Policies
Roadways to Recovery is not an Emergency or Urgent Care Facility
I understand Roadways to Recovery is a private practice and we do not provide emergency / crisis services. For medical / behavioral health care emergencies, please call 911 or go directly to the nearest emergency room.
Patient Rights
All individuals who apply for services, regardless of sex, race, age, color, creed, financial status, or national origin, are assured that their lawful rights as patients shall be guaranteed and protected. While being served, you, the client, are assured and guaranteed the following rights:
Patient Rights
- A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity and with protection of his or her need for privacy.
- A patient has the right to receive care in a safe setting that protects his or her privacy and confidentiality.
- A patient has the right to have his or her cultural, psychosocial, spiritual and personal values, beliefs and preferences respected.
- A patient has the right to formulate advance directives and designate a surrogate to make healthcare decisions on behalf of the patient.
- A patient has the right to participate in the consideration of ethical issues that arise in his or her care.
- A patient has the right to a prompt and reasonable response to questions and requests.
- A patient has the right to know who is providing medical services and who is responsible for his or her care.
- A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
- A patient has the right to receive from the healthcare provider information concerning diagnosis, planned course of treatment, alternatives, risks and prognosis.
- A patient has the right to refuse any care, treatment and services except as otherwise provided by law, and to be informed of the medical consequences of this action.
- A patient has the right to know what rules and regulations apply to his or her conduct.
- A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care. If eligible for Medicare, the patient has the right to know, upon request and in advance of treatment, whether the healthcare provider or healthcare facility accepts the Medicare assignment rate.
- A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care, to receive a clear and understandable itemized statement and upon request to have the charges explained.
- A patient has the right to access, request amendment to and receive an accounting disclosures regarding his or her own health information as permitted under law.
- A patient has the right to impartial access to medical treatment or accommodations regardless of race, national origin, religion, handicap or source of payment.
- A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
- A patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation, and to be free from seclusion or restraints that are not medically necessary or to protect the patient or others from harm.
- A patient has the right to access protective and advocacy services.
- A patient has the right to know if medical treatment is for experimental research purposes and to give his or her consent or refusal to participate in such experimental research.
- A patient has the right to pain management.
- A patient has the right to express grievances regarding any violation of his or her rights, as stated in Indiana law, through the grievance procedure of the healthcare provider or healthcare facility that served him or her and to the appropriate state licensing agency.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Chief Executive Officer or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.
I hereby acknowledge receipt of and understand the "Patient Rights" statement.
Random Drug Testing
All clients of Roadways to Recovery receiving a controlled substance or in treatment for a substance use disorder , "the facility", are required to participate in random drug testing as part of our Controlled Drug Monitoring Policy. The Facility drug test is provided by LabCorp or Aegis or similar companies, and an integral part of the test is the confirmations of the urine test that LabCorp also performs. This letter is clarification of the Facility billing practices regarding the processing of your specimen.
No Surprises Billing
We understand that seeking treatment for your mental health can be challenging and that the cost of treatment is a determining factor for many clients. We want you to have the information necessary to make the best decision for your treatment, and as such have created a list of charges for uninsured or self-pay clients. Payments are due at the time of service and we require a credit card to be on file.
Medication Management
Psychiatric Evaluation with Nurse Practitioner (Diagnosis and Medication Management)
$250.00
Follow up (Return Visits)
99213 low complexity visit $100
99214 moderate complexity $150
99215 high complexity $200
Oral or Urine Drug Screens $50.00 per screen
Medication injections $30.00 per injection
Venipuncture $30.00 - not the actual lab test
Breathalyzer $15.00
Visit frequency care varies; typically clients are seen every 1-3 months until symptoms are stable. If prescribed a controlled substance you will be seen every 1-3 months depending on the controlled substance prescribed
A Good Faith Estimate of Medication Management for mental health only with with monthly appointments and one evaluation per year is $1950.00
A Good Faith Estimate of Medication Management of Substance use treatment of a client who is compliant with treatment plan $2200.00
Therapy
Initial Evaluation
$250
Return Visits 53 min appointment
$150
Therapy visits can be scheduled at different intervals based on your treatment plan and goals. You can further discuss frequency of visits with your therapist at your initial and ongoing visits.
