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SERVICE AGREEMENT
THIS AGREEMENT is made and entered into effective the 1st day of October, 1998,
by and between AES SERVICE GROUP, INC., a Georgia corporation (hereinafter
called "AES"), and NATIONAL DIAGNOSTICS, INC. (NDI) (hereinafter called
"Client").
WITNESSETH:
1. SERVICES TO BE RENDERED BY AES. During the term of this Agreement, AES
shall provide certain services to Client in connection with its
professional practice, which services may include but not be limited to
all or some of the services set forth on Exhibits A through E attached
hereto and incorporated herein by reference, and summarized on Exhibit
I. No other services shall be rendered by AES unless Exhibit I is
modified by the written consent of each party. Client shall provide, in
a timely manner, such information and data requested by AES, in order
for AES to fulfill its obligations hereunder.
2. COMPENSATION. As compensation for the services to be performed, AES
shall, no later than the 10th day of each month, render a billing
statement to Client for monthly services provided for the preceding
month. Each billing statement shall be due and payable upon receipt.
Any payment for fees owed AES under this Agreement not received by the
15th day of the month in which such billing statement is received shall
be considered late and subject to a late fee of 10% of the amount due.
Fees shall be based on the fee schedule as described on Exhibit E. In
addition, Client shall pay a one time, non-refundable, set-up fee of
N/A which shall be due and payable upon signing of this Agreement.
Client hereby agrees that AES may set off any amount due and payable to
it under this Agreement against any right client has to receive money
from AES , including but not limited to any of client's accounts
collected by AES pursuant to this Agreement, and Client agrees to hold
AES harmless from any claims, actions, causes of action, damages and
losses sustained by Client or asserted against Client and arising or
resulting in any way from AES's exercise of its right of set off.
Wherever possible, client shall utilize Lock Box Service from a
mutually agreeable bank to receive its clinical receipts. AES shall be
authorized to electronically debit client's account for payment of fees
due under this agreement.
Non-payment of any AES service fees due under this Agreement, as
described on Exhibit I, within ten (10) calendar days of the date when
due shall be considered a monetary breach as provided for in paragraph
four (4) below. Failure to cure such breach, shall give AES (I) the
right to suspend all services and deny Client access to AES's computer
system and software, (ii) the right to terminate this Agreement and
recover all damages from Client, and (iii) such other rights and
remedies against Client as may be provided under this Agreement and
applicable law.
3. TERM. This Agreement shall continue without interruption for a term of
five (5) year(s) commencing October 1, 1998, and ending September 30,
2003. Upon the expiration of the Original Term, this Agreement will
automatically renew each year for an additional one year period (each a
"Renewal Term") unless terminated by either party by providing sixty
days written notice prior to the expiration of the Original Term or any
Renewal Term. Term commencement shall be delayed until Client has
provided AES all data requested in its New Client Package plus
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any other information deemed essential by AES personnel for
implementation of this Service Agreement.
4. CLIENT'S OBLIGATIONS. AES shall install a data line, at Client's
expense, and maintain this data line in good working condition. Client
agrees that it will provide to AES all accounts accumulated in its
business during the term of this Agreement for processing by AES.
Client agrees to provide AES with the complete information necessary to
xxxx each patient, including but not limited to, current patient name
and address, code numbers, procedure, time and date service was
rendered and other information available to Client and necessary or
requested by AES in the billing and collection process. Any information
delivered to AES not in compliance with specific billing protocols as
provided in the new client package by AES, shall be returned to Client
for completion.
(a) Client agrees to accept and implement the protocols listed in
the Attachments hereto and any other systems established by
AES for the accurate, timely and proper techniques for billing
and collection purposes.
(b) Client shall balance charges, adjustments and payments to the
system daily according to AES protocols.
5. CLIENT'S REPRESENTATIONS AND WARRANTIES. Client represents and warrants
that:
(a) It is duly organized and existing and in good standing under
the laws of the State of Florida.
