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Good Faith Estimate

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.

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  • 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.

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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 a number of 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.

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The "No Surprises Act" as well as ethical, legal, and insurance guidelines require that I provide a formal diagnosis for those I support. A formal diagnosis occurs through careful assessment over approximately three sessions. As such, the GFE will be updated based upon the diagnosis discovered. It is within your rights to decline a diagnosis and/or treatment and my disclosures and privacy policy outlines these rights.

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The journey of healing through therapy is dynamic and unique. The time you may spend in therapy depends on numerous factors including:

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  • Your life circumstances and availability 

  • Therapist availability

  • Your specific challenges and modes of engagement in therapy

  • Personal finances

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We will continuously work together to assess your needs and movement towards goals to determine the frequency of therapy. As changes in frequency arise, a new "Good Faith Estimate" will be issued.

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​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”. They also note that 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 confident in the skills needed to maintain treatment gains”.  
 

In addition to the uniqueness of individual goals, it takes time to develop a therapeutic relationship, identify your goals and work towards accomplishing them. Whatever your number of sessions will be, we will work together to meet your needs.  

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​Common Service Costs

  • 90791: Intake session ($275)

  • 90837: 55 minute psychotherapy session ($250) 


​Where services will be delivered

  • Via teletherapy


​Provider Information

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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.

Intake session ($275) plus 55-minute psychotherapy session ($250) for 51 weeks: $13,025

This is only a general estimate of the financial expectations for a weekly session over a calendar year. The frequency and duration of your care will be based upon your individual needs and goals.

I am happy to answer any questions about the “No Surprises” Act and Good Faith Estimates and we will discuss this in detail when we meet.

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Good Faith Estimate Disclaimer

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  • 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 me at Lori@DrLoriMariani.com to let me 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.

OMB: 0938-XXXX

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