Good Faith Estimate

Effective January 1, 2022, a ruling went into effect called the “No Surprises Act,” which requires mental health practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care to any patient who is uninsured or who is insured but does not plan to use their insurance benefits to pay for health care items and/ or services.  

The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your mental health care needs for an item or service.  The estimate is based on information known when the estimate was created.  The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.

You are entitled to receive this “Good Faith Estimate” of the charges for psychotherapy services provided to you. While a psychotherapist can't know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person upon the initiation of psychotherapy, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you not identified here.  

Good Faith Estimate

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, depending on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

The one-time fee for an initial diagnostic assessment is $200 (CPT Code 90791).  

Beyond this, a traditional 50-minute psychotherapy session (in-person or via telehealth) fee is $200 (CPT Code 90837).  Most clients will attend one psychotherapy visit per week. Still, the frequency of appropriate psychotherapy visits in your case may be more or less than once per week, depending upon your individual needs and preference.  When determining your total estimate, it is also important to consider vacations, holidays, emergencies, and sick time.   

A typical consumer will schedule up to 46 therapy sessions a year. This means that their out-of-pocket expense will be approximately $7,590 a year.

Two Rivers Therapy & Consulting recognizes every client’s therapy journey is unique.  How long you need to engage in therapy and how often you attend sessions will be influenced by many factors, including:

  • Your schedule and life circumstances

  • Therapist availability

  • Ongoing life challenges

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

  • Personal finances

You and your therapist will continually assess the appropriate frequency of therapy. They will work together to determine when you have met your goals and are ready for discharge, and/ or a new “Good Faith Estimate” will be issued should the frequency of session(s) or needs change.  As related, you may request a new GFE at any time in writing during your treatment. 

 

Good Faith Estimate Disclaimer:

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 when the estimate was created.  Your provider may recommend additional services not reflected in this Good Faith Estimate.

The Good Faith Estimate is only estimate—actual items/ service charges may differ.  The Good Faith Estimate does not include any unknown or unanticipated costs that may arise and are not reasonably expected during treatment due to unforeseen events.  You could be charged more if complications or special circumstances occur.  Other potential items and/ or services associated with therapy charges may include but are not limited to no-show/ late cancellation fee(s), record request(s), letter writing(s), the legal fee(s)/ court attendance(s), professional collaboration(s), and in-between session support).  These potential items/services and associated fee(s) are discussed further within the Informed Consent documentation. Should these items/services be initiated, a new Good Faith Estimate will be provided.  The Good Faith Estimate does not obligate the client to obtain listed items or services.

You have a right to initiate a dispute resolution process if the amount charged substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). 

You are encouraged to speak with your provider anytime about any questions regarding your treatment plan or the information provided in this Good Faith Estimate.