FEES & GOOD FAITH ESTIMATE

Individual $125 Couples $175 Families $200

I am an out-of-network provider and do not accept insurance directly.

FEES & GOOD FAITH ESTIMATE
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a "Good Faith Estimate" of expected charges.

THERAPY COSTS

Our standard fee for an hour of clinical service is $125. An individual client pays $125 for a 50 minute session; two clients coming in for couple therapy pays $175 for a 50 minute session, a family coming in for family therapy pays $200 for a 50 minute session. You should have been informed about your fee when you initially made your appointment. If you are unsure what your fee is, your therapist will be able to tell you. The fee given to you is for each 50 minute time period that you are scheduled to spend in therapy. Payment is requested at the time services are rendered and may be made with cash or credit card.

If clients would like to request a fee that is different than our standard fee, they can submit a written request to their clinician stating their requested fee ($10 per 50 minute session minimum) and describing their reason for their request. Common reasons for a sliding fee scale adjustment include documented financial hardship such as medical bills or wage garnishment.

We want our clients to have a good idea what therapy will likely cost. STET staff normally determine a per-session fee with clients during the intake phone call prior to the first session; if clients are ever uncertain about what their session fee is, we are happy to remind them. Having an understanding of their per-session fee and average treatment duration allows clients to get a good faith estimate of treatment costs (fee x number of sessions = cost). Based on our data, estimated average total cost ranges are the following:

6 or fewer sessions cost $125 - $750

7 - 10 sessions cost $875 - $1,250

11 - 15 sessions cost $1,375 - $1,875

16 - 20 sessions cost $2,000 - $2,500

> 21 sessions cost a minimum of 2,625

(These estimates are based on a per-session individual fee rate of $125)

OTHER LESS COMMON COSTS

Clients sometimes request other services and there are charges for these services. The feel for report writing (psychological evaluations, treatment summaries, etc.) is $25 per hour with a minimum of one hour paid in advance. The fee must be paid in full before the requested document is released. Clients and/ or attorneys must pay $50 per hour for courtroom testimony by a therapist, with a minimum of three hours payable in advance, when honoring a subpoena and /or when providing testimony in court, regardless of whether or not the therapist actually testifies. If you or someone representing you requests your clinical record, there is a $10 file location fee (if the request occurs after you have terminated therapy at STET) and a 10 cents per page copying fee.

OBTAINING A GOOD FAITH ESTIMATE

Clients may ask their clinician for a Good Faith Estimate at any time. This good Faith Estimate shows the costs of items and services that are reasonably expected for client health care needs for an item or service. The Good Faith Estimate document includes, but is not limited to, the following information:

Client Name (included below)

Client date of birth (included below)

Description of the services that will be provided, in understandable language: At STET, these services are individual, couple, or family therapy. The CPT codes most often associated with these services are:

90834: Psychotherapy 50 minutes with individual
90837: Psychotherapy 50 minutes with a couple
90846: Family psychotherapy 50 minutes without the patient present
90847: Family psychotherapy 50 minutes conjoining psychotherapy with the patient present
90849: Multiple-family group psychotherapy 50 minutes

Itemized list of goods or services reasonably expected to be provided in connection with the scheduled services: at STET, this would be the expected number of individual, couple, and family therapy sessions based on a description of the average client experience (i.e.,number of sessions, fee range).

Diagnostic codes, service codes, and expected charges associated with each of those goods or services. Before the first session or prior to the completion of a biopsychosocial assessment (i.e., usually within the first three sessions), it is impossible to provide clients with a specific disorder/ dysfunction diagnosis (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, etc.) on their documented good faith estimate. "Other Counseling or Consultation (V65.40)" is the diagnosis we use when clients do not meet the criteria for another diagnosis in the DSM, when clients have yet to complete their biopsychosocial assessment with their clinician, or when the primary topics discussed in treatment are not related to a specific disorder/ dysfunction diagnosis met by a client.

Provider name, NPI, and tax ID number (included above).

Office location where services will be provided. This may include in-person or telehealth sessions. (included above)

DISCLAIMER

The Good Faith Estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not obligate or require the client to obtain any of the listed services from the provider and does not include any unknown or unexpected costs that may arise during treatment. Clients could be charged more if complications or special circumstances occur. If this happens, federal law allows clients to dispute (appeal) the bill.

RIGHT TO DISPUTE

If clients are billed for more than their Good Faith Estimate, they have the right to dispute the bill. Clients may contact the clinician or facility listed on this document to let them know the billed charges are higher than the Good Faith Estimate. Clients can ask them to update the bill to match the Good Faith Estimate, as to negotiate the bill, or ask if there is financial assistance available. Clients may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).

If clients choose to use the dispute resolution process, they must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee (at last check) to use the dispute process. If the agency reviewing a client dispute agrees with the client, the client will have to pay the price on this Good Faith Estimate. If the agency disagrees with the client and agrees with the health care provider or facility, the client will have to pay the higher amount. To learn more and get a form to start the process, to go www.cms.gov/nosurprises or call (800)368-1019.

For questions or more information about client rights to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.