(b) The individual(s) executing this Agreement on behalf of client
have full authority to do so, and Client has obtained all
consents necessary to enter into this Agreement.
(c) Neither the execution nor the consummation of this Agreement
conflicts with nor shall result in a breach of default under
any other Agreement to which Client or any of its physicians
is a party, nor is Client or any of its physicians a party to
any Agreement which would materially impair client's ability
to perform its obligations under this Agreement.
(d) It shall, throughout the term of this Agreement, comply with
all applicable federal, state or local laws governing its
professional practice and employees.
(e) Client has had a full and complete opportunity to seek the
advice of its own independent counsel before entering into
this Agreement.
6. INDEPENDENT CONTRACTOR STATUS. It is understood and agreed that the
services of AES will be rendered as an independent contractor and not
as an employee, partner or joint venture of Client. AES will be
responsible for all federal and state employment taxes, including FICA,
FUTA, worker's compensation, unemployment, income taxes, and any other
applicable taxes and duties payable for or on behalf of itself or its
employees. The parties hereto shall not be considered as employees,
employer, agent, principal, partners, or joint ventures in acting under
this Agreement, and neither party shall be liable or accountable for
any debt, liabilities, or claims of whatsoever nature asserted against
the other. Unless Client shall have given its prior written consent,
under no circumstances shall AES or its employees have authority to
pledge the credit of Client or any of its shareholders, bind Client
under any contract, agreement, note, or otherwise,
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release or discharge any debt due Client, or sell, mortgage, transfer,
or otherwise dispose of any assets of Client.
7. HIRING. Both parties agree that during the term of this Agreement, and
for one hundred eighty days neither party will hire or attempt to hire
any employee or independent contractor of the other without the express
written consent of both parties.
8. CONFIDENTIALITY; DISCLOSURE; PROPRIETARY INFORMATION. Client and AES
mutually recognize and acknowledge that the clients, services,
processes, protocols, and methods of operation of the other party are
valuable, special and unique assets of such other party's business. The
parties further recognize and acknowledge that all business
information, proprietary files, records, analyses, compilations,
studies and opinions (written or oral), financial statements, customer
lists, lists of business acquaintances, processes, techniques,
services, intellectual property, programming, techniques of
application, concepts, purchasing, accounting, marketing,
merchandising, selling, recording or any other activity disclosed to
each other in connection with AES's performance of its obligations
under this Agreement are confidential information. Accordingly, both
parties shall keep in strict secrecy and confidence and shall not
disclose, disseminate, publish or permit disclosure of any and all
information that each party assimilated or obtained or to which either
party had access during the term of this Agreement for any reason or
purpose whatsoever without the prior written consent of the other
party. The terms and conditions of this Section shall survive the term
of this Agreement.
Each party to this Agreement agrees to keep confidential all
information relating to billing and financial information with respect
to each individual physician and professional association included with
Client, and their respective practices, except to the extent reasonably
needed to facilitate the services to be rendered under this Agreement.
9. DISPUTE RESOLUTION. It is the intention of all parties that no dispute
under this Agreement or with respect to relationship between the
parties will be the subject of any court action or litigation until and
after the parties have attempted to mediate their dispute. If any party
hereto wishes to make a claim or to resolve an issue or dispute under
or relating to this Agreement, then such party must give notice of a
request for mediation to the other parties which notice shall set forth
the names of not less than four (4) court approved mediators from the
lists available from the Circuit Court of Hillsborough County. The
parties receiving such notice shall agree upon one or more of such
mediators within seven (7) days of receipt of such notice and a
mediation will be scheduled as soon as feasible between the parties and
their respective advisors, and the parties and their advisors will
cooperate fully with respect to sharing of information and attendance
at meetings in order to seek resolution. The parties will share
mediation expenses. If resolution of the matters between the parties
cannot be resolved in mediation within sixty (60) days of the selection
of a mediator by the party receiving such notice, or within such other
time period as may be agreed by the parties in writing, then any party
may pursue any other rights, remedies, or courses of action available
under this Agreement and/or applicable law to resolve such claims or
disputes. Any party in breach, default or violation of this Agreement
shall pay all reasonable fees and costs, including but not limited to
attorneys', consultant, and expert witness fees, incurred by the other
party relating to such breach, default, or violation, and all other
fees and costs shall be paid as agreed in mediation or as determined
appropriate by a court of competent jurisdiction. It is the intention
of the parties that this Agreement shall be construed and interpreted
in a fair and equitable manner based upon the facts and circumstances
of the parties taking into account the present intention of the parties
to have a fair and equitable agreement under the terms and conditions
set
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forth herein.
