Financial Agreement & Insurance Coverage
 

FINANCIAL AGREEMENT FOR KETAMINE INFUSION THERAPY

I. PURPOSE AND SCOPE OF AGREEMENT

This Financial Agreement pertains specifically to ketamine infusion therapy services provided by this practice. This Agreement establishes the financial terms, payment obligations, and billing practices for ketamine infusion treatments administered for off-label psychiatric and pain management purposes.

II. SELF-PAY REQUIREMENT FOR KETAMINE INFUSION SERVICES

A. Fee Structure

The fee for each ketamine infusion treatment session is $450.00 (Four Hundred Fifty Dollars), payable in full at the time of service or as otherwise agreed upon in writing by the practice.

B. Off-Label Use and Insurance Non-Coverage

I understand and acknowledge the following:

1. Ketamine is FDA-approved solely as an anesthetic agent

2. Ketamine is NOT FDA-approved for the treatment of depression, anxiety, post-traumatic stress disorder (PTSD), chronic pain syndromes, or other psychiatric or pain management conditions

3. The ketamine infusion therapy I will receive constitutes off-label use of this medication

4. My health insurance plan, including Medicare, Medicaid, and private insurance carriers, generally does not provide coverage or reimbursement for off-label ketamine infusion therapy for mental health or chronic pain treatment

5. This practice has experienced insurance claim denials and clawbacks specifically related to ketamine infusion services due to the off-label nature of the treatment

C. Full Financial Responsibility

I acknowledge and agree that I am fully responsible for payment of the $450.00 fee for each ketamine infusion session, regardless of my insurance coverage status. I understand that this is a self-pay service and that I may not submit claims to my insurance carrier for reimbursement of ketamine infusion therapy services.

III. PROHIBITION ON SUPERBILL PROVISION

A. No Superbills Will Be Provided

I understand and acknowledge that this practice will NOT provide superbills, itemized statements, or any other documentation for the purpose of submitting claims to insurance carriers for reimbursement of ketamine infusion therapy services. This prohibition applies to all patients, including those with:

1. Medicare or Medicare Advantage plans

2. Medicaid or state-funded insurance programs

3. Private commercial insurance plans

4. Out-of-network insurance benefits

5. Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs) that require documentation - At your request, the clinic may provide an itemized payment receipt suitable for FSA/HSA substantiation. This receipt will not include insurance billing codes and is not intended for use as an insurance claim or superbill.

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B. Rationale for Superbill Prohibition

This practice maintains credentials and participates with Medicare, and various commercial insurance plans for covered services. Providing superbills for ketamine infusion therapy could:

1. Create regulatory compliance issues with participating insurance contracts

2. Result in improper billing practices under anti-fraud and abuse statutes

3. Lead to sanctions, contract termination, or exclusion from insurance programs

4. Generate additional claim denials and administrative burdens for patients and the practice

C. Patient Acknowledgment

By signing this Agreement, I acknowledge that I will not request, and the practice will not provide, any superbills, receipts with diagnostic or procedure codes, or other insurance claim documentation related to ketamine infusion therapy services.

IV. MEDICARE BENEFICIARY SPECIFIC PROVISIONS

A. Medicare Non-Coverage Notice

If I am a Medicare beneficiary, I understand and acknowledge the following:

1. Medicare does NOT cover ketamine infusion therapy for off-label psychiatric or pain management purposes under any circumstances

2. Ketamine infusion therapy for mental health and chronic pain conditions is considered a never-covered service under Medicare guidelines

3. Medicare will not reimburse me or this practice for ketamine infusion services regardless of medical necessity or documentation provided

4. I am entering into a private contract with this practice for a non-covered service

B. Waiver of Medicare Claims

As a Medicare beneficiary receiving ketamine infusion therapy, I voluntarily agree to:

1. Pay the full self-pay fee of $450.00 per treatment session

2. Waive any right to submit claims to Medicare for ketamine infusion therapy services

3. Hold this practice harmless from any Medicare audit, investigation, or enforcement action related to my ketamine infusion treatments

4. Acknowledge that this practice will not complete or sign any Medicare claim forms, appeals, or documentation related to ketamine infusion therapy

C. Distinction from Covered Services

I understand that while this practice accepts Medicare for covered services such as evaluation and management visits, psychotherapy, medication management, and medically necessary procedures, ketamine infusion therapy specifically is excluded from Medicare coverage and is provided on a private-pay basis only.

