Good Faith Estimates for Therapists: What the No Surprises Act Requires

The No Surprises Act went into effect on January 1, 2022, and it changed the compliance landscape for every therapist who sees self-pay clients. At the center of the law is a requirement that most solo therapists know they should be following but few feel confident they are getting right: the Good Faith Estimate.

If you are a cash-pay therapist -- or if you see any clients who are paying out of pocket, even in an otherwise insurance-based practice -- this applies to you. The requirements are not optional, the penalties are real, and the good news is that compliance is straightforward once you understand what the law actually requires.

This guide covers the what, when, and how of Good Faith Estimates so you can stop guessing and start documenting with confidence.

What Is a Good Faith Estimate?

A Good Faith Estimate (GFE) is a written document that tells a self-pay or uninsured client how much their care is expected to cost. It is exactly what the name suggests: your honest, good-faith projection of the total charges they will incur.

The purpose is transparency. Before the No Surprises Act, a client could begin therapy with no clear understanding of what it would cost over the course of treatment. They might know the per-session rate, but not how many sessions to expect, whether assessment fees apply, or what additional charges might come up. The GFE eliminates that ambiguity.

Who It Applies To

The GFE requirement applies to all healthcare providers, including therapists and counselors, when seeing:

• Uninsured clients who do not have any health coverage
• Self-pay clients who have insurance but choose not to use it for your services

If a client has insurance and you are billing their insurance, the GFE requirements do not apply to that client (different surprise billing protections cover insured patients). But for cash-pay therapists, that means the GFE applies to virtually every client you see.

The Legal Basis

The No Surprises Act (Public Law 116-260, Division BB, Title I) was signed into law in December 2020 and took effect January 1, 2022. The GFE requirements are outlined in Section 112 of the Act. The Centers for Medicare and Medicaid Services (CMS) issued implementing regulations, and enforcement is handled by CMS and state regulators.

This is federal law. It applies in all 50 states regardless of your state licensing board's specific requirements (though some states have additional price transparency laws that may go further).

When Do You Have to Provide a Good Faith Estimate?

The timing requirements are specific and worth understanding clearly.

For Scheduled Services

You must provide a GFE:

• Upon scheduling: When a client schedules a service, you must provide the GFE within specified timeframes
• If the service is scheduled at least 3 business days in advance: Provide the GFE within 1 business day of scheduling
• If the service is scheduled at least 10 business days in advance: Provide the GFE within 3 business days of scheduling

For most therapists, this means you should provide the GFE when a new client books their first appointment. If someone calls on Monday to schedule an intake for Thursday, you need to get the GFE to them by Tuesday.

Upon Request

Any uninsured or self-pay client can request a GFE at any time, even before scheduling. You must provide it within 3 business days of the request.

When the Estimate Changes

If your expected charges change significantly -- say you determine that the client needs more sessions than originally estimated, or you raise your rates -- you should provide an updated GFE. The regulations require a new GFE if the scope of services changes.

Practical Reality for Therapists

Here is where therapy creates a unique challenge. Unlike a surgeon who can estimate "one procedure, one follow-up," therapy is ongoing and open-ended. You do not always know on day one how many sessions a client will need.

The regulations account for this. You are expected to estimate expected charges for the next 12 months of care based on your clinical judgment. This is genuinely a "good faith" estimate -- you are not guaranteeing a total cost, you are providing a reasonable projection based on what you know at the time.

If you typically see a new client weekly for the first three months, then biweekly for three months, then monthly for six months, your GFE should reflect that expected trajectory. You can update it if the treatment plan changes.

What Must a Good Faith Estimate Include?

The GFE has specific required elements. Missing any of them puts you out of compliance.

Required Information

About you (the provider):

• Your name and National Provider Identifier (NPI)
• Your Tax Identification Number (TIN)
• Your practice location and contact information

About the client:

• Client name and date of birth

About the services:

• A description of each item or service being provided
• The diagnosis code(s), if applicable (note: for therapy, you may not have a definitive diagnosis at intake -- use the best available code or a provisional diagnosis)
• The expected charge for each item or service
• The date or expected date range for each service

About the estimate itself:

• The date the GFE was issued
• A disclaimer that the GFE is an estimate, not a contract, and actual charges may differ
• Information about the client's right to dispute a bill that exceeds the GFE by $400 or more

What This Looks Like in Practice

For a solo therapist, a typical GFE might look like:

Service: Individual psychotherapy (CPT 90837 -- 53+ minutes)

• Rate: $175 per session
• Expected frequency: Weekly for 12 weeks, then biweekly for 12 weeks, then monthly for 6 months
• Estimated number of sessions over 12 months: 30
• Estimated total cost over 12 months: $5,250

Service: Initial diagnostic evaluation (CPT 90791)

• Rate: $200
• Expected frequency: One time
• Estimated total cost: $200

Estimated total for 12 months of care: $5,450

This is not a binding contract. It is a projection. If the client improves faster than expected and terminates at session 15, they do not owe you for 30 sessions. If treatment takes longer, you provide an updated estimate.