10. INDEMNIFICATION. Client hereby agrees to indemnify, defend, and hold
AES and/or employees of AES harmless from and against any losses,
claims, damages or expenses, and/or all costs of prosecution or defense
of their rights hereunder, or of any claim asserted by AES by any
person or entity not a party to this Agreement and arising from any act
or omission of Client or its agents, employees or consultants, whether
in judicial proceedings, including appellate proceedings, or out of
court, including without limiting the generality of the foregoing,
attorneys' fees and all costs and expenses of litigation arising from
or growing out of the breach or threatened breach by Client of any
covenant or provision of this Agreement.
11. MISCELLANEOUS.
(a) Litigation Costs and Expenses. Notwithstanding any of the
foregoing, in the event it becomes necessary for any party to
this Agreement to institute litigation concerning this
Agreement against another party to this Agreement, the
prevailing party in such litigation shall be entitled to be
reimbursed by the non-prevailing party for all reasonable
litigation costs and expenses, including but not limited to
attorneys' fees, consultant fees, expert witness fees, court
costs and all other related costs and expenses incurred by the
prevailing party in connection with or relating to such
litigation (including but not limited to copy charges, long
distance and cellular telephone charges, travel related
charges, employee overhead charges, mileage and all court
report charges).
(b) Authority. Each of the parties hereto and each of the
individuals affixing their names hereto on behalf of a party
warrants and represents to the other that the party and such
individual has all necessary and legal authority to do so and
that this representation is a material inducement to the other
party entering into this Agreement.
(c) Binding Effect and Assignability. This Agreement shall be
binding upon and shall inure to the benefit of the respective
parties hereto, their legal representatives, successors and
assigns, provided, however, notwithstanding any provision of
this Agreement to the contrary, no party may assign any of its
rights, obligations or interest in this Agreement without the
prior written consent of all parties to this Agreement, except
that AES may freely assign this Agreement, without Client's
consent, in whole or in part, to a parent company, a
wholly-owned subsidiary or another company owned or controlled
by AES, its parent company or one of its wholly-owned
subsidiaries.
(d) Good Faith. All parties to this Agreement specifically agree
to act in good faith in interpreting this Agreement and in
carrying out their respective duties and obligations
hereunder.
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IN WITNESS WHEREOF, the parties have signed, sealed and delivered this
Agreement in the City of Tampa, State of Florida on the date previously stated.
AES SERVICE GROUP, INC.
a Georgia Corporation
By: /s/ Xxxxxxx X. Xxx By: /s/ Xxxxxxx X. Xxxxxxxxxx
------------------------------- ----------------------------------
Xxxxxxx X. Xxx Xxxxxxx X. Xxxxxxxxxx
Witness President
10/1/98
-------------------------------------
Date
NATIONAL DIAGNOSTICS, INC.
By: /s/ Xxxxxxx X. Xxx By: /s/ Xxxx X. Xxxxxxxx
------------------------------- ----------------------------------
Xxxxxxx X. Xxx Xxxx X. Xxxxxxxx
Witness President
1/25/99
-------------------------------------
Date
CLIENT: AES:
NATIONAL DIAGNOSTICS, INC. AES SERVICE GROUP, INC.
