The No Surprises Act of 2020 is intended to protect healthcare consumers from “surprise” medical bills incurred at larger healthcare facilities for services provided by out-of-network providers at these facilities. I am required to provide you with this “Good Faith Estimate” of the cost of our services.

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Fees are clearly outlined in our Practice Agreement. However, with the course of mental illness and the response to treatment being variable, it’s difficult to predict the cost of our services with certainty, because appointments may need to become more frequent or less frequent, depending on the progress being made. As required by the No Surprises Act, we can offer estimations of what our services will cost you in the following hypothetical scenarios, extrapolated to a 12-month/52-week treatment period:

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• Initial Assessment + WEEKLY Individual Therapy (60 min): $6,575

• Initial Assessment + BI-WEEKLY Individual Therapy (60 min): $3,450

• Initial Assessment + WEEKLY Couples/Family Therapy (60 min): $10,400

• Initial Assessment + BI-WEEKLY Couples/Family Therapy (60 min): $5,200

• Initial Assessment + MONTHLY Individual Therapy (60 min):$1,700

• Initial Assessment + MONTHLY Couples/Family Therapy (60 min):$2,600

Please understand that these estimates are our ‘best guess’ as to what treatment may cost, and carefully consider which of these services apply to you. The cost of “Between-appointment correspondences” such as phone calls or paperwork are not included because these are highly variable and often negligible or totally absent. This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your provider. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

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 If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

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You may contact us to let us know the billed charges are higher than the Good Faith Estimate. You can ask us 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). You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). 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.

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