The No Surprises Act protects you from surprise billing. My practice supports full billing transparency and so I offer my clients a Good Faith Estimate to explain our fee arrangement. Here is information about this document.

The Good Faith Estimate (GFE) provides an estimate of the expenses clients will incur for their psychotherapy services with me (Lori Moussapour, LCSW, PLLC (TEU). It contains information about me and the services each client receives.

While treatment plan, frequency and diagnoses often change, the GFE describes our current agreement regarding the type of therapy you receive, and the fee for said service. It shares that clients are given 1 month’s notice should any changes take place.   It also reminds clients that if they plan to access out of network benefits through a health plan, they may have a deductible that needs to be met prior to receiving any out of network contributions towards these costs. It is the clients’ responsibility to know their own deductible and out of network reimbursement options. 

The GFE may also explain costs associated with additional services and related charges: In addition to these therapy services, clinicians are sometimes tasked with additional work on behalf of or related to a client including: calls between sessions, consultation, coordination of services, legal requests and/or reports. These services may be billed at an additional rate similar to, above and beyond session fees. If this does occur I or your provider will communicate the costs associated with such services. The GFE may also note that our practice has a strict cancellation policy that requires 24 hours notice. When this notice isn’t given, clients will be charged a fee, that is the equivalent to the session fee. 

The GFE may also list additional information and limitations such as those that follow.

The Department of Health and Human Services (HHS) under section 2799B-2(d) of the Public Health Service Act (PHS Act) has identified that good faith estimates are for use when providing items and services to participants, beneficiaries, enrollees, or covered individuals in group health plans or group or individual health insurance coverage, including Federal Employees Health Benefits (FEHB) plans by either: 

• A nonparticipating provider or nonparticipating emergency facility when furnishing certain post-stabilization services, or 

• A nonparticipating provider (or facility on behalf of the provider) when furnishing nonemergency services (other than ancillary services) at certain participating health care facilities. 

Providers and facilities should NOT give these estimates to an individual: 

• Who is seeking items or services from in-network providers only

• Who has Medicare, Medicaid, or any form of coverage other than as previously described, or

• Who is uninsured.

Disclaimer 

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. 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 more than this Good Faith Estimate, you have the right to 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.