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Peer Perspectives

In Good Faith?

By Raffi Bilek, LCSW-C

A few years back I had to do some tests on my knees, which were complaining loudly about the way I positioned them when I slept. The orthopedist was stumped, and he recommended X-rays and then MRIs. It was a source of astonishment and exasperation for me that nobody could tell me how much I was going to have to pay for these services. As the owner of a small business, I have very limited health insurance for myself, so these tests would basically be paid out of pocket. And neither the doctor, nor the imaging lab, nor the insurance company could tell me what the cost would be. I was literally going to have to undergo the procedure and then find out what I owed afterwards. In what other commercial venture does this kind of approach make sense?

So the No Surprises Act seems like a no-brainer. Tell people what they’re going to pay before they have to pay it, or do your best to estimate it. I’m all for that.

But when the law came out, it turns out there’s a funny piece of it that once again redounds on my head for the worse. This is the dreaded Good Faith Estimate that so many therapists have been up in arms about—myself included.

If you’re out of the loop, here’s the deal: for therapists like myself who do not accept insurance (it’s just too painful for me to try dealing with them), there is now a requirement to provide, orally and in writing, a Good Faith Estimate for the cost of services. This seemed inane to me at first, since my rates are posted clearly on my website and they don’t change—same number of dollars for the same number of minutes, every time. Further, my clients pay for their first session at the time of booking, so there is surely No Surprise after the fact. Why the need for extra paperwork?

But then I got a clearer picture of the rule, and it actually seems not just inane but outrageous—we are supposed to give an estimate not for the cost of a session, but for the entire cost of treatment.

I’ll give the lawmakers the benefit of the doubt by assuming that they really weren’t thinking of private therapists when they made this rule. The idea that we would be able to tell in advance even vaguely what kind of course of treatment would be necessary is totally absurd. (We may except here those practitioners who deliberately use a short-term or manualized model.)

Imagine you call up the doctor and say, “Hey Doc, I’ve got a headache. What’ll it cost to figure this out and get rid of it?” What are they supposed to say? It could be an Advil, and it could be years of radiation and chemotherapy. On what basis is the answer supposed to be estimated? This is basically the situation we’re faced with every time a client walks in the door. “I’m feeling down. Don’t know why.” We’re supposed to estimate how long it’s going to take to solve this?

Perhaps we need to present this to the legal folks in their own language: “Pardon me, Counsel, but I’m having a dispute with my landlord. Can you help me deal with this? I’ll be needing an estimate—you can be $400 off plus or minus of course—of what this is going to cost.” (Note that at the fee this attorney probably charges, they’re going to have to get it right to within about an hour of the total amount of work.)

This new obligation leaves us in the position of presenting either an estimate that is too low, putting the client in a bad spot when things take longer than “expected” (not to mention the limitation that is at the heart of this regulation that prevents a provider from charging more than $400 over the estimate), or an estimate that is too high (“here’s what three years of therapy will cost you”) and scaring them off before they even step in the door. This is no service to clients.

But it doesn’t end there. This requirement is yet further detrimental to clients, because it adds on yet more paperwork and fine print to the intake process. I have worked hard to keep my consent forms as short as possible in the hopes that perhaps some clients will actually read them. Do you read all the forms they hand you when you go to the doctor’s? I don’t. There’s just too much of it.

The more pages the clients have to read, the less likely they are to read any of them and to walk away with any of the important points you were hoping to impart. Adding more sheets to the ream, for most clients, means they will absorb less information, not more.

Describe the Good Faith Estimate orally? Sure. That’s time the client is paying for. Not to mention the extra overhead that will accrue with the additional work that goes into preparing the estimates (each one is supposed to have the client’s name, date of birth, and diagnosis on there, so you can’t just print out a stack one time—each new client takes a few minutes of extra administrative time now) will ultimately falls back on the client as rates go up. (By the way, what exactly does it mean to provide a diagnosis before your first session with a client? What kind of nonsense is this?)

This regulation is an affront to private therapy practitioners and a detriment to their clients. Let us hope that as “guidance” comes out, someone is there to guide the guides.

— Raffi Bilek, LCSW-C, is a therapist and director of the Baltimore Therapy Center.