Under Section 2799B-6 of the Public Health Service Act, 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.
This form may be used by the 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 request a Good Faith Estimate, here is what you will receive in your Good Faith Estimate document: Client name, client date of birth, a description of services, the proper CPT code related to services, list of good or services reasonably expected in the course of treatment, diagnostic codes, Provider Name, and Provider NPI, date of Good Faith Estimate, and office location and whether services are provided in person or via telehealth.
Cost Estimate
In accordance with this, I want to ensure that my clients have an understanding of therapy costs. Because I work on a sliding scale based on income, we will determine the cost of services during your complementary 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. Based on these numbers, here is a list of approximate expected costs:
6 or fewer sessions: $690-$1170
7-10 sessions: $805-$1950
11-15 sessions: $1265-$2925
16-20 sessions: $1840-$3900
21 or more sessions: minimum of $2415
OTHER POSSIBLE FEES
While other possible fees are less common, I want to ensure that my clients are aware of charges for services outside of the regular treatment plan. These services 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 is charged whether or not the clinician actually testifies.
DISPUTING CHARGES
Clients have the right to dispute if they are charged more than the Good Faith Estimate. Clients may request the Good Faith Estimate be updated according to new charges, negotiate the bill, or request to see whether there exists financial assistance with the provider.
Clients may choose to initiate a dispute with the US Department of Health and Human Services. To do so, the client 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 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. To learn more about initiating a dispute visit www.cms.gov/nosurprises or call HHS at (800) 368-1019.
Please remember to keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
DISCLAIMER
A Good Faith Estimate shows the costs of items and services that are reasonably expected for your treatment needs. 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. If this happens, federal law allows you to dispute (appeal) the bill.