The Good Faith Estimate: A Therapist's Plain-English Guide to the No Surprises Act

Think back to January 2022. Somewhere between the omicron wave and the third snowstorm, the emails started arriving. Your liability carrier, your listserv, your professional association — all of them suddenly urgent about something called "GFE compliance." The No Surprises Act had taken effect on the first of the year, and apparently it applied to you, a therapist with a rented office and a caseload of eighteen.

Most of us did what you do when a wave like that comes over the bow: grabbed something and held on. Somebody's template got passed around. You turned it into a Word doc, changed the letterhead, and started handing it to new clients. Four years later, that same doc is probably still in your intake folder — and if you're honest, you're not entirely sure it's right. There's a low hum of dread underneath it: what if there's an audit? What if a client disputes a bill and the first question is "where's the estimate?"

Here's the good news, and I mean it: the Good Faith Estimate is one of the most manageable compliance requirements in all of private practice. The law was written with hospitals in mind. For a therapy practice — one provider, a handful of CPT codes, a published fee — it reduces to a single well-built template and one habit. Let's chart the whole thing, buoy by buoy.

What the No Surprises Act actually is

Congress passed the No Surprises Act in late 2020, and it took effect January 1, 2022. The headline target was surprise hospital billing — the anesthesiologist who turned out to be out-of-network, the $80,000 air ambulance. But the law has a second, quieter half: a rule that uninsured and self-pay patients deserve to know what care will cost before they get it. That rule, codified at 45 CFR 149.610, is the Good Faith Estimate requirement, and it was written broadly enough to sweep in essentially every licensed provider — including a solo therapist who has never sent a claim to a hospital in her life. You didn't do anything special to get included. You're a health care provider, and the rule covers health care providers.

Who must get one (and who doesn't)

Two groups of clients are entitled to a Good Faith Estimate:

• Uninsured clients — no coverage at all.
• Self-pay clients — they have insurance but are not using it for your services. This is the one that catches therapists, because in our field it's everywhere. Clients pay out of pocket to keep a diagnosis off their record, to see the therapist they actually want rather than the one in-network, or because you don't take their plan. Every one of them is "self-pay" in the law's eyes, and every one of them gets an estimate.

Who doesn't need one: clients whose care you're billing through their insurance. (The Act imagined a parallel "advanced explanation of benefits" for insured patients, but as of mid-2026 that piece still isn't in effect for providers to act on.) So the sorting question at intake is simple: am I submitting claims for this person? If no — GFE. For a typical private-pay therapy practice, that means nearly everyone.

When it has to be delivered

The timing rules sound fussy but follow one idea: the client should have the estimate in hand with time to think before the appointment.

• Appointment scheduled 10 or more business days out: deliver the estimate within 3 business days of scheduling.
• Appointment scheduled 3 to 9 business days out: deliver it within 1 business day of scheduling.
• On request: anyone — even someone just shopping for a therapist — can ask for an estimate, and you have 3 business days to provide it.
• When charges change: a new estimate. Raised your fee? Moved from weekly to twice-weekly? Added a new service? New GFE, before the client is billed at the new terms.

And one rule that's easy to miss: it must be written — paper or electronic, per the client's preference. Telling a client "sessions are $160" on the phone is good practice and good manners, but it is not a Good Faith Estimate. If it isn't a document, it doesn't count.

What goes on it

This is where most homemade templates leak. The regulation lists required contents, and for a therapy practice they translate concretely:

• The client: name and date of birth.
• You: your name, NPI, tax identification number, and the office (or telehealth) location where you'll provide services.
• The services, in plain language: a clear description a non-clinician can read — "psychotherapy, 53+ minutes" — alongside the expected service codes. For most of us that's 90791 for the intake evaluation, then 90834 or 90837 for ongoing sessions (90847 if you see couples or families).
• The itemized charges: your expected charge per item — $180 for the 90791, $160 per 90837, whatever your fee schedule says. Not a range, not "varies." Numbers.
• Diagnosis codes where applicable: the estimate should carry the diagnosis code associated with the care — with a real caveat for first contact, which we'll get to under myths below.
• For recurring care, the scope: therapy is the textbook recurring service, and the law accommodates it. One estimate can cover a course of sessions if it states the expected frequency and duration — "one 55-minute session per week, approximately 48 sessions over 12 months, $160 per session." The ceiling is 12 months; past that, you issue a fresh one.
• The required disclaimers: that the estimate is only an estimate, that it is not a contract and doesn't obligate the client to obtain care from you, that they have a right to dispute a bill substantially above it, and that they can ask for an updated estimate any time.

