No Surprises Act and Good Faith Estimate
Clinicians are required by law to provide information on the No Surprises Act and a
Good Faith Estimate to clients who are paying fee for service (not using insurance).
No Surprises Act overview
The No Surprises Act, which is part of the Consolidated Appropriations Act of
2021, is designed to protect clients from receiving unexpected medical bills. The Good
Faith Estimate provision of the No Surprises Act is designed to give clients an estimate
of how much they’ll be charged for the healthcare services they’ll be receiving, prior to
their appointment.
Good Faith Estimate
The estimate below is the range of costs that is likely for most new patients. Until I do an initial
evaluation and we start to work together, I will not have a clear picture a client’s diagnosis, issues
and needs.
The number of sessions clients are seen for varies widely depending on diagnoses, co-morbidities,
and other complexities.
The following is an example of charges for psychological services.
Initial evaluation (code 90791) $ 180 rate for payment at the time of service
55 minute Psychotherapy session (code 90837) $ 140 rate for payment at the time of service
I normally schedule clients into a time slot reserved for the client starting with a 55 minute weekly
session. Sessions are reduced as clients make progress in their therapy.
If you attend weekly sessions for 3 months your cost would be $180 + $140 x 11 weeks = $1,720
If you attend weekly sessions for 6 months your cost would be $180 +$140 x 25 weeks = $3,680.
If you attend weekly sessions for 12 months your cost would be $180 +$140 x 51 weeks = $7320.
If services were needed beyond one year, they would be calculated by this formula unless there was
a fee change.
This does not take into consideration time off by clinician or client, crisis services if needed or other
services. In some cases a patient’s needs or concerns may be more difficult or severe, so additional
sessions may be needed during the time covered by this estimate.
Disclaimer
This Good Faith Estimate shows the costs of services that are reasonably expected for the expected
services to address a client’s mental health care needs.
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 are billed for $400 more (per provider) than this Good Faith Estimate (GFE), you have the right
to dispute the bill
You may contact the psychologist/psychology practice to let them know the billed charges are at
least $400 higher than the GFE. You can ask them to update the bill to match the GFE, 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 GFE. 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 and get a form to start the process, go to:
www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process,
visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .
This GFE is not a contract. It does not obligate you to accept the services listed above.