to emergency care or care provided at in-network facilities. Since midwives bill independently and are Out-of-Network providers, I understand that:
these protections usually do not apply to non-emergency midwifery services, and
I am responsible for the full Out-of-Network fee listed in the Provider’s Financial Agreement.
Wisconsin (WI)
Wisconsin does not have special laws preventing Out-of-Network billing for midwifery or routine maternity care. I am responsible for any balance not paid by insurance under the Provider’s Financial Agreement.
Minnesota (MN)
Minnesota requires clear disclosure when providers are Out-of-Network. By signing this form, I acknowledge that my Provider is Out-of-Network and that I am responsible for the full fee regardless of insurance coverage.
Texas (TX)
Texas “Surprise Billing” protections mainly apply to emergency or hospital-based care. Independent midwifery services are not covered by that law, and I may still be billed for the balance of the Provider’s fee according to the Provider’s Financial Agreement.