In compliance with the No Surprises Act that went into effect on January 1, 2022, all healthcare providers are required to notify clients of their federal rights and protections against unexpected or surprise billing for client’s who are uninsured or electing not to use their insurance.  As you know, in my practice sessions are paid for at the time of service, thus there will never be a surprise bill or additional fees charged to you.  And, of course if you ever believe you have been charged incorrectly, please let me know so that we can remedy the situation right away.

 

As you know, I am not in your health plan’s network.  Receiving services from an out-of-network provider could cost you more than going to an in-network provider.  To learn more about your in-network options and to learn if your plan has an out-of-network benefit, please contact your health plan.

 

This act also requires that I give you a Good Faith Estimate of the cost of services.  Prior to your appointment we will discuss and establish a fee for the services you will be receiving.  I will also be emailing you a Good Faith Estimate with your Intake Packet. 

 

Your fee is not based on your diagnosis (if any) but instead on the modality of care you choose to participate in, such as individual vs family therapy, and the length of the session, such as a standard 45-minute session vs a longer session (see standard fee schedule below).

 

Unless otherwise specified, each session is 45 minutes.  Generally, clients attend therapy weekly, but you and I will discuss the frequency that works best for you.  The frequency of therapy will be influenced by many factors, including:

 

• Your schedule and life circumstances

• My availability

• Ongoing life challenges

• The nature of your specific challenges and how you address them

• Personal finances

 

It is difficult to determine the true length of therapy and each client has a right to decide how long they would like to participate in the process.  Appointments are booked 1 week at a time and as long as 24 hours-notice is given, there is no charge for cancellations.  There is a $100 fee if you cancel your appointment with less than 24 hours-notice or if you do not show for your appointment, unless it is an emergency. 

 

And, finally I am required to ask you to sign the form that will be sent with your Intake Packet.  Your signature indicates the following:

• You know that I am an out-of-network provider and that you may be able to receive services from an in-network provider at a lower cost.

• You are giving up your protections under this law (OMB Control Number: 0938-1401).  For more information on your rights and protections visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protection-against-suprise-billing-providers-facilities-health.pdf or call 1-800-368-1019.

• Your insurance plan may not reimburse you for any part of these services and you may own the full cost billed for services received.

• Your health plan may not count any of the amount you pay towards your deductible or out-of-pocket limits.  You may want to contact your health plan for more information.

 

You shouldn’t sign this form if you didn’t have a choice of providers when receiving care.  For example, if a doctor was assigned to you with no opportunity to make a change.

 

The Good Faith Estimate is only an estimate and does not include any unknown or unanticipated costs that may arise and are not reasonably expected during treatment. It is also not a contract and does not obligate you, the client, to obtain or continue the below listed services.

 

GOOD FAITH ESTIMATE: TABLE OF SERVICES AND FEES:

 

CPT Code:

90834 – Usual CPT Code for Individual 45-minute sessions  $150

90837 – CPT Code for Individual 60-minute sessions $200

90847 – Family or Couples therapy (45-minutes) $175

90840 – Add on code for each additional 30 minutes.  For individual sessions $100 per 30 minutes. For family or couple’s sessions $116

Late Cancellations (i.e. less than 24 hours notices was given of desire to cancel or reschedule a session) or No Shows $100

 

And, of course, I will collaborate with you throughout your treatment to determine the optimal frequency and length of treatment.  Considering, appointments are booked 1 week at a time and if 24 hours-notice is given, there is no charge for cancellations. 

 

Thank you for reviewing this information and please feel free to contact me should you have any questions or concerns.

 

 

Sincerely,

 

Kim Scott, LMFT

NPI 1942546619