Good Faith Estimates for therapy practices: what is required and how to send them

Under the No Surprises Act, practices must provide uninsured and self-pay clients with a written Good Faith Estimate of expected charges before scheduled care, upon request, or at scheduling. For ongoing therapy, that usually means an estimate covering a period of sessions rather than a single visit. Most practices write them by hand; the document can be generated from information already collected at intake.

TL;DR

• Uninsured and self-pay clients are owed a written Good Faith Estimate, on request and when care is scheduled.
• The estimate itemizes expected charges, includes provider details and required disclaimers, and any bill at least $400 over it can be disputed.
• Ongoing therapy is the case the rules fit worst, and handling it well is where a practice shows its competence.
• Keep a copy and a delivery record; the estimate matters most when someone asks about it later.
• Keragon can generate and deliver the estimate from intake data without code, with a person reviewing before it goes out.

What is a Good Faith Estimate?

A Good Faith Estimate is a written, itemized estimate of the expected charges for scheduled non-emergency care that the No Surprises Act requires providers to give to clients who are uninsured or who choose not to use their insurance. It is based on what is known at the time it is created; it is an estimate rather than a contract, and it carries a client right that gives it teeth: a final bill at least $400 above the estimate can be taken to the patient-provider dispute resolution process (CMS).

The requirement took effect in January 2022, and it lands squarely on therapy: private-pay caseloads are common in this field for reasons clients choose deliberately, from network gaps to privacy preferences, which means many practices owe estimates to most of their caseload rather than an occasional edge case. Framed properly, that is not a burden but an opening: the estimate is a plain-money conversation at exactly the moment cost anxiety keeps people from starting care, and a practice that handles it cleanly signals it will handle everything else cleanly too.

One disambiguation, because the same phrase lives in two industries: in mortgage lending, a Good Faith Estimate was the loan-cost disclosure form retired in 2015 in favor of the Loan Estimate. If you arrived here about a mortgage, this is the other one. This article is about the healthcare document only.

Who has to receive one, and when?

Two groups: clients with no insurance, and clients who have insurance but choose not to submit the care to their plan. The second group is the one practices miss, and in therapy it is large: a client with excellent employer coverage who self-pays for privacy is owed an estimate exactly as an uninsured client is. The obligation depends on how the care is paid, not on whether coverage exists.

The common confusion, answered generally: an out-of-network client who does not submit claims is owed an estimate. Sliding-scale arrangements do not remove the obligation; the estimate simply reflects the agreed rate. A client who switches from insurance to self-pay mid-treatment becomes owed one at that point. And where care involves multiple providers, current enforcement has focused on each provider's own estimate; check current CMS guidance for the co-provider rules, which have shifted before.

Timing runs from scheduling and from requests, with the windows tightening as the appointment approaches:

Confirm the current windows at CMS when you set your template. The practical reading for a therapy practice: build the estimate into intake and scheduling rather than treating it as a separate task, and the deadlines take care of themselves, because the estimate goes out with the welcome paperwork before any clock gets tight.

What must the estimate include?

The required contents map cleanly onto information a therapy practice already holds, which is what makes this automatable at all:

Two practical notes. Keep the disclaimers in the template text aligned with current CMS language rather than rewritten per estimate; the substance changes per client, and the required language should not. And write the service description for the client, not the coder: "weekly 50-minute individual psychotherapy sessions" does the legal and reassurance jobs at once, whereas a bare code string does neither.

How this works for ongoing therapy, not a one-off procedure

The rules were designed around discrete procedures, and therapy is the case they fit least well: recurring, open-ended, and with the number of sessions a clinical judgment that changes as the work unfolds. This section is where generic Good Faith Estimate content fails therapists, because it simply has nothing to say.

The workable pattern for recurring care: issue an estimate covering a defined period, stating the expected frequency and rate, with the period and totals explicitly stated. Current guidance permits a single estimate to cover recurring services for up to 12 months, with a new estimate thereafter or when the expected scope changes; confirm the current rule with CMS before setting your template's period.

A worked example, using synthetic details: a client beginning weekly individual therapy at $150 per 50-minute session receives an estimate stating the service, the rate, the expected cadence of one session per week, and expected charges of $1,800 over the twelve-week period covered, with a line noting that actual frequency is determined together as treatment progresses and that a revised estimate will be issued if the plan changes. The number of sessions is framed as the expected scope for the period, not a promise of how long therapy takes, which keeps the document honest in both directions.

When the plan changes, and in therapy it does, reissue rather than stretch: a changed frequency, a changed rate, or a materially different expected duration is a new estimate. The reissue is not an admission the first one was wrong; it is the document doing its job of keeping the client's expectations current, and the moment of reissue is a natural, non-awkward opening for the money conversation practices otherwise avoid. Practices that treat the estimate as living paperwork tied to the treatment plan handle this with far less friction than those that treat it as a one-time onboarding form.

Annual rate changes deserve a calendar entry of their own: if fees rise in January, every active self-pay client's estimate needs to be reissued with the new rate, which is exactly the kind of batch task that argues for generating these documents from data rather than writing them.

