“RIGHT TO RECEIVE A GOOD FAITH ESTIMATE
OF EXPECTED CHARGES”
(UNDER THE NO SURPRISES ACT)
You have the right to receive a “Good Faith Estimate” explaining how much your services will cost. This will be provided by the specific therapist you choose and schedule an appointment with in advance of services. Each clinician at MPA operates independently, therefore your Good Faith Estimate will vary depending on who you are working with as a therapist.
Note: The expected cost of therapy is based on the clinician’s fee times the number of sessions needed. Your therapist will work with you throughout your treatment to determine how many sessions and/or services you need to receive the greatest benefit based on your diagnosis(es) or presenting clinical concerns. It is not possible nor therapeutically ethical to estimate the number of sessions needed upfront as ongoing variables contribute to that need and timeline. However, all payment is due at the time of service and all fees are discussed upfront. As a practice, we are committed to being transparent about fees and services so that clients do not experience financial surprises.
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. Most of the clinicians at Midtown Psychotherapy Associates are private pay only therefore, you will likely be entitled to a Good Faith Estimate from your therapist.
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 therapist gives you a Good Faith Estimate in writing at least one business day before your first appointment. You can also ask your therapist, 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 your chosen therapist.
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
(OMB Control Number: 0938-1401)
When you get emergency care or get treated by an out-of-network provider at a non-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
WHAT IS “BALANCE BILLING” (SOMETIMES CALLED “SURPRISE BILLING”?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. If you need to use in network providers, it is your responsibility to clarify and confirm with your therapist prior to scheduling in order to avoid any surprises.
If you believe you’ve been wrongly billed, you may contact GA Secretary of State at 404-656-2881.