Private Pay Therapy Needs More Than a Posted Session Price

Rachael Lara

Oct 12

2 min read

An estimate should describe the expected care

An MFT practice lists its session price on the website. A couple begins weekly appointments and assumes that price tells them everything they need to know about the cost. The practice still needs to determine whether a good faith estimate is required and explain the expected course of services.

CMS explains that uninsured patients and patients choosing not to use insurance usually must receive a good faith estimate when they schedule care at least three business days ahead or request an estimate. These protections under the No Surprises Act took effect January 1, 2022. This is a federal estimate requirement, separate from a payer's coverage decision or the practice's cancellation policy. [1]

A posted rate is useful, but it does not by itself explain the expected number of appointments or total charges.

Describe a realistic recurring arrangement

Ask whether the patient is using insurance for the proposed care. An insured person paying privately can fall within the self-pay estimate framework. Do not limit the intake question to whether the person has an insurance card.

For recurring services, CMS guidance permits one estimate covering a specified course of care for up to 12 months when it identifies the expected frequency, number of services, and time period. Care expected beyond that period needs a new estimate. [2]

For example, an anticipated weekly course of therapy should have a stated period and expected appointment count. Avoid implying that the clinician has committed the patient to treatment for the entire estimated period. An estimate describes expected charges; the clinical plan can change.

Keep the estimate aligned with the plan

Identify who prepares and delivers the estimate, where the copy is retained, and how changes are handled. When the expected scope or charges change, CMS guidance calls for a new estimate no later than one business day before the scheduled service. [2] Do not let an old intake document become the only cost explanation.

When family members participate, make the financial arrangement understandable. Explain whose service is being scheduled and which provider's charges are included. Do not invent separately treated patients or diagnoses to make a private-pay relationship service appear covered.

Give patients a way to ask about an estimate before charges accumulate. Keep estimates distinguishable from bills, receipts, and consent to treatment so patients know what each document means.

At Sunshyn, we want the financial conversation to happen while patients can make an informed choice. A usable estimate puts the expected services and charges in one place and gives the practice a clear reference when the arrangement changes.