The $400 Dispute Threshold

This is the enforcement mechanism that gives the GFE its teeth. If a client's actual bill exceeds the GFE by $400 or more, they have the right to dispute the charge through a patient-provider dispute resolution (PPDR) process.

For therapists, this typically comes into play when:

• You significantly increase your rates without providing an updated GFE
• Treatment extends well beyond your original estimate without communication
• Additional services are provided that were not included in the original estimate

The simplest way to avoid disputes: communicate rate changes in advance, update the GFE when the treatment plan changes, and keep your estimates reasonable.

How to Create Your Good Faith Estimate

You do not need a fancy form or expensive compliance software. What you need is a clear, complete document that covers all the required elements.

Option 1: CMS Standard Form

CMS has published a standard GFE form that you can use. It is designed for all healthcare providers, so some fields will feel more relevant to hospitals than to solo therapists. But using the standard form is the easiest way to ensure you are not missing any required elements.

You can find the standard form on the CMS website by searching for "Good Faith Estimate standard form" or "No Surprises Act patient forms."

Option 2: Custom Template

Many therapists create their own GFE template that includes all the required elements in a format that feels more natural for a therapy practice. This is perfectly acceptable as long as every required element is present.

A good custom template includes:

1. Header: Your practice name, logo, address, phone, NPI, and TIN
2. Client section: Name, date of birth, date of GFE
3. Services table: Each service listed with CPT code, description, per-session rate, expected frequency, and projected cost
4. 12-month total estimate
5. Disclaimers: That this is an estimate; actual costs may differ; the client has the right to dispute charges exceeding the GFE by $400 or more; the GFE does not require the client to obtain the services listed
6. Dispute rights notice: Instructions for how to initiate a dispute (HHS contact information)
7. Signatures: Space for both provider and client signatures and date

Option 3: EHR-Generated Estimates

Some practice management platforms can generate GFEs automatically based on your session rates and treatment plan. This is the most efficient approach because it pulls from data you have already entered -- your fee schedule, session type, and the client's treatment parameters.

TherapyDesk, for instance, is designed for cash-pay solo therapists and includes tools for generating compliant documentation based on your practice settings, so you are not recreating the wheel for every new client.

Whatever method you use, the key is consistency. Create a template once, use it for every self-pay client, and update it when circumstances change.

Delivery Requirements

Creating the GFE is only half the equation. You also need to deliver it properly.

Acceptable Delivery Methods

The GFE can be provided:

• In person (printed copy)
• By mail (physical copy)
• Electronically (email, client portal, secure messaging)

Electronic delivery is fine as long as the client has consented to receive communications electronically. For most therapists using a client portal, this is already established.

Documentation

You need to be able to demonstrate that you provided the GFE. Keep records of:

• When the GFE was created
• When and how it was delivered to the client
• Client acknowledgment (signature or electronic confirmation)
• Any updated GFEs and their delivery dates

Language and Accessibility

The GFE must be provided in a manner the client can understand. If you serve clients with limited English proficiency, you may need to provide translated versions or interpretation services. The estimate should be written in plain, accessible language -- avoid dense legal jargon.

Common Scenarios and How to Handle Them

New Client Intake

Scenario: A new client calls and schedules their first appointment for next week.

Action: Provide the GFE before or at the first session. Include the intake/assessment session and your projected treatment plan based on what you know from the initial phone consultation. If you do not have enough information to project a full treatment plan, estimate based on your typical treatment duration for the presenting concern.

Client Wants to Switch from Insurance to Self-Pay

Scenario: An existing client decides to stop using insurance and pay out of pocket.

Action: Provide a GFE covering the expected remaining course of treatment. Their status has changed to self-pay, which triggers the GFE requirement.

Rate Increase

Scenario: You are raising your session rate from $150 to $165.

Action: Provide an updated GFE to all current self-pay clients reflecting the new rate and updated total estimate. Do this before the rate change takes effect.

Client Needs Additional Services

Scenario: You determine that a client would benefit from adding a psychological assessment or group therapy session that was not included in the original estimate.

Action: Provide an updated GFE that includes the new services and revised total estimate.

Sliding Scale Clients

Scenario: You offer a reduced rate to a client based on financial need.

Action: The GFE should reflect the actual rate the client will pay, not your standard rate. If the sliding scale rate is $100 per session, that is what goes on the GFE.

