No Surprises act
“Good faith estimate”
Information for patients who do not have insurance or choose not to use insurance.
This information pertains to those who do not have insurance or choose not to use insurance to cover psychotherapy sessions. The patient is entitled to receive a Good Faith Estimate of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, the patient has the right to receive an estimate of the cost of services provided. The patient’s total cost of services will depend upon the number of psychotherapy sessions attended, individual circumstances, and the type and amount of services that are provided.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service.
The estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified.
The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
The patient has the right to initiate a dispute resolution process if the actual amount charged to the patient substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). The patient may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. The patient can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. The patient may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If the patient chooses to use the dispute resolution process, the dispute process must start within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with the patient, the patient will have to pay the price on this Good Faith Estimate. If the agency disagrees with the patient and agrees with the health care provider or facility, the patient will have to pay the higher amount.
For questions or more information about the patient’s right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers/new-protections-for-you or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.
The Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that the patient may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in each patient’s case, and the estimated cost for those services, depends on individual needs and what the patient agrees to in consultation with the psychotherapist. The patient is entitled to disagree with any recommendations made to you concerning your treatment and the patient may discontinue treatment at any time.
Considering the unique variables that determine length, frequency, and rate of individualized psychotherapy, the cost of treatment can vary greatly. However, the Good Faith Estimate requires providers to provide an exact estimate and not a range. The following good faith estimate is the amount a client would owe if they were to attend 1 weekly session for every week in a year (52 sessions total without skipping) and the sliding scale rate had not been negotiated:
Individual Psychotherapy Good Faith Estimate: 90791: Intake session ($250) plus 90834: 45-50 minute psychotherapy session ($200) for a total of 52 weeks: $10,450.
The patient is encouraged to speak with the psychotherapist at any time about any questions you may have regarding your treatment plan, or the information provided to you in the Good Faith Estimate.