000 Xxxx Xxxxxxx Xxxxxxxxx 0000 Xxxxx Xxxx Xxxxx Xxx., Xxxxx 000
Xxxxxxx, XX 00000 Xxxxx, XX 00000
813/689-4966 Office 813/882-6567 Office
813/000-0000 Fax 813/000-0000 Fax
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AES SUMMARY OF SERVICES
RIVERSIDE/ORANGE PARK OFFICES
EXHIBIT "A"
PRIMARY BILLING SERVICES/PROVIDED BY AES
On Line Access To Computer System and System Software Support
(7:00 a.m. to 7:00 p.m., Monday through Friday)
(7:00 a.m. to 1:00 p.m., Saturday)
Daily Electronic claims processing
Daily submission of insurance claim
Weekly printing and mailing of statements-sixty cents each (paid by Client)
Standard month end management reports (Only one copy printed at month end)
Extra standard system reports - $50 per report
Customized reports - to be quoted (based on complexity)
Update Fee Schedule, as required and provided by Client
Update Procedure Codes, as required and provided by Client
Appointment recall notices
Posting of payments and insurance adjustments according to contractual
agreements
Daily in-put of all Charge Entry Data (office)
Service billing calls and written inquires
Process refunds
All follow-up of work required for timely collection of accounts receivable
Determine if further collection efforts are required after 120 days. AES to
forward to collections if necessary.
CLIENT'S RESPONSIBILITY
Data entry of all patient demographics including insurance information
Complete insurance verification prior to appointment
Data entry of verification information and authorization/referrals
Obtain authorization/approval on all services
Accepted as Exhibit "A":______________________ Date:______________________
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AES SUMMARY OF SERVICES
XXXXXXX/SUNPOINT OFFICES
EXHIBIT "A (1)"
PRIMARY BILLING SERVICES/PROVIDED BY AES
On Line Access To Computer System and System Software Support
(7:00 a.m. to 7:00 p.m., Monday through Friday)
(7:00 a.m. to 1:00 p.m., Saturday)
Daily Electronic claims processing
Daily submission of insurance claim
Weekly printing and mailing of statements-sixty cents each (paid by Client)
Standard month end management reports (Only one copy printed at month end)
Extra standard system reports - $50 per report
Customized reports - to be quoted (based on complexity)
Update Fee Schedule, as required and provided by Client
Update Procedure Codes, as required and provided by Client
Appointment recall notices
Posting of payments and insurance adjustments according to contractual
agreements
Daily in-put of all Charge Entry Data (office)
Service billing calls and written inquires
Process refunds
All follow-up of work required for timely collection of accounts receivable
Determine if further collection efforts are required after 120 days. AES to
forward to collections if necessary.
CLIENT'S RESPONSIBILITY
Data entry of all patient demographics including insurance information
Complete insurance verification prior to appointment
Data entry of verification information and authorization/referrals
Obtain authorization/approval on all services
Accepted as Exhibit "A (1)":___________________________ Date:____________
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SUMMARY OF SERVICES
EXHIBIT "B"
FINANCIAL/ACCOUNTING SERVICES
AES SERVICE GROUP, INC. offers financial and accounting services specifically
designed to meet the needs of the medical community and the individual practice.
We recognize that medical practitioners require specialized financial/accounting
services that will enhance their business efficiency as well as allow them to
take advantage of emerging opportunities.
Services offered include any, or all, of the following . . . services may be
"packaged" to meet the individual needs of the client.
GENERAL LEDGER Detailed, daily accounting of all
transactions occurring within the business;
i.e., cash receipts, cash disbursements,
payroll, asset transactions, etc. Reports
and analysis developed and reconciled
monthly for client review.
ACCOUNTS PAYABLE Review, verification and processing of
invoices for payment. Checks written and
distributed to vendors per instructions of
the client. Reports and analysis developed
and reconciled monthly for client review.
BANK RECONCILIATIONS Bank account management and balancing
services performed on a monthly basis.
FINANCIAL STATEMENTS Monthly presentation of current financial
position through Balance Sheet detail and
presentation of period activities of incomes
and expenses through Income Statement
detail.
BUDGET REVIEW & ANALYSIS Monthly and/or annual planning, forecasting
and variance analysis in relation to
established budgets or in the process of
developing such documents for future
periods.
