No Surprises Act — Your Rights & Protections

1. What Is the No Surprises Act?

The No Surprises Act is a federal law that protects patients from unexpected medical bills. It was originally enacted as part of the Consolidated Appropriations Act of 2021 and took effect on January 1, 2022, with ongoing regulatory updates through 2026 from the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS).

This law was created because many patients were receiving surprise bills for medical services, particularly when they unknowingly received care from out-of-network providers. The No Surprises Act addresses this problem by establishing clear protections and cost transparency requirements.

Key points about the No Surprises Act:

• It is a federal law that applies to health care providers across the United States, including mental health providers like our practice.
• It protects both insured and uninsured or self-pay patients, though the specific protections differ depending on your insurance status.
• For insured patients, it provides protections against surprise billing for emergency services and certain out-of-network services received at in-network facilities.
• For uninsured or self-pay patients, it requires providers to give you a Good Faith Estimate of expected charges before you receive services.
• It establishes a dispute resolution process if your final bill significantly exceeds the estimate you were given.

2. Your Rights Under the No Surprises Act

Under the No Surprises Act, you have the following rights as a patient:

3. Good Faith Estimate (GFE)

The Good Faith Estimate is one of the most important provisions of the No Surprises Act for patients of an outpatient mental health practice. This section explains what a GFE is, when you will receive one, what it includes, and your rights related to it.

What Is a Good Faith Estimate?

A Good Faith Estimate is a written document that provides you with an estimate of the expected charges for mental health services you are scheduled to receive. It is designed to help you understand your expected costs before your care begins so there are no financial surprises.

The GFE is provided to patients who are uninsured (do not have health insurance) or who are choosing to self-pay (have insurance but choose not to use it for their mental health services). If you have insurance and plan to use it, your cost-sharing is determined by your insurance plan, and the GFE process works differently (see Section 4).

When Will You Receive a Good Faith Estimate?

You will receive a Good Faith Estimate in the following situations:

• When you schedule a service at least 3 business days in advance: We are required to provide you with a GFE before your scheduled service.
• When you request one: You have the right to request a Good Faith Estimate at any time, and we will provide one to you.

The timing for providing the GFE depends on when your service is scheduled:

What Is Included in a Good Faith Estimate?

Your Good Faith Estimate will contain the following information:

• Expected charges: The estimated total cost for the mental health services you are scheduled to receive.
• Provider information: The name of the practice (Paula S. Gordy LISW, LLC), the National Provider Identifier (NPI), and the Tax Identification Number (TIN).
• Diagnosis codes: If applicable, the diagnosis codes associated with your treatment.
• Service codes and descriptions: The specific billing codes (CPT codes) and plain-language descriptions of the services to be provided (for example, individual psychotherapy, 45-minute session).
• Expected service dates and frequency: The anticipated dates, number of sessions, and frequency of your mental health services.
• Disclaimer about estimates: A clear statement that the GFE is an estimate and that actual charges may differ if the scope of services changes.

Your Rights Related to the Good Faith Estimate

Your rights related to the Good Faith Estimate include:

• You can dispute the bill through the patient-provider dispute resolution process if the final charges exceed the GFE by $400 or more.
• You can initiate dispute resolution by contacting the U.S. Department of Health and Human Services (HHS) at 1-800-985-3059.
• You must initiate the dispute within 120 calendar days of receiving the bill in question.
• You have the right to request a new GFE at any time if your treatment plan changes or if you want an updated estimate.

Good Faith Estimate for Recurring Mental Health Services

Because mental health treatment often involves recurring sessions over an extended period, the No Surprises Act includes specific provisions for ongoing care:

4. For Insured Patients

If you have health insurance and use it for your mental health services at our practice, the following applies:

• In-network cost-sharing: If we are a participating (in-network) provider with your insurance plan, your out-of-pocket costs (copays, coinsurance, deductible amounts) are determined by your specific insurance plan. We will verify your benefits before your first appointment whenever possible.
• Protection from balance billing: For in-network services, you are protected from balance billing. This means we cannot bill you for the difference between our billed charges and what your insurance pays, beyond your plan's required cost-sharing.
• Self-pay option with GFE: Even if you have insurance, you may choose to pay for services yourself (self-pay) and not use your insurance benefits. In this case, you may request a Good Faith Estimate, and all of the GFE rights described in Section 3 apply to you.

5. For Uninsured or Self-Pay Patients

If you do not have health insurance or if you choose not to use your insurance for your mental health services, you have specific rights under the No Surprises Act:

• Right to a Good Faith Estimate: You have the right to receive a Good Faith Estimate of expected charges before you receive any mental health services from our practice. You do not need to ask for this; we will provide it automatically when you schedule an appointment. However, you may also request one at any time.
• Right to dispute bills exceeding the GFE: If your actual bill is $400 or more above the amount listed on your Good Faith Estimate, you have the right to dispute those charges.
• Patient-provider dispute resolution: The dispute resolution process is administered by the U.S. Department of Health and Human Services (HHS). You can initiate a dispute by contacting the CMS No Surprises Help Desk.

6. Dispute Resolution Process

If your final bill exceeds your Good Faith Estimate by $400 or more, the following step-by-step process is available to you:

7. Provider Information

The following information identifies our practice as required under the No Surprises Act:

Practice Locations

8. How to Get More Information

If you have questions about the No Surprises Act, your Good Faith Estimate, or your rights as a patient, the following resources are available to you:

9. Notice Regarding Mental Health Services

Mental health treatment is unique in that the duration and scope of care can be difficult to predict at the outset. Unlike many medical procedures with defined start and end points, therapy is an ongoing process that responds to your individual progress and needs.

We want you to be aware of the following as it relates to cost estimates for mental health services:

• Treatment duration is difficult to predict: The length of mental health treatment varies greatly from person to person. Some individuals may benefit from short-term therapy, while others may need longer-term support. Your Good Faith Estimate is based on the treatment plan in place at the time the estimate is provided.
• Estimates are based on current treatment plans: Your GFE reflects the services and frequency outlined in your current treatment plan. If your treatment needs change, the estimate may no longer accurately reflect your expected costs.
• Changes in diagnosis or treatment needs may affect costs: As therapy progresses, your provider may identify additional needs, adjust your diagnosis, or recommend changes to the type or frequency of services. Any of these changes could affect the total cost of your care.
• Updated estimates provided when plans change: If there is a significant change to your treatment plan, we will provide you with an updated Good Faith Estimate so that you have current information about your expected costs.
• Open communication about costs is encouraged: We believe you should never feel uncertain about the cost of your care. We encourage you to ask questions about billing at any time. Our staff is available to discuss your current charges, provide updated estimates, and help you understand your financial responsibility.