Patient Cost Estimate
Legacy Surgery Center – Tampa provides price estimates for services for outpatient services provided at our Ambulatory Surgery Center. Please contact our office at (813) 852-2500 during normal business hours for your estimate. Prior to contacting us, please gather the following information:
1. Referring physician’s name and phone number
2. Procedure code (if known) or type of procedure being performed if you don’t have the procedure code.
3. Insurance information (if you have insurance)
4. Your contact information
Your request can also be mailed to 6918 Gunn Highway, Suite E, Tampa, Florida or faxed to (813) 852-2541. We will provide you a written estimate within 7 business days from receipt of the request.
Service bundle information is a non-personalized estimate of cost that may be incurred by the patient for anticipated services. Actual costs will be based on services actually provided to the patient. It is your right to request a personalized estimate from the center.
Under the law, health care providers must give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. This is call a Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit cms.gov/nosurprises.
Charitable Care/ Financial Assistance
The Center may provide free or reduced cost health care services and supplied from time to time to uninsured or underinsured patients who are unable to pay for these services. The Policy ensure that the decision to provide free or reduced cost health care services and supplies is based upon uniform and objective criteria and specific steps:
- The patient or responsible party is provided with an estimate of the patient’s cost for the same day surgical procedure.
- Full financial evaluation is completed by the patient or responsible party; including all verified sources of income, assets and expenses plus the number of family members in the household. The patient or responsible party provides supporting documentation and attests to the accuracy of all information.
- All information is reviewed by the Center Administrator and Business Office Manager to validate the information and to determine if the patient meets the criteria for assistance.
- Final income is then aligned with the most current version of the Federal Poverty Guidelines which determines the level of discount.
- A fee schedule that is set up to align with the current Federal Poverty Guidelines defines levels of discounts available.
- There is a final determination of the patient’s eligibility and the case is approved or disqualified.
- The patient or the responsible party is then informed of the decision and if approved, they are informed of their payment responsibility if any.
Charitable Care shall not include cash payment in any form, such as the payment of any individual’s health insurance premiums, or fee goods not otherwise furnished in the ordinary course of the Center’s operations. Decision to commit the Center to provide Charitable Care shall be made on a case-by case basis by the Center’s Administrator/Compliance Officer, who is responsible for ensuring that any request for Charitable Care is approved in accordance with this Policy.
The responsibility for all charges, unless otherwise specified under a contractual agreement, belongs to the patient. Every effort will be made to collect payment as early as possible from the patient as well as from third party payers. The patient should be aware of their financial responsibilities at the conclusion of this call.
Please contact health care practitioners anticipated to provide services to the patient while in the center regarding a personalized estimate, billing practices and participation with patient’s insurance provider or health maintenance organization (HMO) as the practitioners may not participate with the same health insurers or HMO as the center
Patient Billing Notice
Services may be provided in this health care facility by the facility as well as by other health care providers who may separately bill you as a patient. These other health care providers may or may not participate with the same health insurers or health maintenance organizations as this facility. Patients and prospective patients may request from this facility and other health care providers a more personalized estimate of charges and other information. Patients and prospective patients should contact each health care practitioner who will provide services in the facility to determine which health insurers and health maintenance organizations the practitioner participates in as a network provider or preferred provider.
“Patients should not rely on this information for specific billing guidance. If you are a patient or prospective patient, please contact the facility to confirm which policies or plans may apply to your situation.”
Services may be provided in this health care facility by the facility as well as by other health care providers who may separately bill the patient and who may or may not participate with the same health insurers or health maintenance organizations as the facility.
Patients and prospective patients may request from this facility and other health care providers a more personalized estimate of charges and other information. Patients and prospective patients should contact each health care practitioner who will provide services in this surgery center to determine the health insurers and health maintenance organizations with which the health care practitioner participates as a network provider or preferred provider.
Contracted Service Providers
As of August 10, 2017, the following providers render services to patients of this surgery center. Patients should contact:
Northstar Anesthesia Billing Services
Attention: Sunbelt Anesthesia Services, LLC PO Box 3024 Plattsburgh, New York 12901-0298
Phone: Call Northstar Anesthesia Billing Services (888-806-0761)
Pathology & Laboratory
5610 W. LaSalle St.
Tampa, FL 33607
Mon - Fri, 6am - 4pm
6918 Gunn Hwy. Tampa, FL 33625, Suite E
SECTION 1557 OF THE AFFORDABLE CARE ACT STATEMENT
Legacy Surgery Center – Tampa complies with applicable Federal civil rights laws and is committed to ensuring that persons with disabilities, including persons who have hearing, vision or speech disabilities, as well as persons of Limited English Proficiency (LEP), have an equal opportunity to participate in any of our services.