INTERFACE WITH CLIENT'S CPA To facilitate and ensure timely tax filings
and accounts processing.
BANKING PLAN Guidance in banking transactions to
associations that will meet current needs
and support those needs as they change and
grow.
Accepted as Exhibit "B": __________________________________ Date:_______________
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AES SUMMARY OF SERVICES
EXHIBIT "C"
CONSULTATION AND EVALUATION SERVICES:
* CPT Code Evaluation
* HCPCS Code Evaluation
* ICD-9-CM Code Evaluation
* Analysis of Encounter Form
* Evaluation of Forms/Registration, Waiver of Liability,
Marketing Brochure, Recalls, Pre-Collection Letters,
Collection Letters, etc.
* Evaluation of A/R, Bad Debt, & Collection Ratio
* Evaluation of Computer System
* Evaluation of Contractual Adjustments/Write-Offs
* Practice Management Studies
Accepted as Exhibit "C": ________________________________ Date: ________________
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AES SUMMARY OF SERVICES
EXHIBIT "D"
BAD DEBT COLLECTION SERVICE
All services required for the collection of "Past Due" accounts (based on
Client's determination)
At the time any account with a balance due reaches 120 days of aging from date
of service a determination will be made to identify the outstanding balance as
commercial or patient due and why payment has not been made. Commercial shall be
corrected and re-billed if required. A patient due balance shall be sent to the
Client to determine whether further normal collection activity should occur or
the balance should be written of as directed by Client or be classified as bad
debt and be handled as provided in Paragraph 17 of this agreement.
Accepted as Exhibit "D": ________________________________ Date: ________________
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SUMMARY OF SERVICES
EXHIBIT "E"
HUMAN RESOURCES
All employees will fall under the policies and procedures of AES (see Employee
Manual). The cost to the Client shall be a direct pass-through of all costs
associated with the employees of their office(s) (salaries, benefits, taxes,
Worker's Compensation, etc.) which will also include an administrative fee paid
to AES.
Employee benefits and payroll shall be implemented and administered in
accordance with AES policy and procedures. In order to utilize this AES service,
Client shall execute additional forms needed to enroll employees in all payroll
and benefit related programs that will be provided by AES.
AES shall be authorized to electronically debit Client banking account to fund
for payroll and benefit costs. Such electronic funding shall occur based on the
mutually agreed payroll cycle.
AES shall provide the following services for the fee disclosed on Exhibit I of
this Agreement.
PERSONNEL MANAGEMENT SERVICES INCLUDED
Employment Administrative Services
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_____ GROSS PAYROLL _____ Short Term Disability
_____ FICA _____ Long Term Disability
_____ FUTA _____ Life Insurance
_____ SUI 401(K) PLAN:
ADMINISTRATIVE COSTS: _____ Maintenance
_____ Paycheck Preparation _____ Audit
_____ Tax Deposits & Reconciliations _____ Communication
_____ Employee Deductions
_____ Garnishments
EMPLOYEE FILES:
_____ W-2s (annual)
_____ W-4s (annual)
_____ I-9s
_____ Employment Applications
_____ Employment Verifications
_____ Direct Deposit
_____ Employment Agreements
INSURANCE PROCUREMENT:
_____ Health Care
_____ Workers' Comp
_____ Other Benefits
BENEFIT PLAN MANAGEMENT:
_____ Medical/RX
_____ Dental
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Recruiting & Selection Services
-------------------------------
_____ JOB DESCRIPTIONS
_____ ADVERTISING
_____ RESUME REVIEW
_____ BACKGROUND CHECKS
_____ SALARY PLANNING/ADMINISTRATION
PERSONNEL POLICIES:
_____ Development
_____ Implementation
_____ Administration
_____ Maintenance
Government Compliance
---------------------
GOVERNMENT REPORTING AND
AGENCY INTERFACE:
_____ Quarterly Reports (940s)
_____ Annual 941
_____ FMLA
_____ COBRA
_____ HIPAA
_____ New Hire Reporting
UNEMPLOYMENT CLAIMS
MANAGEMENT:
_____ Wage Reporting
_____ Employment
Records Management
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AES SUMMARY OF SERVICES
EXHIBIT "I"
The fee schedule below has been constructed to represent the services included
in this Agreement and the cost for such services as described in the Schedule
listed below:
Exhibit "A" 6% of collections
Exhibit "B" Included in contract
Exhibit "C" $ N/A per hour if billing Client; $125.00 per hour for consulting only
Exhibit "D" 30% of monies collected
Exhibit "E" Included in contract
Data Entry $50.00 per hour (as defined in Exhibit B)
Training $50.00 per hour
AES shall be further entitled to reimbursement for postage, envelopes,
statements, forms, data lines, copies, Medifax usage, and any other cost
directly related to Client.
