Good Faith Estimate
No Surprises Act

NO SURPRISES ACT NOTIFICATION 

In compliance with the No Surprises Act (NSA) that went into effect January 1, 2022, all healthcare providers including psychiatrists and therapists are required to notify patients of their federal rights and protections against “surprise billing.” The purpose of the Act is to protect patients from unexpected medical bills. 

This Act requires that clinicians notify patients of their federally protected rights to receive a notification when services are rendered by an out-of-network psychiatrist, if you are uninsured, or if you elect not to use your insurance. 

As an out-of-network psychiatrist, Dr. Frische is required to provide a “Good Faith Estimate” of the cost of services rendered to patients who request this in advance to obtaining non-emergent services. This estimate of anticipated costs is particularly challenging in mental health care due to difficulty in diagnosing before evaluating a patient and predicting the length of treatment and appropriate appointment intervals in advance to exacerbations in psychiatric illness. The details of the Act and how it applies to small group private practices like Frische Psychiatry continues to develop.

Therefore, Frische Psychiatry describes below the fees that typically apply for the types of services offered. Dr. Frische is in constant collaboration with patients to determine appropriate services (length and interval of appointments). We will be as clear as possible with you about the costs of the services we agree on together. You will have “no surprises” here. You can ask us about any costs about which you may be unsure, and we will give you clear information. There will be no situation in which patients would accidentally receive care from Dr. Frische without choice. Patients of Frische Psychiatry are made aware of our fees and services at the onset of establishing care based on the general consent to treatment form which includes the up-to-date fee schedule and financial expectations. 

Insurance plans have changes that happen at the beginning of the calendar year or enrollment period which are not within the control of Frische Psychiatry, but can drastically impact your reimbursement for paid services from Frische Psychiatry. You should check with your insurance plan to get updates about any changes, such as the amount of your deductible or co-pay. Feel free to use the Insurance Out of Network Guide to compile information from your insurance as it applies to psychiatric services. 

GOOD FAITH ESTIMATE

• See the Frische Psychiatry Fee Schedule found within your signed general consent to treatment form for the most up-to-date comprehensive fee schedule

• These fees apply to all DSM diagnostic codes of the American Psychiatric Association.

• Dr. Frische uses diagnostic codes that are clinically accurate, but these do not guarantee reimbursement. 

• Dr. Frische typically recommends seeing patients within 4 to 6 weeks following any medication changes and within 3 to 6 months for patients on a stable prescription regimen.

• Most often treatment continues for six months, one year, or several years, but short-term, brief visits for intercurrent issues are also common. As noted above, because of this variability, please be sure to ask Dr. Frische any clarifying questions about what can be expected for your specific needs. 

• It is your right to determine your goals for treatment and how long you want to remain in treatment under Frische Psychiatry. 

• See example of Good Faith Estimate from Frische Psychiatry for new patient over 12 month period 

Required Disclaimers: 

• Should you have additional questions about your rights under this act, you can contact any of the following: The U.S. Centers for Medicare & Medicaid Services (CMS) at 1- 800-MEDICARE (1-800-633-4227) or visit <https.//www.cms.gov/nosurprises> for more information about your rights under federal law. The North Carolina Department of Insurance, Office of Consumer Health Insurance at 855-408-1212 or at https://www.ncdoi.gov/consumers/health-insurance 

• If you are billed for more than this Good Faith Estimate you have the right to dispute the bill. You may 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 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 Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider, you will have to pay the higher amount.

Your Rights and Protections Against Surprise Medical Bills 

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible. 

What is “balance billing” (sometimes called “surprise billing”)? 

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. 

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit. 

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service. 

You’re protected from balance 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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. 

[Insert plain language summary of any applicable state balance billing laws or requirements OR state-developed language as appropriate] 

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 can 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 types of 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. 

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network. 

[Insert plain language summary of any applicable state balance billing laws or requirements OR state-developed language regarding applicable state law requirements as appropriate] 

When balance billing isn’t allowed, you also have these protections: 

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. 

• Generally, your health plan must: 

o Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”). 

o Cover emergency services by out-of-network providers. 

o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. 

o Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit. 

If you think you’ve been wrongly billed, contact 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.