Good Faith Estimate

Under Section 2799B-6 of the Public Health Service Act, health care providers and facilities are required to inform individuals who are not enrolled in a plan or coverage, or a federal health care program, or who are not seeking to file a claim with their plan or coverage, both orally and in writing of their ability to receive a "Good Faith Estimate" of expected charges, upon request or at the time of scheduling.

This form may be used by health care providers to inform individuals who are not enrolled in a plan or coverage or a federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals), of the expected charges they may be billed for receiving certain health care items and services. A Good Faith Estimate must be provided within 3 business days upon request. Information regarding scheduled items and services must be furnished within 1 business day of scheduling an item or service to be provided in 3 business days; and within 3 business days of scheduling an item or service to be provided in at least 10 business days.

You may request a Good Faith Estimate at any time. If you do, you'll receive a document that includes: client name, client date of birth, a description of services, the proper CPT code(s) related to services, a list of goods or services reasonably expected in the course of treatment, diagnostic codes, provider name, provider NPI, the date of the estimate, and the office location (including whether services are provided in person or via telehealth).

Cost estimate

In accordance with the above, I want to ensure that my clients have a clear sense of therapy costs. Because I work on a sliding scale based on income, we'll determine the exact cost of services during your complimentary intake phone call, prior to your first session. If you ever have any questions about your fee, please ask.

My practice sliding scale is $115 – $195 per session. Based on that range, here are approximate expected total costs:

Other possible fees

While other fees are less common, I want to make sure clients are aware of charges for services outside of the regular treatment plan. These are typically upon client request.

• A client may request a case report or treatment summary at $150 per hour, with one hour paid in advance. The fee must be paid in full before the document is provided.
• If a client requests their clinical record, there is an $80 location and printing fee.
• For courtroom testimony, honoring a subpoena, or preparing for court, I charge a $500 fee per hour to either the client or attorney, with three hours paid in advance. This fee applies whether or not the clinician actually testifies.

Disputing charges

Clients have the right to dispute charges if they are billed more than the Good Faith Estimate. You may request that the estimate be updated to reflect new charges, negotiate the bill, or ask whether financial assistance is available with the provider.

You may also choose to initiate a dispute with the U.S. Department of Health and Human Services. To do so, you must initiate the dispute within 120 days (about four months) of the original bill and pay a $25 fee for use of this process. If the agency reviewing your dispute agrees with you, you'll only owe the Good Faith Estimate price. If they agree with the provider or facility, you'll owe the higher amount.

To learn more, visit www.cms.gov/nosurprises or call HHS at (800) 368-1019. Please keep a copy of your Good Faith Estimate in a safe place, or take a picture of it, you may need it if you are billed a higher amount.

Disclaimer