Accepted as Exhibit "I":____________________________________ Date: _____________
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"ATTACHMENT I"
BILLING PROTOCOLS
All office visits, and procedures must include the following:
A) A Superbill that clearly indicates:
(1) The procedures performed
(2) Diagnoses appropriately linked with their corresponding
procedures
(3) Total charges
(4) Payments must indicate cash, credit card (include credit card
name and number on card), check (include check number)
(5) The appropriate modifiers
(6) A copy of the patient's insurance card(s), front and back
(7) A copy of authorization and/or referral form or an
authorization number only (if applicable)
(8) The physician's signature
(9) Copy of deposit slip
(10) Copy of checks
(11) Copy of Credit Card Release Form
All patient demographic and insurance information must be verified and entered
into the AES Practice Management System before charges are forwarded to AES.
A copy of necessary forms are attached as well as an example of proper
completion of each form. If AES receives any incomplete/inaccurate
documentation, a photocopy of the batch will be returned to the office for
correction and re-submittal within 48 hours.
PLEASE CONTACT THIS OFFICE IF YOU HAVE ANY QUESTIONS.
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"ATTACHMENT III"
INSURANCE VERIFICATION FORM
Date:_____________________
Patient Name:_______________________ Account #:_________________________________
Insurance Name:_________________________________________________________________
Managed Care Company Name:______________________________________________________
Name of Third Party Administrator:_________________________________________
Product Type (HMO, PPO, CAP, Etc.)_________________________________________
Mailing Address for Claims:_____________________________________________________
_____________________________________________________
Effective Date: ________________________________Termination Date:_______________
IF EFFECTIVE DATE IS LESS THAN ONE (1) YEAR, OUTLINE PRE-EXISTING TERMS:
________________________________________________________________________________
Deductible:__________ Annual Met? Yes/No % of Payment (80%, 90%, etc.)_______
CoPay: Office Visit___________ Lab:__________ O/P:________ I/P:__________
Out of Pocket/Stop Loss:______ Annual Met? Yes/No Includes Deductible? Yes/No
Name of Insured:________________________________________________________________
Name of Patient as it should appear on Claim:___________________________________
Coverage Type: Insured Only( ) Insured & Spouse( ) Family( ) Low Income( )
Patient ID #:___________________ Group #:_______________________________________
Precertification/Authorization Required: Yes/No
Authorization #:_______________ For Date of Service:_______________________
Primary Care M.D.:___________________________ Telephone #:______________________
Is policy a Carveout or Non Dupe Plan? Yes/No
Injury Related Benefits: Work:___ Auto:___ Other:___
Adjuster's Name:____________________________________
Claim #:________________ Date of Injury:____________
Employee Claim Form Required? Yes/No Do you accept Electronic Claims? Yes/No
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"ATTACHMENT IV"
SMALL BALANCE ADJUSTMENTS
AES SERVICE GROUP, INC. (AES), on behalf of National Diagnostics, Inc. will
collect all revenues that its clients are due based upon appropriate
reimbursement submittals. In those instances where a patient account is
adversely impacted by circumstances of death, bankruptcy, etc., and/or the
balance falls below specific minimum balances, the following procedural
guidelines will be implemented.
