Good Faith Estimates for Therapists: The 6-Step Self-Pay Workflow That Survives a $400 Dispute (2026)
Under the No Surprises Act, you must give every uninsured or self-pay client a written good faith estimate of expected charges.
If the client schedules at least 3 business days out, you must provide it within 1 business day.
If they schedule 10 or more business days out, or simply ask what therapy costs, you have 3 business days. Civil monetary penalties reach $10,000 per violation.
Here is what actually costs practices money: the deadline is the easy half. The expensive half is the $400 dispute rule, which measures your total billed charges against your total estimated charges - a comparison that open-ended weekly therapy fails almost by design. Estimate 12 sessions and see the client for 25, and you have handed them a dispute-eligible bill without doing anything wrong clinically.
Below is the definition of "self-pay" that trips up therapists, the required fields, the six-step workflow I install in practices, and the five mistakes that turn a compliant estimate into a losing dispute.
Who counts as a self-pay client under the No Surprises Act?
Two groups, and the second one surprises people.
The first is anyone with no coverage at all.
The second is anyone who has commercial coverage but chooses not to have you submit a claim for that service. That second group is where most therapy practices live: the client who has a plan with a $6,000 deductible and decides to pay you cash instead.
Now the exclusion nobody mentions.
The federal definition of an uninsured or self-pay individual in 45 CFR 149.610 covers people without benefits under a group health plan, individual coverage, or a federal health care program.
But the "chooses not to submit a claim" prong lists commercial and federal-employee plans — not federal health care programs.
A Medicare beneficiary who wants to pay you cash is not a self-pay individual you can simply hand a good faith estimate to and move on. Since 2024, LPCs and LMFTs face a separate obligation: you either enroll or formally opt out of Medicare, and that decision drives the entire encounter.
I walk through both paths in the guide to Medicare enrollment for LPCs and LMFTs. Treat Medicare and Medicaid clients as their own workflow, not as self-pay.
One more rule buried in the regulation: any discussion or inquiry about the potential cost of services counts as a request for a good faith estimate.
"How much do you charge?" on a first phone call starts a 3-business-day clock. That single sentence is why the estimate belongs inside your intake process rather than your compliance binder.
When is the good faith estimate due?
Three deadlines, all counted in business days, all starting at scheduling or at the request - never at the session:
Scheduled at least 3 business days before the appointment: deliver within 1 business day of scheduling.
Scheduled at least 10 business days before the appointment: deliver within 3 business days of scheduling.
Requested without scheduling: deliver within 3 business days of the request. When they later schedule, issue a new estimate on the timelines above.
Scope changes (fee change, frequency change, added service): issue a new estimate no later than 1 business day before the affected session.
Practices that answer inquiries in batches miss deadline #1 constantly.
Across the behavioral health practices HireGaynell supports, the practices that return new-client inquiries within one business hour almost never miss a good faith estimate deadline, because the estimate goes out on the same touch as the booking confirmation.
If your callbacks are slow, fix that first - the therapy intake call script I use includes the cost question and the estimate handoff in the same eight steps.
What must a good faith estimate include for a therapy practice?
The regulation lists the fields. Miss one and the document is not a compliant estimate, no matter how quickly you sent it:
Client name and date of birth.
A plain-language description of the primary service, and the scheduled date if known.
An itemized list of expected services, grouped by provider.
Applicable diagnosis codes, expected service codes, and the expected charge for each line. Use CPT codes you actually bill: 90791, 90832, 90834, 90837, 90846, 90847.
Your name, NPI, and TIN, plus the state and office location where you will furnish services.
A list of anything requiring separate scheduling, with a disclaimer that separate estimates follow.
Four disclaimers: that other recommended services may need separate scheduling, that this is an estimate and actual charges may differ, that the client may initiate the patient-provider dispute resolution process, and that the estimate is not a contract.
On diagnosis codes before the intake session: APA Services has published the reasonable reading that until you have completed an evaluation and formed a diagnosis, no applicable diagnosis code exists - see their No Surprises Act FAQs for psychologists.
Issue the initial estimate for the 90791 without a code, then reissue after the evaluation.
Delivery has to be written, on paper or electronically, in a format the client can save and print. You may read it aloud if they ask, but the written copy is still required.
How do you write a good faith estimate for ongoing therapy?
You are allowed to issue one estimate covering recurring sessions, and that is the right move for weekly therapy.
Two conditions apply: the estimate must state the expected scope in clear language - frequency, duration, and total number of sessions - and the scope cannot exceed 12 months. Beyond 12 months, you issue a new one.
So the line reads: Weekly individual psychotherapy, CPT 90834, $150 per session, 44 sessions expected between March 1, 2026 and February 28, 2027, total expected charges $6,600.
Not $150 per session. A per-unit rate with no total is not an estimate of expected charges, and in a dispute it gives the reviewing entity nothing to compare your bill against.
