Good Faith Estimate
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.
Mindful Therapy Practice
Good Faith Estimate
Good Faith Estimate and
Mental Health Services
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.
At Mindful Therapy Practice, we must provide a diagnosis for all clients for both ethical, legal, and insurance reasons.
If you are wanting to submit a superbill to your insurance for re-payment, a superbill must include a diagnosis. The "No Surprises Act" also mandates a diagnosis. 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.
Mindful Therapy Practice 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
Ongoing life challenges
The nature of your specific challenges and how you address them
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.
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 therapist 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 Mindful Therapy Practice
90791: Intake session ($175)
90837: 60 minute psychotherapy session ($175)
90837: 90 minute extended psychotherapy session ($262)
90847/46: Family counseling is not provided by this therapist; however, clients are able to have a significant other (family member, partner, etc) attend a session on occasion, alone or with the client, only if the client grants consent, and if it is helpful for their individual therapy process. Sometimes a client may benefit from their significant other receiving psychoeducation, which means the therapist will provide suggestions on how best to support the client. This is known as a collateral session. A Collateral consent form is available on this website, under Forms.
Where services will be delivered.
Mindful Therapy Practice provides services in the office and via teletherapy
Mindful Therapy Practice Office Locations:
6994 El Camino Real, Ste 205-G, Carlsbad CA 92009
Provider Name: Melissa Barsotti, LCSW
TAX ID/EIN: 88-1116744
Phone #: 626-893-0480
Good Faith Estimate
For a good faith estimate: Remember, this is not a bill or invoice
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. The Estimate for what you would owe in a calendar year, if you were to attend therapy for 52 sessions on a weekly basis, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc., are the following:
90791: Intake session ($175) plus 90837 60 minute psychotherapy session ($175) for 52 weeks: $9,100
90791: Intake session ($175) plus 90837: 90 minute extended psychotherapy session ($262) for 52 weeks: $13,624
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. Payment is accepted at the end of each therapy session. The quote for a calendar year will never be accepted up front because services have not been rendered. You are only responsible for services rendered/received.
We look forward to talking with you and answering any questions you may have about the “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 626-893-0480 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”
Mindful Therapy Practice has always provided transparency in our billing practices by displaying our fee schedule within our Counseling Policies. Please know that the Good Faith Estimate does not change any agreements you have already made with us with regard to self pay. Your review of this form and signature is required so that we can demonstrate our compliance with the mandate. Thank you!