January 27, 2022 | By AATA National Office Staff with Special Thanks to AATA Member Mike Fogel, MA, ATR-BC, LPC, for contributing his significant research on this subject.
The No Surprises Act was signed into law in December 2020 with the intention of protecting health care consumers from “surprise medical bills” and ensuring transparency of charges for patients across clinical settings. Beginning January 1, 2022, health care providers, including art therapists, are required by law to provide uninsured and self-pay clients a Good Faith Estimate of costs for services when they schedule care or when requested.
This document offers a summary and answers some questions art therapists may have about the law.
AATA is working on providing additional expertise to our members on the No Surprises Act. We expect federal agencies will issue additional guidance in response to questions that arise from health care providers as they implement the new requirements. We will monitor and provide comments on additional regulations as they are issued. AATA and our coalition partners will continue to advocate for improvements to the law, especially as they pertain to mental health services and art therapy.
If you have additional questions, please contact Tyler Kirby, AATA’s Policy and Public Affairs Manager, at firstname.lastname@example.org or connect with AATA on the MyAATA Member Community.
About the No Surprises Act
There are two parts to the No Surprises Act of 2020. The first part addresses hospital and institutional billing declarations and largely does not directly impact art therapists’ work. The second part of the No Surprises Act affects some art therapists, specifically if you are in private practice, working with clients who self-pay and don’t seek insurance reimbursement. Those art therapists will need to provide such clients with a Good Faith Estimate (GFE).
Ultimately, a Good Faith Estimate is a document predicting estimated costs for services that art therapists accepting private payment must provide to prospective clients when scheduling their first session. A Good Faith Estimate cannot cover a period greater than 12 months, and would need to be generated annually for ongoing clients.
The No Surprises Act also allows clients the right to initiate dispute resolution in cases where the actual costs for services exceed the latest GFE by over $400.
What is my responsibility regarding the Good Faith Estimate?
- You need to ask each client whether they have insurance and whether they intend to use it to cover your services. If the answer to either question is no, they need a Good Faith Estimate.
- You need to inform every uninsured or self-pay client of their right to receive a Good Faith Estimate both verbally and in writing.
- If the GFE is delivered electronically, it must be provided in a format that the client can save and print if they wish
- A Good Faith Estimate should be provided in connection with the scheduling of a service, and also upon request.
- For clients receiving long-term or ongoing services, a Good Faith Estimate should be completed every 12 months, to cover the next 12 months of planned or potential services.
Which clients must receive Good Faith Estimates (GFEs)?
Private practice art therapists should ask potential clients whether they intend to pay for therapy through insurance during the initial consultation, before scheduling their first therapy session. If a client intends to invoice an insurance plan, this law does not apply, and you do not need to create a GFE.
When a prospective client states that they will not be submitting claims for insurance reimbursement and will pay out of pocket, you are required by law to send them a Good Faith Estimate.
When is Good Faith Estimate given?
- If a service is scheduled at least 10 business days in advance, the Good Faith Estimate must be provided within 3 business days. (This is within 3 business days of the scheduling, not of the appointment itself.)
- If a service is scheduled at least 3 business days in advance, the Good Faith Estimate must be provided within 1 business day of scheduling.
- If a service is scheduled less than 3 business days in advance, a Good Faith Estimate is not required.
- If an individual requests a Good Faith Estimate, it must be provided within 3 business days.
What must be included in a GFE?
A Good Faith Estimate (GFE) must be provided in writing, and include:
- Client name
- Client date of birth
- Description of the services that will be provided, in understandable language
- Itemized list of goods or services reasonably expected to be provided in connection with the scheduled services
- Diagnostic codes, service codes, and expected charges associated with each of those goods or services
- Provider name, NPI, and tax ID number
- Office location where services will be provided
Refer to this CMS document, page 6, for additional information about what must be included in the GFE.
Crucially, you must state your fees and estimate the number of sessions. In other words, it is not enough to just provide your rate per session. The GFE needs to include the rates per session of the service you expect to provide to the client, as well as the projected number (or range, e.g. 8 – 12 sessions) and frequency of sessions. You may provide a single estimate for total services you anticipate providing if you expect to see that client at the same frequency over a period of time, up to 12 months.
The charges in your GFE must be within $400 for the period for which you are estimating. A GFE can estimate costs for only one session, several sessions, or any length of time you deem appropriate, up to 12 months. Good faith means that you must not inflate charges to pad the number of sessions or costs to avoid exceeding the estimated amount. As treatment changes in frequency or structure to meet clients’ needs, you can update GFEs to accurately notify clients of changes in expected charges and should do so before the date of the next scheduled session.
You would need to update the GFE if the client originally came in with a mild diagnosis, but you later discovered an additional diagnosis with a longer course of treatment. If you feel you have made a mistake in your Good Faith Estimate, you should provide a corrected estimate as soon as practicable. If the services have already been provided, you should provide the client with an updated estimate as soon as practicable, at least prior to their next session. However, a client may still initiate the dispute resolution process in the No Surprises Act if the total amount you charged the client is at least $400 more than the charges listed in the estimate.
At this point, the GFE requirement does not appear to carry any direct monetary penalties or fines for noncompliance.
What are my responsibilities in informing clients about the new law?
Clients must be informed of their right to receive a Good Faith Estimate. This can be achieved by publicly posting this message both in your office and on any website where clients can schedule appointments.
What does the patient-provider resolution process entail?
The GFE may be used by the client to initiate a dispute resolution process if billed charges exceed the GFE by $400. The patient has 120 days to initiate the dispute process after receiving the bill. You can find a timeline of the patient-provider resolution process as provided by CMS in this document.
What should I expect around enforcement of this new law?
Potential penalties for violation of this law are fines of up to $10,000 per occurrence. Current guidance around enforcement suggests that the government will not be penalizing practitioners under this law for at least a year. At this point, the GFE requirement does not appear to carry any direct monetary penalties or fines for noncompliance.
- Good Faith Estimate (GFE) and Notice Templates
- CMS-10791 (ZIP)
- Inside the ZIP file linked above, find these two documents that might be useful:
- CMS-10791 – Right to Receive a Good Faith Estimate of Expected Charges Notice.pdf
- CMS-10791 – Good Faith Estimate Template Notice.pdf
- CMS-10791 (ZIP)
- The American Health Law Association may provide referrals for local healthcare lawyers.
- CMS’s landing page for guidance regarding the No Surprises Act
- CMS’s FAQ page about the No Surprises Act
This post does not, and is not intended to, constitute legal advice. Our aim in this post, and all the content and materials we offer on our website, is to provide general information.