( OMB control #0938-1401)

“Surprise billing” is an unexpected or balanced bill. This can happen when you can’t control who is involved in your care. For example, you have an emergency or you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider ( usually in a healthcare setting).

*Applying the act at this practice *
-You only pay for what we agree upon…
*Counseling Services & Good Faith Estimate & No Surprises Act 

•A copy of your Good Faith Estimate for Services us typically offered to you in writing from this office ( usually in writing is our cost per session agreed to prior to service.
•At anytime, if prices as a whole ever change that would be
shared and discussed weeks before it would go into effect.
While working together, should you choose to add or change services to include other people or alter session time, those costs will be shared with you ( in writing & verbally ) prior to the next session.
If you are using insurance through my billing company they too must abide by this act.
please contact me with any questions.

Here are the other important points of this new patient protection act…

For your knowledge in healthcare settings : 

As a patient, you are now ( 2022) protected from balanced billing for: Emergency services …

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount.

This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections  not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up your protections.

When balance billing isn’t allowed, you also have the following protections:
• You are responsible for paying your share of the cost (copayments, coinsurance, and deductibles such that you’d pay in-network). Now, your health insurance will pay out-of-network providers and facilities.

Your health plan must:

•Cover emergency services by out-of-network providers

•Cover emergency services without requiring you to get approval for services in advance (prior authorization).

•Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and display that amount in their explanation of benefits statement.

Factor in any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket

If you believe that you’ve been billed, inaccurately, please contact: www.cms.gov/nosurprises

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf
for further information about your rights under Federal law.

Visit https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills for further information about your rights under New York State law.

Again much of this applies to medical care settings – please see the very top for counseling. You should never receive a surprise bill from this office thank you.