GOOD FAITH ESTIMATE (GFE)
Under the No Surprises Act effective January 2022, health care providers are required to give patients who are uninsured or who are not using insurance (self-pay) an estimate of costs for items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. Health care providers are required to give you a Good Faith Estimate in writing within 1 business day of scheduling the service. You can also ask your health care provider for a Good Faith Estimate before you schedule an item of service.
IS THE GOOD FAITH ESTIMATE BINDING?
The information provided in the Good Faith Estimate is only an estimate, and the actual items, services, or charges may differ from what is included in the Good Faith Estimate. However, uninsured or self-pay individuals may challenge a bill from a provider through a new patient-provider dispute resolution process if the billed charges substantially exceed the expected charges in the good faith estimate. Substantially exceeds means an amount that is at least $400 more than the expected charges listed on the Good Faith Estimate for a specific provider.
ADDITIONAL INFORMATION AND DISCLAIMERS
There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the Good Faith Estimate.
The information provided in the Good Faith Estimate is only an estimate and that actual items, services, or charges may differ from the Good Faith Estimate.
A Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.
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.
Initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to the patient.
RIGHT TO DISPUTE
If you are billed a substantial amount ($400 or more) above the cost in this Good Faith Estimate, you have the right to dispute the bill. 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.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises.
As required by law, the above print notice will be posted at our offices.
CASH RATE PAYMENTS
Our cash rate is $250 for the first session and $200 per 55 minute session thereafter.