Good Faith Estimate

Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provider a "Good Faith Estimate" about out-of-network care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. 

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. You could be charged more if complications or special circumstances occur and will be provided a new "Good Faith Estimate" should this occur. If this happens, federal law allows you to dispute (appeal) the bill if you and your therapist have not previously talked about the change and you have not been given an updated good faith estimate.

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

Note: The PHSA and GFE does not currently apply to any clients who are using insurance benefits, including "out of network benefits (i.e. submitting superbills to insurance for reimbursement).

Every Client's Therapy Journey is Unique

How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including, but not limited to: client schedule and life circumstances, therapist availability, ongoing life challenges, the nature of the specific presenting problems, and client finances.

Most of my clients see me once per week, however clients engaging in active EMDR processing prefer to attend two sessions per week, to enhance the process and shorten the duration of time they will need to engage in weekly psychotherapy. 

Together, we will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change. 

Diagnosis

For ethical and legal reasons, I must document a mental health diagnosis for all clients.
This is also a requirement stipulated as part of the "No Surprises Act".
Your Good Faith Estimate diagnosis is:
Primary Diagnosis: Z73.3 - Stress not elsewhere specified 
Secondary Diagnosis: F99 - Mental Health Disorder, Not Otherwise Specified

This diagnosis is only to satisfy the federal requirement for this form. This is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, we will not update this GFE.

It is within your rights to decline a diagnosis per state and federal guidelines. 

Client Financial Responsibility Summary

For a good faith estimate: the amount listed is the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly sessions without skipping any weeks for holidays, breaks, vacation, unplanned events/sickness, etc.). 

The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range. Out of an abundance of caution and transparency, I will only quote once weekly appointments. 

Common Services I Provide:

  • 90791 | $175: Initial therapy intake (approx. 55 minutes)

  • 90837 | $175: Ongoing and recurring therapy appointments (approx. 55 minutes)

  • 90847 | $175*: Ongoing and recurring family appointments (approx. 55 minutes)

Good Faith Estimate Disclosure

Under the No Surprises Act (H.R. 133 - which went into effect on January 1, 2022), health care providers need to give clients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • 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 based on information known at the time the estimate was created.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes (under the law/when applicable) related costs like medical tests, prescription drugs, equipment, and hospital fees.

  • The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

    • You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You 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.

    • You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process 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 you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

  • Make sure your health care provider gives you a Good Faith Estimate within the following timeframes:

    • If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;

    • If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or

    • If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified timeframes if the patient reschedules the requested item or service.

  • This is the public disclosure of the “Good Faith Estimate”

Note: A Good Faith Estimate is for your awareness only. It does NOT involve you making any sort of commitment.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.