Couples or Family Therapy

Scenario: You are providing couples therapy at a higher per-session rate than individual therapy.

Action: The GFE should list the specific service (couples therapy, CPT 90847) with the corresponding rate. If you anticipate a mix of couples and individual sessions, list both with their respective rates and estimated frequencies.

Penalties for Non-Compliance

The No Surprises Act includes enforcement mechanisms, and while CMS has been focused on education rather than aggressive enforcement in the early years, the penalties exist and the regulatory landscape is maturing.

What Can Happen

• CMS enforcement actions: CMS can impose penalties of up to $10,000 per violation for providers who fail to provide GFEs.
• State-level enforcement: Many states have their own price transparency laws with additional requirements and penalties.
• Patient disputes: Clients can initiate dispute resolution if billed more than $400 over the GFE. If the dispute is found in the client's favor, you may have to adjust the bill.
• Reputational risk: As clients become more aware of their rights under the No Surprises Act, failure to provide GFEs can damage trust.

The Realistic Risk Level

For solo therapists operating in good faith, the risk of a $10,000 penalty is low. CMS enforcement has focused primarily on larger providers and egregious violations. But the client dispute process is real and accessible, and therapists who significantly under-estimate costs without updating GFEs are exposed.

The simplest risk mitigation: just do it. The time investment is minimal once you have a template, and the compliance benefit is substantial.

Building GFEs into Your Intake Workflow

The easiest way to stay compliant is to make the GFE part of your standard intake process, not a separate compliance task you have to remember.

Recommended Workflow

1. During scheduling: When a new self-pay client schedules their first appointment, generate the GFE based on your standard rates and typical treatment duration
2. Before the first session: Send the GFE via your client portal along with other intake paperwork (consent forms, practice policies, demographic form)
3. At intake: Review the GFE briefly with the client. Confirm they understand it is an estimate and that they have the right to dispute charges exceeding it by $400 or more
4. Client signature: Have the client sign and date the GFE (electronic signatures count)
5. File and retain: Store the signed GFE in the client's record
6. Update as needed: If the treatment plan changes significantly or you raise rates, generate and deliver a new GFE

Making It Automatic

The less you have to think about GFEs, the more consistently you will provide them. If your practice management system can auto-generate estimates based on your fee schedule and treatment parameters, that removes the friction entirely.

Set up your system so that a GFE is automatically created as part of the new client intake packet. When you send intake paperwork, the GFE goes with it. When the client completes their portal intake, the GFE is signed along with everything else.

Frequently Asked Questions

Do I need to provide a GFE if the client has insurance but chooses not to use it?

Yes. If the client is self-paying for your services -- regardless of whether they have insurance -- you must provide a GFE. The trigger is self-pay status, not insurance status.

What if I genuinely do not know how long treatment will take?

Estimate based on your clinical experience with similar presentations. A good-faith projection is exactly that -- good faith. If you typically see anxiety clients for 16-20 sessions, use that range. You can always update the estimate as treatment progresses.

Do I need a new GFE for every session?

No. The GFE covers the expected course of treatment. You only need to update it when the scope, frequency, or cost of treatment changes significantly.

What CPT codes should I use?

The most common for individual therapy:

• 90791: Diagnostic evaluation (intake)
• 90834: Individual therapy, 38-52 minutes
• 90837: Individual therapy, 53+ minutes
• 90847: Family/couples therapy with client present
• 90846: Family therapy without client present

Use the codes that reflect the services you actually provide.

Can I include the GFE in my informed consent document?

You can include it in the same packet, but the GFE should be a distinct, identifiable document -- not buried in paragraph 47 of your consent form. The client needs to be able to clearly identify it as their cost estimate.

What if the client refuses to sign the GFE?

Document that you provided the GFE and the client declined to sign. Your obligation is to provide it, not to force acknowledgment. Note the refusal in the client's record.

Do telehealth sessions require a GFE?

Yes. The delivery method of therapy does not change the GFE requirement. If the client is self-pay, they get a GFE whether sessions are in-person or virtual.

Staying Compliant Without Losing Time

Good Faith Estimates are one of those compliance requirements that feel burdensome when you first learn about them but become trivial once systematized. The key is building it into your existing workflow rather than treating it as a separate administrative task.

Create your template once. Include it in your intake packet. Update it when things change. That is genuinely all it takes.

If you are looking for a practice management platform that handles GFE documentation alongside scheduling, billing, and clinical notes -- all designed for cash-pay solo practice -- take a look at TherapyDesk. But regardless of what tools you use, the compliance steps above will keep you on the right side of the No Surprises Act with minimal ongoing effort.

Your clients deserve cost transparency. The law requires it. And once your process is set up, it takes less time than writing a single progress note.