Good Faith Estimate - Jessica Gottlieb LCPC LLC
The No Surprises Act was passed in December 2020, under Section 2799B-6 of the Public Health Service Act, with the aim of protecting consumers from receiving unexpected medical bills. The Good Faith Estimate provision of the No Surprises Act federally mandates that healthcare providers must give clients an estimate of anticipated healthcare items and services, using what is called a “Good Faith Estimate.” This took effect on January 1, 2022.
This document is the first part of that estimate. You will be given a full estimate when you start services with this provider.
Below is the mental health provider who will be giving you services and this Good Faith Estimate reflects their charges.
Jessica Gottlieb of Jessica Gottlieb LCPC, LLC
Bethesda, MD 20814
Telephone: 301-244-8257
Email: jessica@gottliebtherapy.com
NPI: 1073867214
Therapy is taking place via telehealth at this time and in person.
Your therapist is not able to provide a Client Diagnosis before doing an assessment. However, typically, the initial diagnosis is F43.20, Adjustment Disorder, unspecified, which is what will be used for the services and fees of this Good Faith Estimate. As well, this diagnosis may change during the course of treatment.
Charges are for an Initial Intake Assessment and the types of weekly sessions you will have, typically, but this might change depending on the needs of treatment. Given that the course of treatment depends on your needs, there is no way to estimate how many sessions you will want or need to feel better. Therefore, you and the mental health provider will be working together to determine the number of sessions. Total Expected Charges will vary depending on the number of sessions you have which you and your therapist will decide together.
Most clients are scheduled for individual therapy using code 90834 for weekly, 50 minute sessions.
Since the scheduling of an appointment involves the reservation of time set aside especially for you, a minimum of 48 hours notice is required for rescheduling or cancellation of an appointment. If for any reason a session is canceled less than 48 hours prior, the full fee will be charged. As emergencies happen, once every calendar year you can cancel your appointment with less than 48 hours and not be charged for your missed appointment. You may also inquire whether there is an option to meet virtually if you’re unable to attend an in-person session. Please note that most insurance does not reimburse for missed sessions.
Disclaimer:
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
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.
This estimate does not require you to obtain psychotherapy or other services from the provider.
IF YOU ARE BILLED FOR MORE THAN THIS GOOD FAITH ESTIMATE,
YOU HAVE THE RIGHT TO DISPUTE THE BILL.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them 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 HHS at (800) 368-1019.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.
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 a higher amount.