Virtual Visit Program Service Agreement and Notice of Coverage

NOTICE OF COVERAGE

Your health insurance plan has established rules for the payment of health care services. Visits offered through the Brigham Health Virtual Visit Program may be subject to co-payment, deductible, and co-insurance based on your insurance benefits plan.

Physician Office Billing

When your virtual visit takes place with a physician office, you will usually be charged only for the physician’s examination, and your co-payment will usually be your only out-of-pocket cost. Your co-payment will be requested when you check in online or you will receive a bill after your appointment.

Hospital Outpatient Billing

When your virtual visit takes place with a provider in a hospital outpatient location, there will typically be two charges which may result in your paying more for your visit. Your out-of-pocket costs could include the following:

1. You will be charged for the physician’s examination, which will usually be covered by your co-payment.
2. You will also be charged by the hospital for what is called a facility fee. Your health plan may apply these hospital charges to your annual deductible and after using up your deductible, you may be responsible for a co-insurance payment (usually a percentage of the charge).

You may receive a bill that combines the charges from the hospital and physician on one line or these charges may be split into two lines, depending on the location. We will request your co-payment when you check in for your visit online, and we will send you a bill for any unpaid balance after we receive payment from your insurance company.

Referral and Prior Authorization

For both physician office and hospital outpatient visits, your health insurer may require you to get a referral or authorization. In addition, our providers may be considered “In Network” or “Out of Network” depending on the service of your health insurance plan, which could affect the amount you pay.

Laboratory and Imaging Services

If your physician ordered laboratory tests or imaging services (such as X-ray, CT or MRI), you may be billed for these tests by the hospital, clinical laboratory, or imaging center, and you may also be billed for the services of the physicians (usually pathologists and radiologists) who interpreted the test results.

Understanding How Much My Visit Will Cost

It is your right to receive an estimate of the cost of your visit in advance of the visit. Please contact Mass General Brigham Patient Billing Solutions (see below for contact information) at least two business days prior to your visit to get an estimate. Please have as many details as possible about the upcoming visit, including the provider’s name, location and details of the planned service or procedure.

Special Notice for Medicare Patients

If you are a Medicare beneficiary and your visit takes place with a provider in a hospital outpatient location, you will be responsible for Medicare Part B out-of-pocket co-insurance payment of approximately $25 for the hospital facility charge. Procedure charges or other testing could increase your out-of-pocket expense.

Further Information

Please contact the Member Service department of your health insurance plan to verify your coverage and financial responsibility for services described in this guide. This phone number is located on your insurance card.

Mass General Brigham Patient Billing Solutions

Mailing Address:

Patient Billing Solutions

Mass General Brigham

399 Revolution Drive, Suite 410

Somerville, MA 02145–1462

Phone:

(617) 726-3884

Monday – Friday, 8:00 AM to 4:30 PM

Email:

patientbilling@partners.org

https://www.massgeneralbrigham.org/patient-information/billing-and-insurance 

PATIENT AGREEMENT

I have been told by my physician or designee that my insurance or worker’s compensation plan may provide payment for the services identified above. I understand that I have the right to decide whether to receive these services. I am also aware that the videoconference technology in use is secure, reliable and reputable, but may have occasional connection issues. I have decided to receive the services and agree to be personally and fully responsible for necessary electronic equipment for the Brigham Health Virtual Visit Program.

Service Agreement

Brigham Heath’s clinicians will provide the following services: Video Visits

Patient Consent

I understand that my health care could be improved by talking with my Brigham Health clinician using electronic media via a virtual visit. My clinician has talked with me about the benefits and risks of virtual visits to supplement my care.

The clinician may provide care through following electronic media: video, telephone, email, and text message.

Benefits

Staying in touch with my clinician is important. Virtual visits will allow me to communicate with my clinician from my home, work or other locations. We will use the online format(s) noted above. Therefore, I will not need to travel to my clinician’s office to participate in the Virtual Visit Program. However, I will still need to go to in-person appointments as needed as directed by my physician.

Risks

Federal law requires that health care clinicians protect the privacy and security of my health information. This information is called Protected Health Information (PHI). I understand that my clinician will take all necessary steps to protect the privacy and security of my PHI. However, I understand that as with any electronic transmission, the privacy and security of my PHI cannot be guaranteed. I also understand that I should conduct my virtual visit in a private and secure place, so that others cannot see or hear my PHI discussed.

Important Information

I understand that a virtual visit does not replace the in-person relationship between me and my clinician. I am responsible for calling my clinician if I have any questions or concerns about my health in between virtual visits. I understand that if I have a medical emergency, I should call 911 right away.