How to stop writing them one at a time

Everything the estimate needs is captured at intake, which means the document can be assembled rather than authored. Written by hand, each estimate is ten minutes of transcription from systems that already hold every field, plus the risk of a stale rate or a missed reissue. Generated, it is a review-and-send. The pattern practices automate:

Workflow diagram

1. Intake captures payer status, the agreed rate, and the expected cadence
2. Self-pay and uninsured clients are flagged automatically, including insured clients electing self-pay
3. The estimate is generated from the fee schedule and the treatment cadence into the practice's template
4. A person reviews it, because the estimate is a representation the practice is making to a client
5. It is delivered through a HIPAA-compliant channel in the client's preferred format
6. A copy and a delivery timestamp are retained with the client record
7. A change to rate or cadence, or the period ending, triggers a reissue through the same loop

The review step is deliberate and stays. Human in front, automation behind: the generation, delivery, and record-keeping automate cleanly, and the judgment about what the practice is promising does not. Keragon runs this pattern from the intake workflow with a BAA on every paid plan and a 14-day free trial; see Keragon Workflows and Agents. Keragon generates and delivers the document from data the practice already holds; compliance itself remains the practice's obligation, which is exactly why the review step exists. More mental health automations live on the mental health hub.

What to keep on file

The part everyone forgets until it matters: keep the estimate itself and evidence of when and how it was delivered. If a bill runs at least $400 over the estimate, the client can open the patient-provider dispute resolution process, and the practice's position in that process is the paper trail (CMS). A practice that can produce the estimate, the delivery record, and the treatment-plan change that explains a difference is in a strong position; a practice that cannot is arguing from memory.

Make retention automatic rather than remembered: store each estimate alongside the intake paperwork in the client record, let the delivery step write its own timestamp, and keep superseded estimates when you reissue, because the sequence of estimates is itself the record of how expectations were kept current. The dispute process exists to be fair to both sides, and good records are what fairness runs on.

Five mistakes therapy practices make with Good Faith Estimates

The failure modes are consistent, and all five are process problems rather than knowledge problems:

• Treating it as one-time onboarding paperwork. The estimate has a period and a scope; when either lapses or changes, it needs to be reissued, and a January rate change means a batch of them.
• Missing the insured client who self-pays. The obligation follows how the care is paid. The privacy-motivated self-payer with good coverage is the classic missed case.
• Letting the disclaimers drift. Required language belongs in a maintained template, checked against current CMS text, not retyped and mutated across dozens of documents.
• Delivering without a record. An estimate that cannot be shown to have been delivered, and when, does half its job. The timestamp is as much a part of the document as the number.
• Lowballing to reassure. The estimate must be a genuine expectation. An optimistic number that keeps the $400 dispute door open serves nobody, least of all the client it was meant to comfort. If the honest expectation is uncertain, say so in the scope language rather than in the arithmetic.

FAQ

Do therapists have to provide Good Faith Estimates?

Yes. The No Surprises Act's estimate requirement applies to licensed providers including therapists, for uninsured and self-pay clients. Given how common self-pay is in therapy, most practices owe estimates to a substantial share of their caseload.

Does a client with insurance need one?

If they choose not to submit the care to their plan, yes. The obligation depends on how the care is paid, not on whether coverage exists. A client who normally uses their insurance is not owed one under this requirement.

How far in advance must it be given?

The windows run from scheduling: care scheduled at least three business days out requires the estimate within one business day of scheduling; care scheduled at least ten business days out allows three business days; and a request with nothing scheduled must be answered within three business days. Build it into scheduling, and the windows handle themselves. Confirm current windows at CMS.

How do you estimate ongoing therapy sessions?

State a period, a frequency, and a rate: for example, weekly sessions at the practice rate over the covered period, with the expected total explicit and the scope framed as expected rather than promised. Current guidance permits covering recurring care for up to 12 months per estimate; confirm the current rule before finalizing your template.

What if the number of sessions changes?

Reissue the estimate. A changed cadence, rate, or expected duration is a new representation to the client, and the reissued document is the system working as designed, not a correction of an error. Keep the superseded versions; the sequence is the record.

Does a GFE have to be signed?

The requirement is delivery, not signature: the client must receive it in writing, in the format they prefer. Many practices collect an acknowledgment anyway because it strengthens the delivery record, which is a sensible practice rather than a federal requirement.

Is a superbill the same as a Good Faith Estimate?

No, and they run in opposite directions. A Good Faith Estimate is forward-looking: expected charges before care. A superbill is backward-looking: a receipt for services delivered that a client may submit to their plan for reimbursement. A self-pay caseload typically involves both documents.

Can a GFE be emailed?

Yes; written delivery includes electronic formats, in the format the client prefers. Treat the delivery channel like any other client communication: use HIPAA-compliant tooling with a BAA and retain a record of what was sent and when.

What happens if the final bill is higher?

A bill at least $400 above the estimate can be taken to the patient-provider dispute resolution process, where the estimate and the billing records are reviewed. Clear estimates, reissued when plans change, plus a clean delivery record are what keep a practice out of that situation and well-positioned in it.

Does the requirement apply to telehealth sessions?

Yes. The obligation attaches to the care, and how it is paid, not to where it is delivered, so self-pay telehealth sessions are estimated exactly as in-person ones are.

Can Good Faith Estimates be automated?

The assembly, delivery, and record-keeping can: the estimate is generated from intake data and the fee schedule, delivered through a compliant channel, and archived with a timestamp, with reissues triggered by rate or cadence changes. The review before it goes out stays with a person, because the estimate is a representation the practice is making.