The No Surprises Act and
the Good Faith Estimate

The No Surprises Act targets price transparency from health care providers, including decreasing the chances of acquiring a “surprise” medical/mental health bill.

As of January 1st, 2022, health care providers are required by law to issue a Good Faith Estimate to clients and their families. A Good Faith Estimate (GFE)

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What do I need to Know About a Good Faith Estimate?

Health care providers and health care facilities are mandated to issue a good faith estimate of expected charges for items and services to clients who are not enrolled in a plan/coverage, a Federal health care program, or who are not seeking to a file a claim with their coverage. Health care providers are required to review the good faith estimate both orally and in writing, upon request or at the time of scheduling health care items/services.

When should I expect to receive a good faith estimate from Equilibrium Mental Health?

A good faith estimate will be supplied to you and your family. The No Surprises Act indicates that a good faith estimate must be furnished to clients within these timeframes:

1.     If the service is scheduled at least three business days before the appointment date, a client will be issued a good faith estimate no later than one business day after the date of scheduling.

2.     If the service/item is scheduled at least 10 business days before the appointment date, no later than 3 business days after the date of scheduling.

3.     If a client requests a good faith estimate (without scheduling a service or item), a good faith estimate will be provided no later than three business days after the date of request. A new good faith estimate will be provided to the client, within the specified times if the client reschedules the requested item or service.

How should I expect to receive a good faith estimate?

You will receive an electronic copy of a Good Faith Estimate via Simple Practice, our HIPAA-compliant health care information platform. The Good Faith Estimate is stored in the client’s electronic medical record, accessible to each client. In order to access this information, clients can login to their secure client portal via Simple Practice.

What is the good faith estimate based on?

A good faith estimate is a notification of expected charges for a scheduled or requested service (or item). The "expected charge" for an item or service is either:

  1. The cash pay rate or rate established by the health care provider, or
     

  2. The amount the provider would expect to charge if the provider intended to bill a health care plan directly for such item or service.

Is the good faith estimate binding or absolute?

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, you have the right to challenge a bill from a health care provider through a new provider dispute resolution process. Clients have the right to engage in this dispute resolution process if the billing charges exceed the expected charges in the good faith estimate. If the billing charges exceed an amount that is at least $400.00 more than expected charges listed on the good faith estimate, clients have the right to initiate a dispute/resolution process.

What information can I expect to view on the good faith estimate?

The following is a list of information you can expect on the good faith estimate:

  • The client’s name and date of birth.

  • A description of the primary item or service being provided to the patient (and when applicable, specific scheduling information).

  • An itemized list of items or services that are reasonably expected to be provided.

  • Applicable diagnoses codes, expected service codes, and expected charges associated with the listed item or service.

  • The name, National Provider Identifier, and the business Tax Identification Number (TIN).

  • A list of services that we anticipate will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service;

  • A disclaimer that there may be additional items or services that are not reflected on the good faith estimate;

  • A disclaimer that 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 disclaimer that informs the clients of their right to initiate a client/provider dispute resolution process if the actual billed charges substantially exceed the expected charges in the good faith estimate.

Is the good faith estimate a contract?

Disclaimer: the good faith estimate is not a contract. As such, it does not require clients/families to obtain all anticipated items/services from any health care provider/facility identified in the good faith estimate.

Do I have the right to request a good faith estimate? What about an updated estimate?

Absolutely! You have the right to request an estimate of services at any juncture in the course of treatment. Consistent with the law, your request will be honored no later than 3 business days after the date of your request.

How do I initiate a patient-provider dispute resolution process?

If you feel that you are billed substantially more than the good faith estimate (exceeding $400.00), you have the right to dispute the bill.

Please contact us if you believe that you have been billed charges higher than the Good Faith Estimate. You can ask us to:

  1. Update the bill to match the Good Faith Estimate

  2. Ask to negotiate the bill, or

  3. 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 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 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.

How are all the charges captured in the estimate?

Psychotherapy is a health care service that is often time-limited and recurrent, with appointments scheduled on a regular basis (e.g. Weekly, biweekly, monthly). In this respect, Equilibrium Mental Health will issue clients with a singular good faith estimate that captures recurring services/items.

Once I receive the good faith estimate, what should I do with it?

Store it safely for your records. Take a picture, make a copy of the estimate, or save it to your personal files.