GOOD FAITH ESTIMATE FOR HEALTHCARE COSTS AND SERVICES

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On January 1, 2022 a new federal law, the "No Surprises Act" (NSA), took effect. This law, part of the Consolidated Appropriations Act COVID-19 relief bill, was signed on December 27, 2020, and was primarily designed to increase price transparency and reduce the potential for unexpected medical bills. The No Surprise Act requires providers to give clients a good faith estimate of expected charges for items and services to individuals who are not enrolled in an insurance 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, upon request or at the time of scheduling health care items and services. 

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CMS No Surprises Act Implementation Info

More details, regulations, and resources are forthcoming by the government as it specifically pertains to Behavior Healthcare Providers. However, some of the key takeaways of the No Surprises Act include the following (American Hospital Association, 2021): 

 

(1) Protects patients from receiving surprise medical bills resulting from gaps in coverage for emergency services and certain services provided by out-of-network clinicians at in-network facilities, including by air ambulances

 

(2) Holds patients liable only for their in-network cost-sharing amount, while giving providers and insurers an opportunity to negotiate reimbursement

 

(3) Allows providers and insurers to access an independent dispute resolution process in the event disputes arise around reimbursement. The legislation does not set a benchmark reimbursement amount

 

(4) Requires both providers and health plans to assist patients in accessing health care cost information

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Surprise Billing Protection Info

The purpose of the following is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. This notice is for clients whose insurance does not cover Debi J Pruitt LCMHC PLLC and/or if Debi J Pruitt LCMHC PLLC is out-of-network with your insurance, and/or because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan. 

 

Please note that it is ultimately up to you to determine if your insurance company covers me as a therapist, otherwise, you may remain liable for incurring non-covered costs. For example, I am in-network with most BCBS plans but not all, so it is important that you verify coverage.

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If I am not covered by your insurance network getting care from this provider or facility could cost you more. 

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If your plan covers the item or service you’re getting, federal law protects you from higher bills: 

• When you get emergency care from out-of-network providers and facilities, or 

• When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your                   knowledge or consent

 

Ask your health care provider or patient advocate if you need help knowing if these protections apply to you. If you want to choose out-of-network coverage and are willing to pay more you will be asked to sign a form acknowledging you may pay more because:

• You are giving up your protections under the law

• You may owe the full costs billed for items and services received

• Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information

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Before deciding whether to sign such a form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.

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GOOD FAITH COST ESTIMATE

If you have no insurance and are paying out-of-pocket or choosing to use us out-of-network, you may be charged the following example rates:

90791 Diagnostic Interview, 1 @ $175

90834 Counseling, $140 per session

90847 Counseling with family member present, $140 per session

 

It is unknown at the outset of counseling how many sessions a client may need and can range from several to 50 in a calendar year. 

For 3 sessions the cost would be $455 ($175 + $140 + $140) 

For 50 sessions the cost would be $7035 ($175 + $140x49)

 

However, a more realistic model would be based on 12 sessions that can be adjusted to meet specific client needs.

The 12 session model would cost $1715 ($175 + $140x11)

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A Good Faith Estimate may be made available to you in writing from your therapist. The GFE document will include the above cost information as well as your therapists name, license, license number, NPI, and taxpayer ID.