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Additional Billing Information

Prompt Payment Discount

Policy updated January 2023

InterMed offers a discount on services for uninsured, self-pay patients.

Self-pay patients

InterMed offers a discount on eligible services for self-pay patients. Any existing patient can self pay regardless of whether or not they have health insurance coverage when they receive eligible services provided by InterMed. It is important to note that InterMed does not accept self-pay for new patients.


A self-pay patient is eligible for a 25% discount if the discount is requested before or at the time of service and payment is made in full as outlined below under Eligible Services.

The patient needs to complete and sign the Acknowledgement of Self-Pay Status Patient Responsibility form

A patient who receives a discount under this policy, and who pays the remaining 75% of charges in full, acknowledges that InterMed will not submit charges to the patient’s insurance company for reimbursement. 

Eligible Services

Services eligible for a 25% discount are: 

  • Office visit: An estimate of total eligible charges may be provided to the patient at the time of check out for an office visit. The patient must pay in full for the 75%  at check out.

  • Other InterMed services, not including those from the Ambulatory Surgical Center: Because an estimate of charges will not be available to the patient at the time of service, the patient must pay in full for the 75% of charges within 30 days of the bill date.  The discount will be forfeited on Day 31 without payment, and the full billed amount will be due.

  • Ambulatory Surgical Center: An estimate of total patient charges will be provided to the patient prior to service. The patient is expected to pay in full for the 75% of charges before the date of service.

If an overpayment is made, a credit will be posted to the patient’s account.

This discount does not apply to any services that are billed by any organization outside of InterMed. Those include outside lab processing and radiologist interpretation of imaging services.

InterMed reserves the right to forfeit the self-pay discount if the required fee is not paid at time of service.

Financial Hardship Program

InterMed is committed to providing care without compromise to our patients regardless of their financial status.

The Financial Hardship Program is available for medically necessary services, in which you may qualify for free care or a reduced cost after insurance processing.

Complete the Financial Hardship Application, complete the Financial Hardship Disclosure Form (on Page 3-4) and provide documentation of proof of household income. Appropriate documentation providing proof of income is one of the following:

  1. Pay stubs from the last 90 days

  2. Recent forms from MaineCare or other State funded assistance

  3. Proof of ALL sources of household income


  • Third parties who may be liable for payment are excluded from coverage of this policy. Access to one discount policy only per patient/family.

  • Only medically necessary services are eligible for use of this policy; cosmetic or services that are not deemed medically necessary by the payer are excluded from coverage of financial assistance.

  • Patients must complete a financial hardship application and provide proof of income for the preceding three months.

  • All financial documents must be provided within 10 business days of the application for assistance or will be denied assistance for lack of documentation.

Eligibility Period

  • The patient’s account will never be permanently designated as financial hardship. The status of financial hardship will be effective for duration of six months. Once the term has ended, the patient will need to reapply and provide recent income information.

  • The patient may be awarded the discount for services incurred up to a maximum of three months prior to the effective date of financial hardship designation.

Income will be annualized from the date of the request based on documentation provided. Any denial of “financial hardship” discount request will be written and include instructions for reconsideration. All information relating to financial hardship request will be kept confidential.

If you have any questions regarding the financial hardship application process, please call Business Office Customer Service at (207) 828-0361.

Guidelines used to determine financial hardship based off income

Persons in Family 2021 Federal Poverty Guideline 150% Poverty Level:
InterMed, P.A.
100% Financial Assistance
175% Poverty Level 200% Poverty Level
1 $12,880 $19,320 $22,540 $25,760
2 $17,420 $25,130 $30,485 $34,840
3 $21,960 $32,940 $38,430 $43,920
4 $26,500 $39,750 $46,375 $53,000
5 $31,040 $46,560 $54,320 $62,080
6 $35,580 $53,370 $62,265 $71,160
7 $40,120 $60,180 $70,210 $80,240
8 $44,660 $66,990 $78,155 $89,320
Qualifying % 100% 100% 50% 25%
For each additional person, add $4,540 $4,540 $4,540 $4,540

Source:, January 13, 2021; 2020 Federal Poverty Level Charts

Please provide all applicable documents listed below so we may complete your application:

  • Pay stubs for the past 90 days for all persons employed in the home

  • Unemployment pay stubs for the past 90 days

  • Proof of all other income for the past 90 days

Please sign the Financial Hardship Disclosure Form after completion. Your application will not be processed if not signed. Return all items by mail in the self-addressed envelope or in person.

Return to:

Billing Office
100 Gannett Drive, Suite C
South Portland, ME 04106

Extra Charges (Split Billing)

During your preventive care visit, we are happy to provide additional services which are generally not included in these routine visits. However, some issues discussed and managed during this visit may not be covered under your insurance’s preventive benefits, and you may incur a separate charge. Your insurance carrier determines which services are included in the preventive care visit (routine annual exam).

Preventive care services generally covered by insurance include:

  • Physical exam, as appropriate for your age, gender and health status

  • Detailed questions about your current health status

  • Determination of risk for health problems and diseases

  • Recommendations for screening tests/vaccines that are appropriate for your age and gender

Services generally NOT considered part of preventive coverage:

  • Evaluation and management of new or acute/worsening health problems (for example a cold, rash, backache and uncontrolled conditions such as diabetes or cholesterol)

  • Tests used to assist in diagnosis of a new condition or to monitor an existing, uncontrolled medical condition

If you prefer to receive only preventive care, let your provider know at the beginning of your visit.

Contact your insurance carrier for details about which services are considered preventive care under the coverage and benefits of your policy.

Your health is very important to us. We are committed to providing you with exceptional care.

Collection Policy

Thirty (30) days from the date of the first statement, your account will be considered past due. This does not mean your account has been or will be sent to the collection agency, only that you need to give it your prompt attention.

Please call our Billing Office at (207) 828-0361 if you are unable to pay your balances in full within (30) days.

If your outstanding balance reaches 90 days past due, the balance will be transferred to the Thomas Agency for further collection action.

It is your responsibility to present your current insurance information to InterMed check-in staff at each of your appointments. If you receive a statement that shows no insurance payments or adjustments, you will need to contact our Business Office at (207) 828-0361. Please read your statement messages, as they are important and will inform you of your account status. Note that insurance companies have timely filing limits. If InterMed is no longer able to file the claim with your insurance company due to timely filing, the claim balance will be patient responsibility.

Having your correct insurance information will prevent claim problems and collections issues.

No Surprises Act

Your rights and protections against surprise medical bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is 'balance billing' or 'surprise billing'?

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).

  • Cover emergency services by out-of-network

  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of

  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket

If you believe you’ve been wrongly billed, you may contact the Maine Bureau of Insurance by calling 207-624-8475, or 800-300-5000 (toll free).

For more information about your rights under federal law, visit the Maine Bureau of Insurance website.

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