Good Faith Estimate

Information for Clients Who Do Not Have Insurance or Who Are Not Using Insurance

Notice: You have a right to receive a “Good Faith Estimate” which explains the cost of your medical and mental health care

Effective January 1, 2022, federal laws regulating client care have been updated to include the “No Surprises” Act. Under the law, healthcare providers are required 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

Under the law, health care providers are responsible for providing uninsured or self-pay patients (patients who opt out of using their insurance) an estimate of the bill for medical products and services.

  • You have a right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs such as medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider(s) give you a GFE in writing at least 1 business day before your medical item or service. You can also request your healthcare provider(s) for a GFE before you schedule an item, procedure or service.
  • If you receive a bill that is at least $400 more than your GFE, you have a right to dispute the bill.
  • It is helpful to save a copy of your GFE.

Genesis Clinical Counseling, LLC Good Faith Estimate

Please be advised, there are several factors that make it challenging to provide an estimate on the length of time it will take for a client/patient to complete psychotherapy/mental health treatment, and much depends on the individual client and their progression towards goals identified therapy. Some clients are satisfied with a reduction in symptoms after a few sessions while others continue longer based on needs.  Others begin to schedule less frequently and may continue to come in for “booster sessions” or as needed.  

At Genesis Clinical Counseling, LLC 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 Genesis Clinical Counseling include, but are not limited to:

    • Adjustment Disorder (F43.23)
    • Mental Disorder, Not Otherwise Specified (F99)
    • Depression (F33.1)
    • Anxiety (F41.1)
    • PTSD/Complex PTSD (F43.10 and F43.12)
    • Acute Stress Reaction (F43.0)

    Common Services at Genesis Clinical Counseling, LLC:

    • 90791: Initial Intake Session ($175)
    • 90834: 45–50-minute psychotherapy session ($100)
    • 90837: 53+ minute extended psychotherapy session ($150)

    Where services will be delivered:

    • Genesis Clinical Counseling, LLC provides services in-person in our office located at 2255 Dunn Ave. Suite 2016, Jacksonville, FL 32218
    • Via teletherapy through a HIPAA compliant secure EHR (Electronic Health Records).

    Provider Information:

    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 ($100) for 51 weeks: $5,275

    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 tamaraLMHC@genesisclinicalcounseling.com or call 904-201-9658 to let us know if 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”.