V. INSURANCE COVERAGE FOR OTHER SERVICES

A. Covered Services

I understand that my insurance, including Medicare, MAY be billed for the following services when provided by this practice:

1. Initial psychiatric or medical evaluations

2. Follow-up office visits for evaluation and management purposes that are not directly linked to ketamine infusion administration

3. Psychotherapy sessions

4. Medication management visits for FDA-approved medications

5. Other medically necessary services that are not related to the off-label administration of ketamine

B. Separate Billing Determination

The practice will determine on a case-by-case basis whether a particular office visit qualifies as a covered insurance service or constitutes part of the ketamine infusion therapy program requiring self-pay. Visits occurring on the same day as ketamine infusion administration or visits specifically for monitoring ketamine therapy response may be considered part of the self-pay ketamine program and not billed to insurance.

VI. CREDIT CARD ON FILE REQUIREMENT

A. Mandatory Credit Card Authorization

As a condition of receiving ketamine infusion therapy services at this practice, I agree to provide and authorize the practice to maintain a valid credit card on file. This requirement is mandatory and non-negotiable.

B. Credit Card Information

I authorize the practice to securely store the following credit card information:

1. Cardholder name

2. Credit card number

3. Expiration date

4. Security code (CVV)

5. Billing address associated with the card

C. Authorized Charges

I authorize this practice to charge my credit card on file for:

1. The full $450.00 fee for each ketamine infusion treatment session

2. Any outstanding balances for ketamine infusion services previously rendered

3. Missed appointment fees or cancellation fees as specified in the practice's cancellation policy

4. Any other fees or charges related to ketamine infusion therapy services as agreed upon in writing

D. Timing of Charges

I understand that my credit card on file may be charged:

1. At the time of service (preferred method)

2. Within seventy-two (72) hours following the date of service

3. At the time of appointment scheduling if prepayment is required

4. Upon failure to appear for a scheduled appointment in accordance with the practice's no-show policy

E. Credit Card Updates

I agree to:

1. Promptly notify the practice of any changes to my credit card information, including card number, expiration date, or billing address

2. Provide updated credit card information immediately upon expiration or cancellation of the card on file

3. Ensure that adequate credit is available on the card to cover the $450.00 treatment fee at the time of each scheduled appointment

F. Failed Payment Processing

I understand that if a credit card charge is declined, rejected, or otherwise fails to process:

1. I remain fully responsible for payment of all fees owed

2. The practice may attempt to process payment using the same card or an alternative payment method I have provided

3. The practice may suspend or terminate ketamine infusion therapy services until all outstanding balances are paid in full

4. I may be charged reasonable fees associated with failed payment processing, including insufficient funds fees or payment recovery costs as permitted by law

G. Data Security and HIPAA Compliance

I acknowledge that:

1. Credit card information is considered Protected Health Information (PHI) under HIPAA when stored by a healthcare provider

2. This practice maintains appropriate administrative, physical, and technical safeguards to protect my credit card information in accordance with HIPAA Security Rule requirements

3. Credit card information will be stored in encrypted, secure systems and accessible only to authorized personnel

4. The practice utilizes HIPAA-compliant payment processing services

H. Revocation of Credit Card Authorization

I understand that maintaining a valid credit card on file is a mandatory condition of receiving ketamine infusion therapy at this practice. If I revoke this authorization or fail to maintain a valid credit card on file, the practice may discontinue providing ketamine infusion services until this requirement is satisfied.

VII. PAYMENT POLICIES

A. Payment Due at Time of Service

Unless alternative arrangements have been made in writing and approved by the practice administrator, full payment of $450.00 is due at the time of each ketamine infusion treatment session.

B. Accepted Payment Methods

The practice accepts the following payment methods:

1. Credit cards (Visa, MasterCard, American Express, Discover)

2. Debit cards with credit card processing capability

3. Health Savings Account (HSA) cards

4. Flexible Spending Account (FSA) cards

Note: While HSA and FSA funds may be used for payment, the practice will not provide superbills. However, at your request, the clinic may provide an itemized payment receipt suitable for FSA/HSA substantiation. This receipt will not include insurance billing codes and is not intended for use as an insurance claim or superbill.

C. Outstanding Balances

Any outstanding balances not paid at the time of service will be automatically charged to the credit card on file within seventy-two (72) hours of the treatment date. Continued failure to maintain payment may result in suspension of treatment services and/or referral to collections.

VIII. CANCELLATION AND NO-SHOW POLICY

A. Cancellation Notice Requirement

Patients must provide at least forty-eight (48) hours advance notice to cancel or reschedule a ketamine infusion appointment. Cancellations must be made by telephone during regular business hours.

