Good Faith Estimates and the No Surprises Act: A Therapist's Guide

If you see uninsured or self-pay clients, the No Surprises Act applies to you. Bomi handles the billing side so your self-pay charges go out cleanly once the estimate is in your client's hands.

Since January 1, 2022, the federal No Surprises Act has required health care providers — including mental health therapists in private practice — to give a written Good Faith Estimate (GFE) to clients who are uninsured or who choose not to use their insurance. This guide walks through who needs one, what it has to say, when it has to go out, and one point that trips up a lot of practices: a Good Faith Estimate is something you provide — it is not a contract your client has to sign.

What is the No Surprises Act?

The No Surprises Act is a federal law aimed at protecting patients from unexpected medical bills. Most of the public attention went to its rules on emergency care and out-of-network charges, but one provision applies squarely to outpatient mental health: any provider who treats uninsured or self-pay clients must give those clients a written estimate of expected costs before care. For a solo or group therapy practice, that estimate is the Good Faith Estimate.

What is a Good Faith Estimate?

A Good Faith Estimate is a written, itemized projection of what a client can expect to pay for your services when they are not billing insurance. It lists the services you expect to provide, the codes and charges associated with them, and a few required disclaimers. The point is simple: the client should know, up front and in writing, roughly what therapy with you will cost.

Which clients need a Good Faith Estimate?

A GFE is required for two groups:

• Uninsured clients — clients who do not have health coverage.

• Self-pay clients — clients who have insurance but choose not to use it for your services (for example, they prefer to pay out of pocket or you are out of network and they are not submitting claims).

If a client is using their insurance benefits for your services, the GFE requirement does not apply to that client — their cost-sharing flows through the plan instead.

When do you have to provide the GFE?

Timing is tied to when care is scheduled or requested:

• If services are scheduled at least 3 business days in advance: provide the GFE within 1 business day of scheduling.

• If services are scheduled at least 10 business days in advance: provide the GFE within 3 business days of scheduling.

• If a client simply asks for an estimate (no appointment yet): provide it within 3 business days of the request.

Because therapy is ongoing rather than a single visit, a GFE can cover recurring services for up to 12 months. You will need to issue a fresh estimate when that period ends, or sooner if the expected services or charges change materially.

What a Good Faith Estimate must include

At minimum, a compliant GFE should contain:

• The client's name and date of birth

• A description of the services you expect to provide (for example, an intake and ongoing individual psychotherapy)

• Itemized service codes (CPT) and applicable diagnosis codes, with the expected charge for each

• Your practice details: provider/practice name, NPI, tax ID (TIN), and the service location

• A total expected cost, plus any services that would need to be scheduled or estimated separately

• Required disclaimers: that this is an estimate and actual costs may differ, that the client has a right to dispute charges that exceed the estimate, and that the GFE is not a contract and does not obligate the client to obtain services.

A GFE is provided, not signed — and that's what lets you bill

This is the point that causes the most confusion, so it is worth stating plainly: under the No Surprises Act, the requirement is that the Good Faith Estimate is provided to the client in writing or electronically — it does not require the client's signature.

Many practices keep an internal sliding-scale or self-pay agreement that they like clients to sign. That document is the practice's own paperwork — it is good practice to have, but it is not your billing prerequisite. Once the GFE has been delivered to the client at the self-pay rate, you are clear to bill the self-pay sessions, whether or not the client has signed anything. There is no need to hold billing while you wait on a signature.

One nuance worth getting right: the trigger is the GFE being delivered to the client — not merely created and saved in your records. A GFE sitting on file that the client never received has not yet been “provided.” If you can confirm it reached the client, you are covered.

What if the final bill exceeds the estimate?

A Good Faith Estimate is an estimate, not a cap — but there is a guardrail. If a client is billed substantially more than the estimate — $400 or more above the total on the GFE — they can challenge the bill through the federal patient-provider dispute resolution process, generally within 120 days of getting the bill. The practical takeaway: keep your estimate realistic. If your client's needs change in a way that meaningfully changes cost, issue an updated GFE rather than letting the gap grow.

Common mistakes therapists make with GFEs

• Treating a signed self-pay agreement as a billing requirement. It isn't — the GFE provided in writing is the requirement.

• Creating a GFE but never actually delivering it to the client. Delivery is the trigger, not creation.

• Forgetting to re-issue. A GFE covers recurring care for up to 12 months; ongoing clients need a fresh one after that or when costs change materially.

• Assuming it only applies to the uninsured. Insured clients who choose to self-pay are covered too.

How Bomi helps

Bomi runs the billing side of a mental health practice end to end, including self-pay. We make sure your self-pay charges only go out once the Good Faith Estimate has been provided to the client — no held-up billing waiting on a signature that the law never required, and no charges going out ahead of the estimate. You stay compliant; your clients get a clear estimate; and the charges land on time.

This article is general information, not legal advice. For the authoritative rules, see the federal No Surprises Act guidance at cms.gov/nosurprises.

Have questions about self-pay billing or Good Faith Estimates for your practice? We're happy to help — reach us here https://www.billwithbomi.com/#contact.