Patient Price Information List (Effective 1/01/2010)

Inpatient Nursing Care

In addition to the Room Charge per day, a daily Nursing Care Level is charged to patients receiving Routine Care and Intensive/Coronary Care. No Nursing Care Level is charged to Rehabilitation and Transitional Care Patients due to the nature of the service provided. Patients are assessed on a daily basis and a care level is assigned based upon the amount of resources that are utilized and the intensity of care for the patient. These resources include, but are not limited to, the amount of nursing time that is involved in caring for the patient, IV and PCA pumps, cardiac monitoring, glucose meters, routine supplies and other technologies.

Birthing Center Charges

The following list does not include charges for anesthesia, anesthesia administration drugs, or supplies required for a particular delivery room procedure. This list also does not include charges for any diagnostic testing or physician services performed during a labor and delivery stay.

Emergency Center Charges

Emergency Center charges are based upon the level of emergency care provided to our patients. The levels, with level 1 representing basic emergency care, reflect the type of accommodations needed, the personnel resources, the intensity of care and the amount of time needed to provide treatment. The following levels of care do not include fees for drugs, supplies, or additional ancillary procedures that may be required for emergency treatment. The Hospital also bills for the emergency room physician allowing the patient to receive one bill. We also offer Urgent Care Services during select after hours and weekends in St. Marys at the Emergency Center and in Wapakoneta at Wapakoneta Primary Care. We triage patients coming in to both the Emergency Center and Urgent Care Center to ensure that they are seen in the appropriate setting for the care the patient needs.

Urgent Care Charges

JTDMH offers Urgent Care services in St. Marys at the Emergency Center and in Wapakoneta at Wapakoneta Primary Care. The following levels of care do not include fees for drugs, supplies, or additional ancillary procedures that may be required for urgent care treatment. We triage patients coming in to both the Emergency Center and Urgent Care Center to ensure that they are seen in the appropriate setting for the care the patient needs. This aids the patient both financially and clinically. The Hospital also bills for the urgent care physician allowing the patient to receive one bill.

Surgical Center Charges

Surgical classification charges are by specialty and classified by the type of procedure, equipment, instrumentation, supplies and staffing that are unique to each class. There is an initial charge, which includes the first 30 minutes of surgery, as well as a charge for each additional minute until the operation is complete. The following charges do not include charges for anesthesia, recovery room, medications, implants, pathology and patient-specific supplies used during the procedure.

Physical Therapy Charges

The following charges reflect the most common services offered by our Physical Therapy department. Patients may have additional charges, depending on the services performed.

Occupational Therapy Charges

The following charges reflect the most common services offered by our Occupational Therapy department. Patients may have additional charges, depending on the services performed.

Pulmonary Therapy Charges

The following charges reflect the most common services offered by our Pulmonary Therapy department. Patients may have additional charges, depending on the services performed.

Medical Imaging (Radiology) Charges

The following charges reflect the 30 most common services offered by our Medical Imaging department. Patients may have additional charges, depending on the services performed. These charges do not include services provided by a physician/radiologist for the interpretation of these studies. A radiologist from West Ohio Xray will perform the medical imaging interpretation and you will receive a separate bill for this service.

Laboratory Charges

The following charges reflect the 30 most common services offered by our Laboratory Department.

For information regarding lab testing and what tests mean, please visit: http://www.labtestsonline.org The laboratory has a menu of specific tests that patients may order for themselves (direct access testing). These tests are general health screening tests such as would be found at a health fair. Health panels, Liver, Kidney and Thyroid function panels, as well as Lipid, Iron and Diabetes assessment profiles are among the tests offered. Like health fair tests, these tests are offered at a considerable discount, but must be paid for prior to blood draw. Print off a copy of the order form or pick up a form at the Outpatient Registration desk at the hospital. The results of these tests will be reported back to you. To learn more about your tests, go to http://www.labtestsonline.org/.

Hospital Billing Policies

When you arrive at JTDMH, you will need to be registered into the hospital’s information system. During registration, you will need to provide information regarding yourself and your insurance coverage; if you do have insurance coverage, please be sure to bring your insurance card(s) with you. An account number will be assigned by the hospital’s information system for your visit and the information you provide during registration will be stored in the system. You will also need to sign a form regarding Consent for Treatment and Conditions for Admission. This form provides information regarding authorization for medical treatment and disclosure of information, patient rights and responsibilities, and financial responsibility. Ultimately, patients are financially responsible for the healthcare services they are provided. In the event that insurance information is provided, JTDMH will file a claim to the insurance company on the patient’s behalf for the benefits assigned to it. Once the insurance company has finished processing the claim, or if the claim is not processed timely, a statement will be sent to the patient for the balance due. An itemized bill showing the detail of all services provided will be issued to the patient upon request. Individuals without insurance will automatically receive an itemized bill showing the detail of all services provided to them. A statement will also be sent to the patient for the balance due. A prompt pay discount of 5% is available to all self-pay patients who do not have insurance and pay their bill timely for the services they were provided. Please contact the Patient Accounts Department at 419-394-3387, ext 2128 for more information. Individuals who are not able to pay the balance of their account in full should contact the Patient Accounts Department at 419-394-3387, ext 2128 or 2146 to set up an acceptable payment plan. Individuals who are uninsured or underinsured, and are not able to pay on their account should contact the Patient Accounts Department at 419-394-3387, ext 2146 to inquire about free or discounted care based upon the Federal Poverty Level Guidelines and guidelines issued by the State of Ohio. Patient Account Representatives are available Monday through Friday, 8:00am – 4:30pm to assist with questions and completion of necessary forms for financial assistance. Please note that delinquent accounts are referred to an outside agency for collection when payment on the account is overdue or appropriate payment plans have not been arranged. To help facilitate patients in paying for their healthcare services, JTDMH has consolidated the billing of many physician services that are rendered during a hospital visit. Physician charges for Anesthesiology, Emergency Room, the Hospitalist, Pain Management, Pathology, and Urgent Care are combined with the hospital bill. Patients will receive a separate bill for physician services provided for Cardiology, Radiology, and any services performed by a surgeon or family physician, as these services are not billed by the hospital.

Consumers can access a number of government and private Websites, which provide additional information on hospitals' charges and quality. For a complete listing of available online resources, please visit the Consumer's Guide to Quality Healthcare in Ohio at www.ohanet.org/portal.