Good Faith Estimate

The No Surprises Act requires healthcare providers, including psychotherapists, to provide a "Good Faith Estimate" (GFE) of the cost of services to uninsured or self-pay patients. This estimate helps patients understand and plan for the potential costs of their mental health care. 

Key Aspects of a Psychotherapy GFE

  • Who receives a GFE? Only patients who are uninsured or self-pay (not using insurance to cover their therapy) need to receive a GFE.

  • What's included? The GFE outlines the reasonably expected costs for psychotherapy services, including the type of therapy, session frequency and duration, the therapist's rates, and other potential fees (e.g., late cancellation fees). It should be based on the services the therapist expects to provide, using their cash pay rate or the rate they would bill an insurer.

  • Itemized list: The estimate needs to be itemized, detailing each service, diagnosis codes (if known), billing codes, and the estimated cost for each.

  • Provider information: The GFE must include the therapist's name, credentials, practice information, and contact details.

  • Disclaimers: It should clearly state that the estimate is based on information known at the time it was created and that actual costs may vary. It also needs to inform patients of their rights, including the right to dispute the bill if it's substantially higher (at least $400) than the estimate.

  • Delivery: Therapists must provide the GFE in writing (paper or electronic) within specific timeframes:

    • Within 3 business days of scheduling, if the appointment is at least 10 days away.

    • Within 1 business day of scheduling, if the appointment is 3 to 9 days away.

    • Within 3 business days of a patient's request, even if no appointment has been scheduled.

  • Not a contract: The GFE is an estimate, not a binding contract. The actual cost of treatment may differ from the estimate based on the patient's individual needs and progress in therapy.

  • Updates: If there are significant changes to the treatment plan or costs, the therapist needs to provide an updated GFE at least one business day before the updated services begin.

  • Record keeping: Therapists must keep a copy of the GFE as part of the client's record for at least six years. 

Challenges and Considerations

  • Uncertainty in treatment: It can be challenging for therapists to estimate the exact number of sessions required, especially at the beginning of treatment. In such cases, therapists may provide a range of potential costs or an estimate for an initial period and update it as needed.

  • Client communication: Therapists should be prepared to discuss the GFE with clients, answer questions, and address any concerns or disagreements about the estimated costs. Transparency and open communication are crucial for maintaining a strong therapeutic alliance.

  • Updating the estimate: Regular review and updating of the estimate are important to reflect changes in the treatment plan or duration. 

By understanding the requirements and purpose of the Good Faith Estimate, therapists can ensure compliance with the No Surprises Act and foster greater transparency and trust with their clients regarding the financial aspects of psychotherapy.

For questions or more information about your right to a Good Faith Estimate, you can visit the official CMS website.