What is the Good Faith Estimate? (GFE)
Effective January 1, 2022, a ruling went into effect called the “No Surprises Act” which requires practitioners to provide a “Good Faith Estimate” about services delivered which are considered either out-of-network or cash pay. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. 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 and will be provided a new “Good Faith Estimate” in these instances. If this happens, federal law allows you to dispute (appeal) the bill if you and your therapist have not previously talked about the change and you have not been given an updated good faith estimate.
Under Section 2799B-6 of the Public Health Service Act (PHSA), 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.
Note: The PHSA and GFE does not currently apply to any clients who are using insurance benefits, including “out of network benefits (i.e.., submitting superbills to insurance for reimbursement), however the likelihood of this changing later has led RFC to institute this policy across all clients regardless of their funding source.
Timeline requirements: Practitioners are required to provide a good faith estimate of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service.” That estimate must be provided within specified timeframes:
- If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or
- If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling; or
- If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified timeframes if the patient reschedules the requested item or service.
Where Services are Delivered
At the request of the client, services will be delivered either in person or online. Although Room for Change bills the same amount for in person and online appointments, insurance based services may differ in price due to insurance policies regarding reimbursement rates of in person versus virtual services. For instance, some insurance companies may cover a different percentage of service fees based on how the service is delivered.
Common Diagnosis Codes Used at Room for Change
Below are common diagnosis codes at Room for Change; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your therapist with any questions or concerns.
Adjustment Disorder (F43.23)
Mental Disorder, Not Otherwise Specified (F99)
Major Depressive Disorder (F32.9)
Generalized Anxiety Disorder (F41.1)
Bipolar Disorder (F31.9)
PTSD/Post Traumatic Stress Disorder (F43.10)
Encounter for Screening (Z 13.30)
Mental Health Disorder, Not Otherwise Specified (F99)
Stress not Elsewhere Specified (Z73.3)
This diagnosis is largely to satisfy the federal requirement for this form. “Z 13.30 Encounter for Screening”, “F99 Mental Health Disorder, Not Otherwise Specified” and “Z73.3 Stress not Elsewhere Specified” are not a formal psychological diagnoses. A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, we will not update this GFE and possibly any plans to use your medical insurance as they require a diagnosis in order to bill for services. It is within your rights to decline a diagnosis per state and federal guidelines.
Common Services Provided by Room for Change
90791: Initial therapy intake (60 minutes) Cost is $40 if service delivered by student, $80 if service delivered by licensed associate, $125 if service delivered by independently licensed clinician (LPC or LCSW), $150 if service delivered by Amanda Esquivel.
You will be provided another GFE after your first appointment. Those services are billed using 90837: Ongoing therapy appointments (approx 55 minutes) Cost is $40 if service delivered by student, $80 if service delivered by licensed associate, $125 if service delivered by independently licensed clinician (LPC or LCSW), $150 if service delivered by Amanda Esquivel.
Everyone’s Treatment & Journey is Unique
How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including:
- Your schedule and life circumstances
- Therapist availability
- Ongoing life challenges
- The nature of your specific challenges and how you address them
- Personal finances
- Changes to your motivation for change
- Illness and pandemic related closures
You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new “Good Faith Estimate” will be issued should your frequency or needs change.
Generally we recommend 8- 12 weeks of weekly appointments , 8-12 weeks of biweekly appointments, and 4-6 months of monthly appointments. We will use the higher end of these ranges below, thus multiplying by 24 appointments (12 weekly+6 biweekly+6 monthly).
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 do not receive an updated GFE.
Please refer to the RFC “Counseling Disclosure & Agreement” sections “Payment for Services”, “Insurance Claims”, and “Other financial considerations” for more information pertaining to any and all additional non-routine fees such as crisis appointments and court appearances.
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 HHS at (800) 368-1019.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.
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.