Good Faith Estimates for self-pay therapy clients

If you see clients who pay you directly and do not use insurance, a federal rule asks you to give them a cost estimate before care starts. It is called a Good Faith Estimate, and it comes from the No Surprises Act. This guide covers what the Centers for Medicare and Medicaid Services (CMS) says about who needs one, when it is due, and what it has to contain.

Who needs a Good Faith Estimate

CMS says the estimate is for people who have no health coverage, and for people who have certain coverage but do not plan to use it, the "self-pay" clients. It applies when a client schedules a service at least 3 business days ahead, or when a client asks for an estimate or asks what care would cost. If a service is scheduled fewer than 3 business days before it happens, an estimate is not required.

CMS also notes that people enrolled in federal health care programs are not eligible for a Good Faith Estimate, even if they do not plan to use that coverage. Check each client's situation, and ask a health care attorney if a case is unclear.

When it is due

The client	The estimate is due
Asks for an estimate without scheduling	No later than 3 business days after the request
Schedules 3 to 9 business days before the service	No later than 1 business day after scheduling
Schedules at least 10 business days before the service	No later than 3 business days after scheduling

You can give the estimate by phone or in person if the client asks, but you must follow up in writing, on paper or electronically, in the format the client prefers.

What it has to contain

CMS publishes a sample form and says you do not have to use that exact form as long as yours includes the required information. Based on the sample, an estimate includes the following.

• The client's name, date of birth and contact details
• The primary service and, if it has been determined, the diagnosis and its diagnosis code
• The date or dates of service, if scheduled
• Your name, address and contact person, your National Provider Identifier (NPI) and your Taxpayer Identification Number (TIN)
• Each service with its code, quantity and expected cost
• A statement of the client's right to dispute the bill if the amount charged is substantially higher than the estimate

The full list of requirements is in the federal regulation at 45 CFR 149.610(c). Read it or have it reviewed before you finalize a template.

Weekly therapy and recurring visits

If you expect to provide recurring services, CMS says you may give one Good Faith Estimate for the whole series instead of one per visit. CMS names counseling services as an example. If the expected providers, items or services change before a scheduled visit, you send a new estimate at least 1 business day before the service date.

What happens if the bill is higher

CMS says a client may be able to dispute a bill that is at least $400 more than the estimate. That is why the estimate should reflect the fee you actually expect to charge, including any recurring sessions you have already discussed.

A short checklist

1. Tell self-pay clients at scheduling that they are entitled to an estimate.
2. Send the written estimate within the deadline for their scheduling window.
3. Include every element from the CMS sample.
4. Keep a copy with the client record, and issue a new one if the plan changes.

If you use practice software to produce estimates, check its output against the list above. On the Professional plan, RafaNest issues a Good Faith Estimate with these elements and will not issue one without the client's date of birth or your NPI, Tax ID and clinic address. Whichever tool you use, compare its output with the CMS list before you rely on it. See also superbills and Good Faith Estimates.

Sources are the CMS Good Faith Estimate page, the CMS decision tree for self-pay individuals (revised September 2023) and the CMS sample estimate form. This is general information and not legal advice.