A Good Faith estimate of therapy services for one (1) year of services, having weekly appointments and one evaluation per year, is $7,900
Peer Counseling
$30.00 per 15 min interval
Outside Labs
clients may need to have various laboratory tests completed by outside laboratories. These tests could include but not limited to drug screens, bloodwork, and genetic testing. Some drug screens will be sent to outside laboratories to clarify results of our point of care results and as determined by the provider and as sometimes required by the State of Indiana for certain treatments. The outside laboratories are responsible for billing your insurance company and invoicing the client for charges. Roadways to Recovery is not involved in billing/charges for outside laboratory work. Some Laboratories have special programs for clients without insurance or out of network. Always be sure to inquire with the labs for payment options or discounts.
Non-Covered Services
Document Preparation - Document review with signature only will be charged a minimum of $10.00 per signature. A fee of $50 per every 15 min of time required to complete paperwork (including but not limited to work, disability, FMLA life insurance, etc.) will be charged outside of your scheduled office visit. Payment in full is required prior to the release of your paperwork.
Medical Records - 14 days are required to request medical records. A current written release of information required for all requests. All requests for medical records will be charged according to Indiana State Law. Payment is due prior to the processing of your request. There is no charge for records released directly to another healthcare professional for treatment purposes.
Pages 1-10 - $1 dollar per page
Pages 11-50 - $0.50 per page
Pages 51 and higher $0.25 per page
There will be a labor fee of $20.00 for records longer than 10 pages. You will be charged for postage if mailing of records is required.
Certified Medical Records $20.00
There is no charge for records released to another healthcare professional for treatment purposes.
Telehealth
The laws that protect the confidentiality of my personal information also apply to telehealth. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the Facility, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. The Facility utilizes secure, encrypted audio/video transmission software to deliver telehealth. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my nurse practitioner or therapist to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed.
I understand billing will occur from my provider as usual. I have been able to ask questions in regard to this procedure, my questions have been answered and any practical alternatives have been discussed. The Facility offers telehealth appointments and in order to communicate effectively in my care, I authorize the Facility to communicate with me via telephone, email and text messages. I understand and consent for links for telehealth maybe sent via text or email. I understand I must be within the state of Indiana in order to be seen. Coverage is determined by your insurance carrier. We highly encourage you to verify your telehealth benefits with your insurance company or your human resources representative.
Electronic Communication
The transmission of client information by email and/or text has several risks that clients should consider prior to the use of these forms of communication. These include, but are not limited to, the following: Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy. Employers and on-line services have a right to inspect emails sent through their company systems. Emails and texts can be intercepted, altered, forwarded, or used without authorization or detection. Email and texts can be used as evidence in court. Email and texts may not be secure and therefore it is possible that the confidentiality of such communication may be breached by a third party. I understand the risks of communicating through electronic means.
Substance Abuse Treatment
Program rules
1. Buprenorphine-naloxone (Suboxone) shall only by taken by placing it under the tongue to dissolve and be absorbed. No eating or drinking anything for at least 15-30 mins after the film or tablet has been dissolved. Buprenorphine products will never be injected or take it intravenously (IV), because IV use could lead to sudden and severe opiate withdrawal.
2. Roadways to Recovery medical provider will be notified of all other doctor and dentist appointments, and any medications (prescription or non-prescription) participant is taking. Report any change in medical history. A release of information must be signed for all other medical providers or therapist.
3. Buprenorphine/Suboxone will not be combined alcohol or other sedatives (such as Valium, Ativan, Xanax, Klonopin, Librium) and benzodiazepines. Participants must agree to abstain from ALCOHOL and SEDATIVES while being treated with buprenorphine/Suboxone. This is for safety and to ensure that another medication is not prescribed which may lead to harmful side effects. A positive drug test for these substances can result in a discharge from Roadways to Recovery.
4. Participant agrees to abstain from all drugs, including alcohol, marijuana, and other street drugs. Participants agree to work with the provider to design an individualized treatment program to assist me in discontinuing the use of other drugs.