PROCEDURE:
1. A small balance adjustment will be done on balances that are $10.00 or
less, and the patient has been sent at least one letter or statement
and no payment has been received.
2. Regarding a bad address:
(a) If the balance is $10.00 or less, a small balance adjustment
will be done.
(b) If the balance is between $10.01 and $25.00,
I. Contact physician's office,
ii. Call information,
iii. Check Hill Xxxxxxxx Cross Reference after which, if no
address is found, a bad debt adjustment will be done.
(c) If the balance is over $25.01 and no address can be found, the
account will be sent to the physician with a recommendation
that it go to the Bad Debt Collections Department.
3. Regarding a deceased patient:
(a) If the balance is less than $50.00, a Deceased adjustment will
be done.
(b) If the balance is greater than $50.01, verification will be
made with the County Court to see if an estate has been filed.
If an estate has been filed, charges will be submitted. If no
estate has been filed, efforts will be made to contact the
spouse to see if a payment arrangement can be set up. If this
fails, a Deceased adjustment will be done.
4. If a patient refuses to pay and has not made any payment after the
account reaches 90+ days, two Audit Review Letters will be sent along
with a phone call. If no payment is made after 30 more days, the
account is sent to the Client with the recommendation that it go to the
Bad Debt Collections Department or be adjusted off.
5. If bankruptcy is filed, a bad debt adjustment will be done.
APPROVED BY:______________________________________ DATE:________________________
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"ATTACHMENT V"
BUDGET PLAN AGREEMENT
AES SERVICE GROUP, INC. (AES) has developed a new policy and procedure for
budget plan agreements. Please review the policy amounts and acceptable period
to pay for outstanding balances below:
BALANCE OF ACCOUNT PERIOD TO PAY MINIMUM PAYMENT
------------------ ------------- ---------------
$ 75.00 to $250.00 3 Months $ 25.00 - $ 83.00
$250.01 to $500.00 4 Months 62.50 - 125.00
$500.01 to $750.00 5 Months 100.00 - 150.00
$750.01 to $900.00 9 Months 84.00 - 100.00
$900.01 and up 12 Months 75.00 - 84.00
All patients will be offered a budget plan arrangement if they are having
difficulties paying the complete balance. When we have patients that are not
able to pay the above indicated amounts, individual consideration will be made
for hardship accounts and a payment plan approved by senior management. All
patients will be sent an "agreement" to sign and forward along with their first
payment. If a patient fails to abide by the signed agreement, the accounts will
be placed on a Xxxxx 00 report with the recommendations of turning the account
over to Accounts Management, Inc.
Please sign below if the above agreement is acceptable.
Accepted: Date:
----------------------------------- ---------------------------
CLIENT SIGNATURE
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"ATTACHMENT VIII"
REFUND PROTOCOL
AES SERVICE GROUP, INC. (AES), on behalf of National Diagnostics, Inc., will
collect all revenues that its clients are due based upon appropriate
reimbursement submittal. In those instances where a patient account
inappropriately receives a greater reimbursement than required, the following
procedural guidelines will be implemented:
1. PROCEDURE:
(a) A small balance adjustment will be done on balances that are
ten (10) dollars or less
(b) All refund requests regarding overpayments by patients
(personal payments) will be researched and appropriate back up
supplied to the client's office for issue of refund check.
(c) All refund requests regarding overpayments, other than
personal payments, will be researched and appropriate back up
supplied to the client's office for issue of refund check
"only" upon a written reimbursement request from the payor.
(d) When an account has remained in a credit status for six (6)
months, AES will appropriately handle a receipt adjustment
(5000 transaction) to the remaining credit balance. If a
written reimbursement request is received from the payor, AES
will reverse the prior adjustment and abide by the above
procedural guidelines.
If the above procedural guidelines are acceptable, please sign below and return.
Should you require additions or changes, please indicate and return for
corrections.
Accepted: Date:
-------------------------------- --------------------------
CLIENT SIGNATURE