B. Late Cancellation and No-Show Fees

1. Cancellations made with less than forty-eight (48) hours notice will result in a late cancellation fee equal to fifty percent (50%) of the treatment fee ($225.00)

2. Failure to appear for a scheduled appointment without prior cancellation will result in a no-show fee equal to the full treatment fee ($450.00)

3. Late cancellation and no-show fees will be charged to the credit card on file

C. Emergency Exceptions

Late cancellation and no-show fees may be waived at the practice's discretion in cases of documented medical emergencies or other extenuating circumstances.

IX. INFORMED CONSENT AND MEDICAL NECESSITY

A. Separate Informed Consent

This Financial Agreement is separate from and in addition to the medical informed consent for ketamine infusion therapy. I understand that I must also complete and sign a comprehensive informed consent document addressing the medical risks, benefits, alternatives, and off-label nature of ketamine treatment.

B. Medical Necessity Determination

I understand that:

1. The treating physician or qualified healthcare provider will determine whether ketamine infusion therapy is medically appropriate for my condition

2. This Financial Agreement does not guarantee that ketamine infusion therapy is medically necessary or appropriate for me

3. The practice reserves the right to decline to provide or to discontinue ketamine infusion therapy services based on clinical judgment and safety considerations

X. LEGAL COMPLIANCE AND REGULATORY CONSIDERATIONS

A. Federal and State Law Compliance

This practice complies with all applicable federal and state laws and regulations governing healthcare billing practices, including but not limited to:

1. Health Insurance Portability and Accountability Act (HIPAA)

2. Federal Anti-Kickback Statute

3. Stark Law (Physician Self-Referral Law)

4. False Claims Act

5. Medicare and Medicaid program regulations

6. State insurance laws and regulations

7. State medical board regulations

B. Private Contract for Non-Covered Services

I acknowledge that this Agreement constitutes a private contract between myself and this practice for services that are not covered by Medicare, Medicaid, or other insurance programs. This private contract does not affect my rights to coverage for other medically necessary services provided by this practice.

C. No Violation of Participation Agreements

I understand that this practice maintains participation agreements with Medicare and various insurance carriers for covered services. By entering into this private-pay agreement for non-covered ketamine infusion services, the practice is not violating any participation agreement, balance billing prohibition, or assignment of benefits requirement.

XI. PATIENT ACKNOWLEDGMENTS

By signing below, I acknowledge, understand, and agree to the following:

1. I have read this entire Financial Agreement and have had the opportunity to ask questions

2. I understand that ketamine infusion therapy is an off-label use of medication and is not covered by Medicare, Medicaid, or most insurance plans

3. I accept full financial responsibility for the $450.00 fee for each ketamine infusion treatment session

4. I understand that the practice will not provide superbills or insurance claim documentation for ketamine infusion services

5. If I am a Medicare beneficiary, I acknowledge that ketamine infusion therapy is a never-covered service and I waive any right to submit claims to Medicare

6. I authorize the practice to maintain my credit card information on file and to charge my credit card for ketamine infusion services, outstanding balances, and applicable fees

7. I agree to maintain a valid credit card on file as a mandatory condition of receiving ketamine infusion therapy

8. I understand the cancellation and no-show fee policies

9. I understand that my insurance may still be used for initial evaluations, office visits, and other services not directly linked to ketamine infusion administration

10. I have received a copy of this Financial Agreement for my records

11. This Agreement remains in effect for all ketamine infusion treatments I receive at this practice unless modified in writing and signed by both parties

XII. MODIFICATION AND TERMINATION

A. Amendment

This Agreement may only be modified by a written amendment signed by both the patient and an authorized representative of the practice. No oral modifications are valid or enforceable.

B. Termination by Patient

I may terminate this Agreement at any time by providing written notice to the practice. Termination does not relieve me of financial obligations for services already rendered or scheduled appointments requiring cancellation notice.

C. Termination by Practice

The practice may terminate this Agreement and discontinue ketamine infusion services if:

1. I fail to maintain a valid credit card on file

2. I have outstanding unpaid balances for ketamine infusion services

3. I repeatedly violate the cancellation policy

4. The treating provider determines that continued treatment is not clinically appropriate or safe

5. I engage in threatening, abusive, or inappropriate behavior toward practice staff or providers

XIII. SEVERABILITY

If any provision of this Agreement is found to be invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect.

XIV. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of Idaho, without regard to conflict of law principles.

XV. SIGNATURES

By signing below, I certify that I have read, understand, and agree to all terms and conditions set forth in this Financial Agreement for Ketamine Infusion Therapy.