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Right to Receive a Good Faith Estimate of The Expected Charged”Under the No Surprise Act

Right to Receive a Good Faith Estimate of Expected Charges Under the No Surprise Act

APCSFL
Location: 160 Ave E NW, Winter Haven, FL 33881 or via Telehealth
Phone: (863) 888-0808
Email: info@apcsfl.com
Website: https://www.apcsfl.com

Main Purpose:
APCSFL primarily focuses on testing for disability and surgical readiness, such as for bariatric surgery or spinal cord stimulation. Therapy for counseling is not provided at the moment.

Under Section 2799B-6 of the Public Health Service Act, health care providers and facilities must inform individuals who are not enrolled in a health plan or coverage, or a Federal health care program, and those who are not seeking to file a claim with their plan or coverage, both orally and in writing, of their right to receive a “Good Faith Estimate” of expected charges. This estimate is available upon request or at the time of scheduling health care items and services.

What is a Good Faith Estimate?

A Good Faith Estimate provides a detailed breakdown of expected charges for medical services, allowing patients to understand the potential costs before receiving care. This transparency helps individuals plan for their medical expenses and avoid unexpected bills.

Brief Explanation of the Estimate for New Patients:

The estimate provided below outlines the likely range of costs for most patients undergoing therapy. The frequency of therapy sessions varies based on individual needs and treatment recommendations. Since therapy is a voluntary process, the frequency of sessions is determined collaboratively between the client and the provider.

• Highest frequency: Once a week
• Most common frequency: Twice a month

Example Cost: If you attend therapy twice a month for one year, your total cost will range from $2,000 to $3,000. This range represents the estimated cost for the care of our clients, although the number of sessions required may vary as treatment progresses.

Details of the Estimate

The following is a detailed list of expected charges for common therapy services:

• 90791: Mental health diagnostic evaluation — $100 to $160
  

  Type of Evaluation	Expected Timeframe
  Neuropsychological evaluations (inclusive of time for administration, scoring, interpretation and report write-up)	8 hours
  Psychological testing to determine readiness for a medical procedure (i.e. bariatric surgery, spinal cord stimulation)	3-4 hours
  Psychological testing to diagnose uncomplicated Attention-Deficit/Hyperactivity Disorder (combination presentation, predominantly inattentive or hyperactive/impulsive presentation). Neuropsychological testing for Attention Deficit/Hyperactivity Disorder is indicated only when there is remarkable evidence of medical or neurological history.	3-4 hours

  Additional Information:

  • Psychological or neuropsychological testing is limited to once per calendar year. More than one claim submission for testing per year may be subject to medical records and a medical necessity review.
  • A minimum of 16 minutes must be provided to report a 30-minute code.
  • A minimum of 31 minutes must be provided to report any per-hour code.

Please note: Each medical plan has different rates. The costs listed are for your benefit as an estimate, but the final price will be provided with a document titled Good Faith Estimate prior to the evaluation for cash payers.

Cost Psychological Evaluations

The following is a list of the most common psychological evaluations performed at our office and their costs:

• Comprehensive Psychoeducational Assessment: $1,500
• Comprehensive Autism Evaluation: $2,000
• Comprehensive ADHD Evaluation: $1,000 to $1,300
• Intellectual Disability Assessment: $800 to $1,000
• Personality Assessment / Basic Psychodiagnostic Evaluation: $600

Total estimated cost for an evaluation will depend on the type of evaluation.

Surgical Readiness or   Surgical Clearance

• Surgical Psychological Evaluation: $500 to $750

The cost for surgical clearance can vary due to the individual nature of each case. Factors influencing this variability include the complexity of the evaluation, the specific requirements of the surgical procedure, and any additional assessments that may be necessary.

Individuality of Each Case

Each client’s therapeutic journey is unique, and treatment plans are tailored to meet individual needs. This personalized approach means that therapy frequency, duration, and specific services required can vary significantly from one client to another. The provided estimates reflect common scenarios, but actual costs may differ based on:

• Client’s specific needs: Individual treatment plans are developed based on a comprehensive assessment of the client’s mental health and personal circumstances.
• Treatment progress: The number of sessions and types of services required can change as treatment progresses, responding to the client’s evolving needs.
• Collaborative decision-making: Therapy is a voluntary process, and the frequency and duration of sessions are decided in collaboration between the client and the provider, ensuring that the treatment plan remains flexible and responsive to the client’s goals.

Informed Consent

All therapy processes at APCSFL will begin with obtaining the client’s prior signed consent. This ensures that clients are fully informed about the nature of their treatment, the expected costs, and their rights and responsibilities. Informed consent is a crucial step that involves:

• Explanation of services: Clients receive a detailed explanation of the therapy services offered, including the potential benefits and risks.
• Cost estimates: Clients are provided with a Good Faith Estimate of the expected charges for their therapy, ensuring transparency in financial matters.
• Voluntary participation: Clients acknowledge that therapy is a voluntary process, and they have the right to accept or decline services.
• Agreement to treatment: Clients provide written consent indicating their understanding and agreement to participate in the proposed therapy plan.

Disclaimer

This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to us when we did the estimate.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill.

You may contact the psychology practice at the contact listed above to let them know the billed charges are at least $400 higher than the GFE. You can ask them to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to: www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

This GFE is not a contract. It does not obligate you to accept the services listed above.

Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above.