Good Faith Estimate
Information for Clients Who Do Not Have Insurance or Who Are Not Using Insurance
Notice: You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 800-985-3059.
Out of The Box Counseling Good Faith Estimate
Beginning January 1, 2022, federal laws regulating client care have been updated to include the “No Surprises” Act. Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services called a “Good Faith Estimate” (GFE) explaining how much your medical care will cost.
This new regulation is designed to provide transparency to patients regarding their expected medical expenses and to protect them from surprises when they receive their medical bills. It allows patients to understand how much their health care will cost before they receive services.
There are several factors that make it challenging to provide an estimate on how long it will take for a client to complete therapeutic treatment, and much depends on the individual client and their goals in seeking therapy. Some clients are satisfied with a reduction in symptoms while others continue longer because it feels beneficial to do so. Others begin to schedule less frequently and may continue to come in for “tune ups” or when issues arise. Ultimately, as the client, it is your decision when to stop therapy.
At Out of The Box Counseling, we must provide a diagnosis for all clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act". A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, we will not update the GFE. It is within your rights to decline a diagnosis per state and federal guidelines.
Common Diagnosis Codes at Out of The Box Counseling: Below are common diagnosis codes at Out of The Box Counseling; however, the list is not exhaustive. With that said, diagnosis codes can changes based on many factors. Please speak to your therapist with any questions or concerns.
- Adjustment Disorder (F43.23)
- Mental Disorder, Not Otherwise Specified (F99)
- Depression (F33.1)
- Anxiety (F41.1)
- Bipolar I and Bipolar II (F31.10 and F31.81)
- Borderline Personality Disorder (F60.3)
- PTSD/Complex PTSD (F43.10 and F43.12)
Out of The Box Counseling 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 and 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 your frequency or needs change.
According to the American Psychological Association, “on average 15 to 20 sessions are required for 50 percent of patients to recover as indicated by self-reported symptom measures”. Additionally, they state that through the working relationship between the client and counselor sometimes the preference is for “longer periods (e.g., 20 to 30 sessions over six months), to achieve more complete symptom remission and to feel confidence in the skills needed to maintain treatment gains”.
So, it depends on several factors because everyone has unique counseling goals. Like any other relationship, it takes time to develop a therapeutic relationship with your counselor and identify your treatment goals, establish a plan of action, and work towards accomplishing them. Whatever your number of sessions will be, we will work together to meet your needs.
Common Services at Out of The Box Counseling
- 90791: Intake Session ($175)
- 90834: 45–50-minute psychotherapy session ($150)
- 90837: 53+ minute extended psychotherapy session ($150)
Where services will be delivered:
- Out of The Box Counseling provides services via teletherapy through a HIPAA compliant secure EHR (Electronic Health Records).
- Out of The Box Counseling provides teletherapy to adults only who reside in Florida.
Out of The Box Counseling office location
- 1301 Riverplace Blvd Suite 800 Jacksonville, FL 32207
- Provider Name: Out of The Box Counseling, LLC NPI: 183185690
- TAX ID: 85-1610654
- Email: email@example.com
- Phone #: 904-690-3900
- Fax #: 904-690-3930
Good Faith Estimate
For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range. Out of an abundance of caution and transparency, we will only quote weekly appointments.
90791: Intake session ($175) plus 90834: 45–50-minute psychotherapy session ($150) for 51 weeks: $7,825
90791: Intake session ($175) plus 90837: 53+ minute extended psychotherapy session ($150) for 51 weeks: $7,825
The above examples are provided to give an idea of the financial expectations for a calendar year. The frequency and duration is dependent on your individual needs and goals.
We look forward to talking with you and answering any questions you may have about that “No Surprises” Act and Good Faith Estimates.
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 at the time the estimate was created.
- 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 us at firstname.lastname@example.org or call 904-690-3900 to let us know the billed charges are higher than the Good Faith Estimate. You can ask us 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 the health care provider or facility, 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 or call 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 or call 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.
This is the public disclosure of the “Good Faith Estimate”
Public Disclosure of the Good Faith Estimate