No Surprises Act

A notice to all current and future clients:

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The No Surprises Act went into effect January 1st 2022 and is intended to protect patients and clients from unanticipated costs related to receiving services from health care providers, including therapists. Under this new law, clients are to be given access to anticipated billing estimates to allow for a clear understanding of potential charges. This information is available upon request, and will include services anticipated to be rendered, practice information, expected service codes (including anticipated diagnostic codes), and any unanticipated services with associated costs.

 

Example of a “Good Faith” estimate:

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Services to be provided by Gray Cat Counseling
1384 Old Freeport Rd. STE 2AF

Pittsburgh, PA 15238

NPI: 1346889060
TIN: 84-4049878

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Client: Jane Doe
DOB: 1/1/21 

Diagnosis codes: TBD

Services anticipated: Intake Session 90791 (60min). Out of Pocket billed at $170*
60 minute psychotherapy appointment 90837 (60 min). Out of pocket billed at $150*

Typically individual clients will be seen and billed for one intake session (90791), and subsequent psychotherapy sessions (90837). If a client cancels without giving 24 hours notice or does not attend the session without giving notice, the fee will be the out of pocket cost of that appointment. It will not be run through insurance. 
The yearly cost for individual sessions will depend on the number of sessions that a client attends. 
($160 intake session fee)+[(__# of sessions) x ($140 session fee)]= (total yearly fee)**
More detailed information is available upon request. 
*Rates subject to change; clients will be notified if there is an increase in billed rate.

**Estimate is subject to change if number of sessions scheduled is adjusted. A new estimate will be provided upon request or as needed.

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. 

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 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 1-800-985-3059. 

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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. 
 

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