5. Medication must be protected from theft or unauthorized use and stored in a locked cabinet. where it cannot be taken accidentally by children, pets, or be stolen. If medications are stolen, a police must be filed and copy of report brought to the next visit. Participants must full responsibility for the safekeeping of buprenorphine/Suboxone. Lost or stolen buprenorphine/Suboxone will not be refilled before the date it was due. The medical provider reserves the right to refuse refills if the participant is not complying with program rules. Participant may be discharged from Roadways to Recovery if not following this treatment agreement.
6. Participant will not sell, share, or give any medication to another person and understand that such mishandling of medication is a serious violation of this treatment agreement and would result in treatment being terminated without recourse for appeal.
7. If a prescription is altered or forged, provider will terminate care immediately and will inform the pharmacy and legal authorities of this felony act.
8. Participants agree to participate in a regular program of professional counseling as recommended by the practice staff while being treated with buprenorphine/ Suboxone. If substance abuse counselor is located outside of the clinic, participant will provide proof of regular substance abuse therapy attendance (which may be in the form of a note from substance abuse counselor) at each visit to medical provider.
9. Participant agrees to receive support from peers as recommended by the MAT (Medication Assisted Treatment) clinic staff, and agree to invite significant persons/family to participate in treatment.
10. Participants agree that a network of support is an important part of recovery, and honest communication among people within the network is important for treatment. Participant will provide authorization to allow telephone, email, or face-to-face contact, between the MAT clinic staff and physicians, therapists, probation or parole officers, the Department of Social Services, and parents to discuss treatment and progress. Participant must consent to allow the staff Roadways to Recovery to provide others with information regarding medication usage as needed for treatment or as otherwise permitted or required by law. Participant must agree to sign a release of information with all parties involved in treatment.
11. Buprenorphine/Suboxone refills will only be prescribed during scheduled office visits with buprenorphine provider and I will not be able to obtain buprenorphine refills during walk-in visits, after regular clinic hours, or on weekends.
12. Medications must be taken as prescribed by buprenorphine provider. .
13. Participant agrees to meet with buprenorphine/Suboxone provider on a regular basis. The frequency of visits will be up to buprenorphine provider.
14. Missed appointments - medications will not be refilled until the time of the next appointment. If an appointment is missed refills will not be given until seen by a provider.
15. Buprenorphine tablets or strips will be counted randomly and all medication must be brought into the appointment.
16. Participant may be asked to bring in or send a picture of Suboxone medication to be counted at any time, and will submit pill/film counts within 24 hours of receiving such a request. You will receive a text message to submit the pill count with a code. Place your pills/strips in rows and columns on a plain white sheet of paper write the code provided in the text message along with the date and time you send in the medication count. Then email a Contact@roadwaystorecovery.com with the picture.
17. Payment of all office fees for this treatment at the time of visits. Failure to do so is cause for immediate termination of services.
18. Females only - understand there are increased risks to the fetus if I use buprenorphine/Suboxone during pregnancy, immediately notify MAT provider if I suspect pregnancy is a possibility, or if desire to become pregnant.
Financial Policy
- Insurance Billed Services - Co-payments & deductibles are due at the time of service
- Insurance Participation - Our providers participate with different insurance plans. We make every attempt to schedule you with an in-network provider; however, it is the client's responsibility to confirm that any/all providers with whom they are scheduled with are participating in their insurance network. clients will be responsible for charges incurred for services rendered by an out-of-network provider.
- Insurance Benefits - Please be aware that mental health benefits are normally different from your medical benefits. Roadways to Recovery does not verify insurance benefits information until after your initial visit with our group. It is your responsibility to verify and familiarize yourself with your mental health benefits.
- Changes to Insurance – It is your responsibility to make sure we have your most current insurance card on file. Sometimes insurance may change to a different insurance company, other times it may just be a simple change to your ID number. Anytime you receive a new card, please notify our office or you can upload a copy through our website.