Read that list again and notice what it isn't: it isn't a treatment plan, a financial agreement, or a consent form. It's a price tag with your credentials on it. Once the template exists, filling it in takes about as long as writing an appointment reminder.

The $400 rule: what happens if you blow past your estimate

Here's the enforcement mechanism with teeth. If your actual billed charges come in $400 or more above the Good Faith Estimate, the client can take the bill to the federal patient-provider dispute resolution process. A third-party reviewer looks at the estimate, looks at the bill, and can hold you to something close to the number you promised. The client pays a small administrative fee to start it; you can lose the difference.

Now, breathe. In therapy, blowing an estimate by $400 almost never happens by accident. There's no surprise anesthesiologist in your office. You drift past an estimate in exactly two ways: you raised your rates mid-year, or you changed the frequency or type of service — weekly became twice-weekly, individual sessions added a monthly couples session. Both are foreseeable, and both have the same fix: issue an updated GFE at the moment things change. Do that, and the dispute process has nothing to grab. The $400 rule isn't a reef waiting to hole your practice; it's a lighthouse telling you when to update a document.

The practical system: template once, then let intake do the work

Compliance systems fail when they depend on remembering. The GFE should be lashed to things you already do:

• Build the template once. Your identifiers, your standard codes, your disclaimers — all static. The only per-client fields are name, date of birth, fee, frequency, and (when known) diagnosis.
• Generate it at intake, inside the packet. The estimate belongs with the consent forms and practice policies a new client signs before session one — that's how the timing rules take care of themselves. If your intake process is a checklist, the GFE is simply an item on it.
• Store the acknowledged copy in the chart. A signature isn't legally required, but an acknowledged, dated copy in the record is what protects you if a question ever comes. An estimate you can't produce is an estimate you didn't give. File it like you'd file any clinical documentation: dated, retrievable, attached to the client.
• Refresh on rate change, and at least every 12 months. Tie it to the same calendar moment you use for annual rate reviews — the letter announcing the new fee and the updated GFE should travel together.

That's the entire system. Four habits, three of which you arguably already have. This is also exactly the kind of paperwork software should quietly absorb: Practice Harbor generates the Good Faith Estimate from your fee schedule during intake and files the acknowledged copy in the client's chart, so the document exists because the client exists — compliance as a byproduct of a normal Tuesday.

Four myths worth sinking

• "This doesn't apply to therapists." It does. The rule covers licensed health care providers generally, and psychotherapy is health care. Solo practice, cash-only, part-time, pre-licensed under supervision — none of those are exemptions.
• "I told them my fee, so I'm covered." Verbal doesn't count. The estimate must be a written document, on paper or delivered electronically, in the format the client prefers.
• "One estimate covers the client forever." Twelve months, maximum, for recurring services — and sooner if anything about the charges changes. An estimate from 2023 protects no one.
• "I can't issue a GFE without a diagnosis code." Gentler than it looks. The estimate should include the applicable diagnosis code where one exists — but at first contact, before you've even done the intake, there may not be one yet, and federal FAQ guidance has recognized that an estimate can go out without a diagnosis when none has been determined. List the expected service codes and charges, leave the diagnosis field empty or marked "not yet established," and update the estimate once assessment gives you one. Don't invent a code to fill a box.

One honest caveat before we drop anchor: this article is education, not legal advice — rules get tweaked and states add wrinkles, so when something in your situation feels genuinely ambiguous, a quick consult with a health care attorney or your professional association is worth the hour.

But don't let that caveat re-inflate the dread. The Good Faith Estimate asks you to tell people what therapy costs, in writing, before they start — which is something most good therapists were doing anyway, out of plain respect. The law just wants it on letterhead. Build the template this week, bolt it into your intake packet, and the wave that swamped everyone's inbox in January 2022 becomes, at last, calm water.