No Surprises Act Implementation for Counseling Services
This document is not intended to serve as legal advice and is offered for educational purposes only.
Starting January 1, 2022, mental health professionals will be required by law to give uninsured and self-pay clients a good faith estimate of costs for services when scheduling care or when the client requests an estimate. This law is intended to give more transparency in medical care costs and protect clients from any “surprise billing.”
Who is subject to the No Surprises Act?
The term “provider” is defined broadly to include any health care provider who is acting within the scope of the provider’s license or certification under applicable state law. Mental Health Professionals working in a clinical setting with a state-issued practitioner license meet this definition and are subject to this law.
The definition of “items and services” for which the good faith estimate must be provided is also broadly defined to encompass “all encounters, procedures, medical tests, … provided or assessed in connection with the provision of health care.” Services related to mental health and substance use disorders (E/M services, psychotherapy, etc.) are specifically included.
What needs to be included in my Good Faith Estimate (GFE)?
The Centers for Medicare and Medicaid Services (CMS) have provided instructions for healthcare providers and a sample good faith estimate template. The good faith estimate must contain the following information provided in the template in a clear and understandable language for the client.
When should I issue a Good Faith Estimate (GFE)?
You should provide a good faith estimate to a client within the following time frames:
- If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling.
- If the service is scheduled at least 10 business days before the appointment date, no later than three business days after scheduling.
- If the uninsured or self-pay client requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified time frames if the client schedules the requested service. If the information included in the GFE changes, the provider must issue a new GFE no later than one business day before the item or service is scheduled to be furnished.
Does the No Surprises Act and Good Faith Estimate (GFE) affect all my clients?
Under the law, mental health professionals need to give clients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
Currently, this does not affect any new/existing clients who are using insurance. However, this does currently affect any new/existing clients who are currently self-pay or are not using insurance.
The requirement for a good faith estimate applies to these categories of clients:
- Clients who do NOT have health insurance of any kind, (i.e., commercial insurance, HMOs, union health plans or government health plans.)
- Clients who DO have health insurance that would pay for all or part of your treatment, but who DECLINE to use their insurance for the cost of your treatment. Patients who are shopping for care.
How long do the services the Good Faith Estimate (GFE) I provide a client’s cover?
Counselors can provide clients with a single GFE for recurring services (such as ongoing counseling visits), which is good for one year. But if the information, including costs, services needed or billing codes, changes at any point, then providers must issue a new GFE no later than one business day before the next scheduled appointment.
I have an appointment with a new patient who I haven’t seen before. How do I fill in the information requesting “applicable diagnosis codes”?
Applicable diagnosis codes are one of the required elements for an estimate. The American Psychological Association believes that a reasonable interpretation of the requirement is that until you have given a patient an initial evaluation and formulated a diagnosis, there is no applicable diagnosis code (unless, for example, the patient has been referred by another mental health professional who provided a diagnosis.) Thus, for most new patients you can indicate “TBD” under the “diagnosis code” section. If you later assign a diagnosis to that patient, you can update this information in future estimates provided to the patient.
The American Counseling Association recommends the suggestion of completing one general GFE form (using for example, a code such as Z03.89 “no diagnosis”) to provide individuals (potential clients) prior to the first session (intake assessment) occurring.
Is the Good Faith Estimate (GFE) binding?
No, the Good Faith Estimate (GFE) is an estimate. The actual amount charged may differ from the estimate. However, if the actual amount charged is substantially higher defined as being $400 or more than the good faith estimate, the client has the right to dispute the charges through a new federal patient/provider dispute resolution process.
Should I keep a copy of each the Good Faith Estimate (GFE)?
Yes, a Good Faith Estimate (GFE) is considered part of the client’s medical record and must be maintained in the same manner. Providers must provide a copy of any previously issued GFEs furnished within the last 6 years to an uninsured or self-pay client upon request.
What if I make a mistake or forget information in the Good Faith Estimate (GFE) I provided to a client?
If the services have not yet been provided to the patient, you should provide a corrected estimate to the patient as soon as practicable. If the services have already been provided, you should provide the patient with an updated estimate as soon as practicable, at least prior to their next appointment. A patient may still initiate the dispute resolution process in the No Surprises Act if the total amount you charge the patient (per provider) is at least $400 more than the charges listed in the estimate.
What documentation do I need to provide if a client disputes a charge?
Upon notice from a selected dispute resolution (“SDR”) that a client has initiated the dispute resolution process, a provider has 10 business days to provide:
- A copy of the good faith estimate provided to the client
- A copy of the bill sent to the client
- Any supporting documentation demonstrating that the difference between the billed charges and the expected charges in the GFE reflects (i) the costs of a medically necessary item or service and (ii) is based on unforeseen circumstances that could not have reasonably been anticipated by the provider or facility when the good faith estimate was provided.
For more questions about the No Surprises Act or Good Faith Estimate, please visit The Centers for Medicare and Medicaid Services (CMS) webpage here: https://www.cms.gov/nosurprises