Em Scott Therapy

Los Angeles Therapist

Good Faith Estimate

Pursuant to the No Surprises Act (H.R. 133, Title 45 Section 149.610), health care providers, including licensed psychotherapists, are required to provide clients who are uninsured or self-pay with a Good Faith Estimate (GFE) of expected charges for services.

This page outlines your rights and the obligations of this practice under the law.

Your Right to a Good Faith Estimate

You are entitled to receive a written Good Faith Estimate of the expected charges for psychotherapy services. The Good Faith Estimate will be provided upon request, and will include:

  • Applicable disclaimers required by law
  • The provider’s name, supervisor’s name and National Provider Identifier (NPI)
  • A description of expected services
  • The frequency and duration of expected services
  • The estimated total cost of services over a defined period

Estimated Charges for Services

  • Service Provided: The length of each appointment (is 50 minutes for individual therapy (telehealth or in person), 50 minutes for couples/relationship therapy, 75 minutes for family therapy, and 90 minutes for group therapy.
  • Rate: Generally rates are $125-185 per session for individual therapy, $150-195 for couples/relationship therapy, $195 for family therapy, and $50 per member per session for group therapy (or as outlined in informed consent paperwork). Rates for gender-affirming care letters are sliding scale based on financial need, not to exceed $185. All fees are discussed with client ahead of the first session for any type of therapy.
  • Typical Frequency: Weekly or Biweekly depending on client needs
  • Estimated Annual Total: Varies depending on type of therapy, frequency of therapy, length of therapy.

The number of sessions necessary will depend on your individual circumstances and clinical needs, and may increase or decrease based on your progress and mutual agreement between you and your therapist.

All estimated costs of service are outlined on the Treatment Agreement/Informed Consent Paperwork that is signed by the Client and Therapist before the first date of service.

Disputing a Bill

If you get a bill that is at least $400 more for any provider of facility than the total expected charges for that provider or facility on the good faith estimate, there is a new patient-provider dispute resolution (PPDR) process available to you. Under the PPDR process, you may request a payment review and decision from an independent company certified by HHS. These companies are referred to as Selected Dispute Resolution (SDR) entities. The SDR entity will decide what amount you must pay if your bill is at least $400 more for any provider or facility than your good faith estimate from that provider or facility.

Here’s how:

  • Contact me to clarify or revise the bill.
  • Ask about payment plan options or financial support, if available.
  • If needed, you can initiate a dispute resolution process through the U.S. Department of Health and Human Services (HHS).
    • TheIf you receive a bill that is at least $400 more than your Good Faith Estimate, you may initiate the Patient-Provider Dispute Resolution (PPDR) process.
    • Key points:
    • The request must be submitted to the U.S. Department of Health and Human Services (HHS) within 120 calendar days of receiving the disputed bill.
    • A non-refundable administrative fee of $25 applies.
    • An independent third-party reviewer certified by HHS will determine whether the billed charges or the Good Faith Estimate (or another amount) is appropriate.
    • The decision of the reviewer is binding.
    • For more information or to begin the process, visit www.cms.gov/nosurprises or call 1-800-368-1019.

Disclaimer

This Good Faith Estimate:

  • Is based on information known at the time of creation.
  • Does not include any unknown or unexpected costs that may arise during treatment.
  • Does not constitute a recommendation for a specific treatment plan or number of sessions.
  • May be revised upon request or upon changes to the treatment plan or service frequency.

You have the right to request an updated Good Faith Estimate at any time.

Keep a Copy for Your Records

I recommend keeping a copy or screenshot of this Good Faith Estimate in case you need it later. You’re also welcome to request an updated version at any time.

Where can an uninsured (or self-pay) individual find information about a good faith estimate?

You should find information about good faith estimates on your provider or facility’s website and in the provider or facility’s office or on-site where you might schedule items or services or have questions about your costs. If you have questions about the cost of items or services, your provider or facility must inform you in writing or orally about requesting a good faith estimate. All of this information must also be available in accessible formats and languages.

Questions? Let’s Talk

You’re always welcome to ask questions about this estimate, your therapy plan, or anything else. I’m here to help you feel informed and supported—financially and emotionally.