The No Surprises Act & Good Faith Estimates for Therapists

no surprises

If you were surprised by the No Surprises Act, you weren't alone. This new law went into effect January 1, 2022 and contains a complex set of mandates for all licensed or certified psychotherapists, regardless of insurance acceptance.

While we highly recommend checking out CMS.gov's No Surprises webpage, here are some quick facts about this new law.

 

Quick facts for therapists about the Good Faith Estimate

  • Although the law is in effect now, the US Department of Health & Human Services (HHS) has hinted it will “use discretion” when enforcing the law in the first year, i.e until 2023. If you make any effort at all toward compliance in this first year, you probably can expect leniency. We anticipate the law will be modified (and rules clarified) in the coming months.
  • If a new client reports that they WILL NOT be using insurance for their appointments, you must give them information about your fees. This includes both your hourly rate and the total cost of an expected course of treatment. This Good Faith Estimate must be in writing, and must be given within a small time frame of their first request to schedule an appointment. The length of that time frame is not explicitly outlined within the regulation, but please see below for our suggestions.
  • If a client reports that they WILL be using insurance, you aren’t obligated to provide a Good Faith Estimate. But there is no harm in doing so for everyone, and this can make things easier for you.

 

What information is included within a Good Faith Estimate?

A specific set of information needs to be included within a Good Faith Estimate. Some of this information is absurd for psychotherapy. For example, you are required to give the client’s diagnosis before you have met the client for the first session, which is of course ethically impossible. More on this below

  • Include the following in your Good Faith Estimate:
    • Client name 
    • Client date of birth
    •  Simple description of services to be provided
    • List of services reasonably expected to be provided
    • Diagnostic codes
    • Service codes
    • Expected charges associated with each service
    • Provider name
    • Your practice's NPI
    • Your practice's Tax ID Number
    • Office location where services will be provided.

If treatment lasts for more than a year, you must provide an updated Good Faith Estimate at the end of the year. This time it should include the client's diagnosis and a real estimate of costs. You must also provide an updated estimate upon a request from the client.

 

...Or use a template!

For TherapyAppointment users, here's good news: we've simplified most of the process for your practice. You can find a Good Faith Estimate template in your Online Forms Library.

Once you've modified the template to fit your practice, you can either auto-assign to new clients at intake or you can create different versions to fit specific referrals. (For example, if you need one Good Faith Estimate for psychotherapy and one for an ADHD evaluation, you can save your various versions and assign at intake.) Learn more about the Good Faith Estimate template and how to use it here. 

 

What is the timeline for providing a Good Faith Estimate?

Bear with us here. The timeline for compliance with delivering a Good Faith Estimate may feel a bit complicated at best. 

If the service is scheduled... A Good Faith Estimate must be provided within...
At least 10 business days in advance 3 business days. (This is within 3 business days of the scheduling, not of the appointment itself)
At least 3 business days in advance 1 business day of scheduling
Less than 3 business days in advance Not required. However, if an individual requests a Good Faith Estimate, it must be provided within 3 business days

It's important to note that the Good Faith Estimate must be provided within the timeframe listed above from scheduling an appointment. Not from the appointment date. So, for example, if someone schedule an appointment with you today for an appointment in 2 weeks, you must send the Good Faith Estimate within 3 days from today (the scheduling). 

A simple way to accomplish this task is though automating the sending of your Good Faith Estimate within your intake process. We can only speak directly on how to do that within our system -- jump here to learn how.

 

How do I assign a Good Faith Estimate without a diagnosis?

But what about the unreasonable expectation that -- prior to meeting the client for the first time -- you should supply a diagnosis and an expected course of treatment?

This is actually to your advantage! You can universally report the diagnosis of “R69” which translates as “diagnosis deferred”--no need for tailoring to this particular client.

Since you are only required to give a Good Faith Estimate, giving a total of an average course of therapy is sufficient for a client you have not met. APA reports that, on average, psychotherapy lasts for 18 sessions, so use that.

 

How do I provide the Good Faith Estimate by Mail?

So, if you prefer to do this the Luddite way (on paper and mailed to them promptly), your form for traditional psychotherapy could look like this:


 

[Your Practice Name]
Good Faith Estimate

Name:________________________________ Date of Birth:_________________

You have been referred to my office for treatment. I’m required by the 2022 No Surprises Act to give you a Good Faith Estimate of the cost of treatment if you are uninsured or don’t want to use insurance for this care. Since we haven't met, and don’t yet know if you want to use insurance for your treatment, the information below is based on “fee for service” (out of pocket) rates. 

If you DO intend to use insurance, check with your insurance carrier to find out what your copayment or coinsurance rates will be–they are likely to be much smaller. 

Since I have not yet evaluated your difficulties or symptoms, I must at this point estimate your course of treatment based upon the national average for a course of psychotherapy, which is 18 encounters. 

This initial estimate is valid for 12 months, but you are entitled to receive an update on this estimate at any time upon request.

Current ICD-10 diagnosis: R69 (diagnosis deferred).
Anticipated treatment: 
  • 1 session of CPT 90791 (diagnostic evaluation) at [ Your rates here]
  • 17 weekly sessions of CPT 90834 (psychotherapy, 45 minutes) at [ Your rates here] per session
  • Total of estimated “fee for services” treatment without insurance: [ Your rates here]

This is just a rough estimate based on national averages. The duration of our work together can be longer or shorter depending upon your symptoms, your work between sessions, and your response to treatment. 

Unless required by a court order (an extremely rare situation), you are free to discontinue treatment at any time, and free to discuss any other modifications to treatment modalities, frequency, or duration. You are ultimately in control of your own healthcare; I am just here to provide help at your request.

Location of treatment: All sessions will take place in my office at [Your address here/Online]
My identifying information: 
[Your name here], [Credentials]
National Provider Identifier: [NPI number here]
Tax ID number: [Tax ID Number here (do NOT provide your social security number if you are using this for your practice's Tax ID number)]

 


 

Final Thoughts

This information should not be constituted as legal advice. Information surrounding compliance of the No Surprises Act is vague, at this point. If you have questions about compliance and regulations, please visit the CMS.gov or speak to your practice's attorney. 

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