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) to patients who do not have insurance or patients who have insurance but are out-of-network. This ruling requires me to diagnose you prior to our initial visit, so I have provided you with the generic diagnosis above. If you wish to have a formal diagnosis we can discuss after a minimum of three sessions. Note that many clients do not wish to have a diagnosis and desire to focus treatment on symptoms and areas of growth instead. This is totally your preference, and I am open to talking about both with you. When/if the diagnosis is changed, I will provide you with an updated GFE.
The Good Faith Estimate's purpose is to show the cost of services to avoid an unreasonably large bill. Your treatment and cost of treatment will vary based on your individual needs, amount of therapy sessions needed/wanted, and the type and length of services you attend. I have no way of predicting the exact amount of therapy sessions or services that will be needed however I will provide some examples of total cost of treatment for reference. Please remember you can always discuss billing, cost, treatment plan, length of sessions, and amount of sessions with me at any time.
This document is NOT a contract and does not obligate you to obtain any services from Courtney Miller Psychotherapy. The Good Faith Estimate is not intended to serve as a recommendation for treatment or prediction to attend a specific number of psychotherapy visits nor does it provide an all-inclusive treatment plan. Therapy is and will always be voluntary and unique to fit your specific needs.
Here is a breakdown of my Services & Fees effective January 31, 2022 thru December 31, 2022:
- New Patient/Initial Diagnostic Evaluation 90 Minutes $225 (CPT Code 90791)
- New Patient/Initial Diagnostic Evaluation 60 Minutes $165 (CPT Code 90791)
- 30 Minute Individual Psychotherapy $85 (CPT Code 90832 ); 30 Minute Family or couples psychotherapy without the patient present $85 (CPT Code 90846); 30 Minute Family or couples psychotherapy with the patient present $85 (CPT Code 90847)
- 60 Minute Individual Psychotherapy $165 (CPT Code 90837); 60 Minute Family or couples psychotherapy without the patient present $165 (CPT Code 90846); 60 Minute Family or couples psychotherapy with the patient present $165 (CPT Code 90847)
- 90 Minute Individual Psychotherapy $225 (CPT Code 90837, 99354); 90 Minute Family or couples psychotherapy without the patient present $225 (CPT Code 90846); 90 Minute Family or couples psychotherapy with the patient present $225 (CPT Code 90847)
- No Show/Late Cancellation $85-$225 to equal fee of service requested
- In-Between Session Support $42.50 per 15 minutes (CPT Code 98967)
If you book a session and are late you are still responsible for the full fee. I will typically wait 30 minutes past your session start time as I understand things happen and people run late but after 30 minutes you will be charged the no show/late cancellation fee. If this is unclear, please discuss with me during our first session.
Examples of Good Faith Estimates: (Please note these are estimates and your exact cost of treatment will depend on the amount of sessions you wish to have weekly, length of sessions, and additional services requested.)
Example 1 (Individual - weekly): $165 Initial evaluation fee + $165 session fee x 4 weeks/month x 12 months = $8,085.
Example 2 (Individual - bi-monthly): $165 Initial evaluation fee + $165 session fee x 2 weeks/month x 12 months = $4,125
Example 3 (Couple - weekly): $225 Initial evaluation fee (x3) + $165 session fee x 4 weeks/month x 12 months = $8,595.
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 at the time the estimate was created. For instance, if you attend therapy bi-weekly (2x/week) or for longer than 12 months, your total cost of service will be higher. 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.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact Courtney Miller Psychotherapy 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 your health care provider, 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/consumers or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
You may use the equation above to calculate your total cost of service. If you are unsure, please discuss with me at some point during a session.
Courtney Miller Psychotherapy will continue to bill you after each session. Should you feel your bill is unreasonably higher (in excess of $400) than the above equation(s) specify, you may dispute the charges. For more information you may visit www.cms.go/nosuprises or call (800) 368-1019. Keep a copy of this Good Faith Estimate in a safe place and again if you should have any questions, please feel free to discuss with me at any point during one of our sessions.