Good Faith Estimate

What’s Surprise or Balance billing?

When a therapist or other health care provider is:

• out of your insurance network or

• you choose not to use your insurance or

• you receive services not covered by insurance

  you will pay “out-of-pocket” or “private pay,” meaning you are responsible for the full fee being billed.

“Surprise billing” is an unexpected bill. This sometimes happens in an emergency room, when the doctor who treats you in an emergency is not in your insurance network. This can result in surprise medical bills that could run into the thousands of dollars.

When you are paying “out-of-pocket” you are entitled to a Good Faith Estimate (GFE): a summary of expected expenses associated with your care.

A GFE for our services if you private pay

Common psychotherapy codes:

90791 - Psychiatric Diagnostic Evaluation

90837- Psychotherapy, 55 minutes

90847 - Family psychotherapy, conjoint psychotherapy with the patient present

Our services and billing are straight-forward, there are no surprises. Expected expenses are as follows:

• Our first session is an intake -90791 billed at the agreed upon fee set prior to that appointment.

• The number of subsequent sessions will depend on mutual agreement and therapy goals established.

Disclaimer:

• Additional services or items that may be recommended as part of the treatment are separate and not reflected in this good faith estimate.

• The information provided in this good faith estimate is only an estimate and actual items, services or charges may differ. If those services differ you will be notified before incurring any fees.

• The client has the right to engage in a dispute resolution process if the actual costs of services significantly exceed those listed in the Good Faith Estimate.

• This Good Faith Estimate is not a binding contract. It does not require you to obtain psychotherapy from our practice.