- Claims Submission - Roadways to Recovery will file all claims with your primary insurance company upon submission of proof of insurance. Roadways to Recovery will file secondary insurance claims for contracted insurance carriers only.
- We require clients to have a credit card on file who will not bill insurance or have commercial insurance. State and Federal plans are excluded from credit card requirements.
- Past Due Balances - Our office reserves the right to cancel or refuse services for client accounts with past due balances. clients will be unable to schedule appointments if they have 2 outstanding co-payments, an account balance of $100 or more, or if your account balance is greater than 30 days past due after insurance processing.
- Returned Check Fees - All returned checks will be assessed a $50 processing fee. The original check amount plus the processing fee must be paid at your next appointment or within 10 days.
- Statements - will be emailed upon request
- Payment in full is due upon receipt of the statement.
- Acceptable methods of payment -bank cards or HSA cards including VISA, MasterCard, Discover and American Express.
- Claim / charge dispute – Our clinical, clerical staff, and/or billing department personnel are unable to waive or modify fees. The decision rests with the administration of Roadways to Recovery. The client must complete and submit a Charge Dispute Form that is available on our website under the Forms tab.
- Financial Responsibility - The client / responsible party is responsible for all charges incurred with Roadways to Recovery.
- Collections - Accounts in violation of our financial policy are subject to placement with a third-party collection agency. The client will be responsible for reasonable attorney and collection fees.
Out of Network Billing
- Private Pay Services / Out of Network Insurance Billed Services - Payment in full is due at the time of service.
- For your convenience Roadways to Recovery will file out of network claims upon proof of insurance.
- Roadways to Recovery is not responsible for obtaining authorization for out of network services.
- Discounts will not be applied to out of network claims.
- Roadways to Recovery is not responsible for processing errors caused by the insurance on out of network claims.
- Roadways to Recovery is not responsible for pursuing payment from the insurance for out of network claims.
Nonpayment
Non Payment. If your account is past due, you will receive a notice stating that you have 90 days to pay your account in full. During that 90 days, you will be required to pay in full for scheduled office visits. If you are unable to pay in full for the visit, we will reschedule your appointment. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency, and you may be discharged from this practice. If this is to occur, you will be notified that you have 30 days to find alternative medical care. During that 30-day period, our provider will only be able to treat you on an emergency basis.
End of Year Change
Many people experience insurance changes towards the end of the year. It is the responsibility of the client to provide Roadways to Recovery with any changes to insurance policy and coverage, including those effective January 1st, of each year. I understand that by not providing this information in its entirety and in a timely manner may result in a change to my Good Faith Estimate and my amount owed to Roadways to Recovery. I agree to provide any changes to Roadways to Recovery and accept responsibility for incurred charges by not providing the most accurate insurance information.
Refill Policy
All prescription medications require regular appointments and careful monitoring as part of your care. Because of the potential risks and side effects of certain medications, they may need to be adjusted; therefore, we will normally give you only enough medication to last until your next appointment. It is important for you to let us know about any other medications you are taking, either prescribed by other physicians, or purchased over-the-counter, such as cold pills, diet aids or homeopathic drugs. We make every effort to prescribe enough medication to last until your next appointment. It is our policy not to call in medications. I understand that if I miss or cancel an appointment, I may not be able to refill my medication until I am seen by the Nurse Practitioner ordering the medication. It will be at your provider's discretion to refill your medication to your next appointment. If a refill is needed before your scheduled appointment please notify your provider within 72 business hours. Refills will not be processed after 5pm, weekends or holidays. Refills are not considered medical emergencies. Roadways to Recovery does not accept automated pharmacy fax refill requests
No Show Policy
I understand a no-show appointment is a missed appointment in which I do not present for the appointment, or I cancel the appointment less than 24 hours prior to the scheduled appointment.
In the event that a client has two (2) or more no-show appointments in a six (6) month period, that client may not be able to schedule appointments for 6 months and must use the virtual walk-in clinic during virtual walk-in clinic hours. Therapy is not offered in the virtual walk-in clinic. Only one issue may be addressed in the virtual walk-in clinic. If a client has 3 no-shows in 365 consecutive days, they may be discharged from the practice.