Rebecca M. Fishaut, MSW, LICSW, PLLC

1417 NW 54^th St., #334    Seattle, WA 98107

(425) 954-7473   (844) 308-5012 (fax)

becca@rebeccamfishaut.com

 

“No Surprises Act” Good Faith Estimate 

 

This estimate is for psychotherapy services provided by Rebecca M. Fishaut, MSW, LICSW (NPI 1174815922, TIN 48-3122078) for 12 months following the date of this estimate unless another Good Faith Estimate replaces it.

 

The estimate below is the range of costs that is likely for most clients.  The actual number of sessions will be determined on an individual basis, depending on each client’s diagnosis, current concerns, needs, progress, and treatment methods used.  I typically meet with clients weekly or every other week, at least to begin the work.  Often, after progress has been made on goals and symptoms, my client and I will determine that monthly or as-needed sessions is the needed frequency of sessions.  The duration of care is based on the client’s situation, progress, and intensity of need.  Typically, the duration of care is 6 months to several years.  I discuss these matters with my clients on an on-going basis.

 

The billing codes that I use and the price for each are as follows:

Description                                                                                 Code           Price

Initial evaluation (only billed for new clients)                            90791           $200

*Psychotherapy session lasting 53 minutes or more                   90837           $160

  Psychotherapy session lasting 38 to 52 minutes                       90834            $140

  Psychotherapy session lasting 16–37 minutes                          90832            $120

*This is the code used most of the time.

 

Typically, I meet with a client for an initial intake/evaluation once and then meet weekly for at least 6 months weekly with a client.  The cost to the client if they are paying entirely out of pocket for six months is ~$4200.  If a client engages in weekly therapy for a year following the initial intake, the cost would be ~$8360 (though it would be rare to meet every single week for a year given holidays and client and therapist vacations).  Services may extend beyond one year and will be billed based on the above information.

 

I offer my clients the service of submitting claims to their health insurance company, even if I am an out-of-network provider.  If the client uses out-of-network coverage, the cost will be adjusted based on their individual plan coverage.  Most clients have deductibles, copays, and/or coinsurance to fulfill.  The amount owed to this therapist is determined once the claim is settled by the insurance company.  If there is no payment from an insurance company for 90 days after submission, the client will be responsible for the full amount.  If a client no shows or cancels less than 24 hours prior to the session, I will charge $100.  Ultimately, the client is responsible for payment for services.

 

Disclaimer

 

This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to me as I created this estimate.  The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

 

If you are billed for $400 more (per provider) than this Good Faith Estimate, you have the right to dispute the bill.

 

You may contact Rebecca M. Fishaut, MSW, LICSW, the provider, at (425) 954-7473 to let her know the billed charges are at least $400 higher than the Good Faith Estimate.  You can ask her to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

 

You may also 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 calendar 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 health care provider or facility, you will have to pay the higher amount.

 

To learn more and get a form to start the process, go to: www.cms.gov/nosurprises or call CMS at 1-800-985-3059.  For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

 

This Good Faith Estimate is not a contract.  It does not obligate you to accept the services listed above.

 

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above.

 

If you have any questions about this estimate, please contact Rebecca M. Fishaut, MSW, LICSW at (425) 954-7473.