The good faith estimates must be given this year to uninsured or self-pay patients for medical or mental healthcare services. They were included in the No Surprises Act as part of a broader effort to give patients a good idea of cost, both per visit and for a course of treatment, in advance.
Therapists say their professional codes of ethics already require disclosure to patients of per-visit costs. Requiring diagnostic billing codes in the estimate before even seeing a patient — as they interpret the rule — is unethical, they argue, and tallying up what might be weeks or even months of treatment costs could keep some patients from undergoing care.
“If people see a large dollar amount, they might be intimidated or scared into not getting help at all,” said Linda Michaels, a private practice therapist in Chicago and co-chair of the Psychotherapy Action Network.
The counterargument, though, is that one of the law’s aims was to provide patients with pricing information — for mental health services or medical care — that is less opaque and more similar to what they’re used to when shopping for other types of goods or services.
Benedic Ippolito, an economist at the American Enterprise Institute, said he is sympathetic to medical providers’ concerns about the extra administrative burden. But “giving consumers a better sense of financial obligation they are exposed to and imposing some cost pressure on providers are both reasonable goals,” he said.
Even among providers, there is no universal agreement on how burdensome the estimates will be.
“It’s not an unreasonable thing, frankly, for psychiatrists, not just plastic surgeons or podiatrists, to say, ‘If you want me to do this and you’re not covered by insurance or whatever, it will cost you X amount for the whole episode of care and this is what you get in return,’” said Dr. Robert Trestman, chair of psychiatry and behavioral medicine at the Virginia Tech Carilion School of Medicine. Although he serves on an American Psychiatric Association committee, he was voicing his own opinion.
The Centers for Medicare & Medicaid Services said mental health providers are not exempt from the rules about good faith estimates, in a written statement to KHN. It added, however, that the agency is working on “technical assistance geared toward mental health providers and facilities.” Federal agencies often issue additional clarification of rules, sometimes in the form of FAQs.
The No Surprises Act took effect on Jan. 1. Its thrust was to bar medical providers from sending what are called surprise or “balance” bills to insured patients for out-of-network care provided in emergencies or for nonemergency situations at in-network facilities. Common before the law passed, such bills often amounted to hundreds or thousands of dollars, representing the difference between the amount insurers paid toward out-of-network care and the often much higher amounts charged.
Now, insured patients in most cases will pay only what they would have been billed for in-network care. Any additional amount must be worked out between their insurer and the provider. Groups representing emergency doctors, anesthesiologists, air ambulance providers, and hospitals have filed lawsuits over a Biden administration rule that outlines the factors independent arbitrators should consider when deciding how much an insurer must pay the medical provider toward disputed bills.
Most mental health services, however, aren’t directly touched by this part of the directive because treatment is not typically performed in emergency situations or in-network facilities.
Instead, the complaint from mental health providers focuses on the good faith estimates.
Additional rules are expected soon that will spell out how upfront estimates will be handled for people with health coverage. In their letter to HHS, the behavioral health groups say they fear the estimates will then be used by insurers to limit treatment for insured patients, or influence pay negotiations with therapists.
Several policy experts say they do not think the law will affect mental health reimbursement in most cases.
“Mental health professionals will have the exact same ability to bill out-of-network, to have patients agree to whatever market price is for their services,” said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, who has long studied balance billing issues. “Nothing about the No Surprises Act restricts that.”
Some of the therapy groups’ concerns may stem from misreading the law or rules implementing it, say policy experts, but they still reflect the confusion providers share surrounding the rollout of the law.
As for how to handle pre-treatment diagnoses that are needed to deliver good faith estimates, CMS said in its email to KHN that providers could estimate costs for an initial screening, then follow up with an additional estimate after a diagnosis.
“No one is going to be forced to make a diagnosis of a patient they have not met,” Adler said.
Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.