The 6-step good faith estimate workflow for a self-pay therapy practice
This is the build I install. Setup runs about 90 minutes once; after that it costs roughly four minutes per new self-pay client.
Post the notice
The rule requires information about the right to a good faith estimate to be prominently displayed and easily searchable on your website, posted in the office, and available wherever scheduling happens.
When practices come to us without a written estimate workflow, the missing website notice is the most common gap I find - and it is the one a state regulator can see without ever opening a chart.
Ask the coverage question at first contact
Scripted, every time: are you enrolled in a health plan, and do you want me to bill it? Log the answer.
That single question determines whether this client needs a good faith estimate or a full benefits check.
For the insured path, run the 9-step insurance benefit verification checklist instead - eligibility alone will not tell you what the plan pays for behavioral health.
Generate the estimate at scheduling, not at intake
Build it as an intake document in your EHR so it fires automatically.
In SimplePractice, TherapyNotes, and TheraNest alike, a custom intake form or template attached to the self-pay client type does the job. The EHR timestamps delivery, which is the evidence you will want later.
Set the scope high, honestly
Estimate the number of sessions you genuinely expect at the upper end of a normal course of care, and say so. Under-estimating creates dispute exposure; a well-documented higher estimate does not.
Reissue on every change
Fee increase, cadence change from weekly to biweekly, a switch from 90834 to 90837 - new estimate, delivered at least one business day before the affected session. Put a recurring quarterly task on your calendar to sweep active self-pay clients for drift.
File and retain
The estimate is part of the medical record. You must be able to produce any estimate issued in the last six years on request. Store it in the chart, not in your email sent folder.
Six years is the federal floor here, and your state's therapy records retention requirements may run longer.
What happens if a client disputes the bill? The $400 rule explained
If your total billed charges exceed the total expected charges on your estimate by $400 or more, the client can open the federal patient-provider dispute resolution process.
Per CMS, they have 120 calendar days from receiving the initial bill and pay a $25 administrative fee to start it.
Once a dispute is open, the operational consequences land on you, not on the estimate.
Per CMS guidance for providers, you cannot move the bill to collections or threaten to; you must pause collections already underway; you cannot charge late fees on the disputed amount, and you cannot retaliate.
A dispute resolution entity then decides whether the client pays your estimate, your bill, or something between.
Practices without an accounts receivable system feel this immediately - a frozen balance behaves exactly like an aged claim, which is why the aging AR follow-up system needs a hold status, not just a chase cadence.
There is a real safe harbor. If you acted in good faith with reasonable diligence and made an error, you do not fail compliance as long as you correct it as soon as practicable. That protection only works if you can show a dated, delivered estimate and a dated correction.
What are the penalties for not providing a good faith estimate?
States enforce first. Where a state does not substantially enforce, HHS may impose a corrective action plan and civil monetary penalties up to $10,000 per violation.
The Secretary must waive penalties where the provider did not knowingly violate the rule, withdraws the bill, and reimburses the excess with interest.
Read that sequence carefully. The penalty risk is real but conditional; the dispute risk is automatic and arithmetic.
A solo practice will almost certainly meet a $400 overage before it meets a federal investigator.
Do you need a good faith estimate for a no-show fee?
A no-show fee is not a health care item or service furnished to the client, so it does not belong in the itemized service lines. Disclose it in your financial policy and informed consent instead, signed at intake, with the amount stated in dollars.
[ CMS has not squarely addressed missed-appointment fees in the good faith estimate FAQs.]
The practical rule I use: anything you will ever put on a bill must appear in a document the client signed before session one.
That is also the cheapest fix available for missed sessions generally, which I cover in the guide to reducing no-shows in a therapy practice.
The 5 mistakes that turn a compliant estimate into a losing dispute
Quoting a per-session rate with no total expected charges.
Treating a cost question as small talk instead of a request that starts a clock.
Issuing one estimate at intake and never touching it again through a fee increase.
Sending the estimate by email and never filing it in the chart, so nothing surfaces when the six-year request arrives.
Handing a Medicare beneficiary a good faith estimate instead of resolving enrollment or opt-out status.
Conclusion
In my experience running behavioral health operations, the single thing that separates practices that never think about the No Surprises Act from practices that get blindsided by a dispute is where the estimate gets generated.
If a human being writes it, it will be late, incomplete, or stale within a quarter.
If your EHR generates it automatically the moment a self-pay client is scheduled, and reissues it on a quarterly sweep, compliance costs you four minutes per client, and you stop thinking about it.
Build it into intake once, not into your to-do list forever.
If your self-pay intake is still running on memory and good intentions, that is exactly the kind of workflow I build and run for practices - see HireGaynell's virtual assistant and practice administration services for what that looks like in your EHR.
