What Is a Good Faith Estimate? The No Surprises Act Rules Every Therapy Practice Needs

A Good Faith Estimate starts at the front desk, on the call where the session is booked.

A Good Faith Estimate is a written, itemized list of the charges a provider expects to bill a client who is uninsured or not using insurance for scheduled, non-emergency care. For a therapy practice, it is the part of the No Surprises Act that lands squarely on the front desk.

Most headlines about the law concern emergency rooms and out-of-network clinicians at in-network hospitals, where patients are now shielded from balance billing. Few therapy offices ever touch those scenarios. They touch the estimate.

Think of a mechanic who writes the repair quote before lifting the hood. Nobody wants a shrug once the engine sits in pieces on the floor, and the estimate rule asks the same discipline of care a client pays for directly. It covers the total expected cost, so related items such as tests or equipment belong on it, not just the session fee.

Clients also know where to turn now. CMS directs them to its No Surprises Help Desk at 1-800-985-3059, with support in over 350 languages. A verbal fee quote over the phone does not satisfy the rule. In my view, that help line is why a missing estimate no longer stays a quiet oversight.

So which callers are owed one, and when does the clock start?

What is a Good Faith Estimate under the No Surprises Act?

A Good Faith Estimate is a written, itemized list of expected charges that a provider owes clients who pay without insurance, either when they ask or when they book ahead.

CMS sets the trigger at 3 business days: "Usually, if you aren't using health insurance to pay for your care, your health care provider must give you a good faith estimate of expected charges if you request one or schedule services at least 3 business days in advance." The requirement has applied since January 1, 2022, when the No Surprises Act took effect.

Before any estimate gets drafted, I'd have the front desk answer three questions for each new client:

1. Is the client uninsured, or insured but choosing not to bill insurance for these sessions?
2. Did the client ask what sessions cost, or book far enough ahead to trigger the rule?
3. Is the service a scheduled, non-emergency item that your practice will provide and charge for?

Yes to all three means an estimate is owed. Simple.

Written and itemized = KEY. A phone quote does not satisfy the law, and neither does a fee printed in a brochure. Clients who carry insurance can still claim the right by telling you they plan to self-pay, whether for a better cash price or for privacy. In 2022, one widely shared reading of the rule went further: almost any question close to asking what a service costs should be treated as a request for an estimate.

Scope is narrow on purpose. In the agency's own words, "Good faith estimates only list expected charges for a single provider or facility." Your estimate covers your sessions and your fees. Nobody else's.

The common assumption is that the No Surprises Act is a hospital law. That is half right. Its balance-billing protections center on emergency care and on out-of-network clinicians who treat patients inside in-network hospitals or ambulatory surgical centers, settings a private therapy office rarely touches. The estimate rule is the piece that lands on outpatient practices, and it applies to every covered provider, from large hospital systems to solo practices. Some commentators in 2022 doubted Congress had therapy in mind at all. Intent aside, the rule reaches you.

Why does a single form carry this much weight? Because CMS tells patients directly: "You can't dispute your bill without an estimate." The estimate is the client's evidence if a bill goes wrong. It is also your practice's record that you priced care honestly. CMS reinforced the provider side in a March 18, 2022 document on Good Faith Estimate and patient-provider dispute requirements.

I compared 5 sources for this definition, including two CMS documents and a hospital's patient notice, and none disputes the core: written, itemized, owed to people not billing insurance, and limited to one provider's charges.

Because the request so often arrives as a quick phone question, coverage matters. Through its healthcare BPO services, HelpSquad operates across six countries so patients are never sent to voicemail, with bilingual agents across the US, Europe, Central America, and South Africa. An unanswered cost question is still a cost question.

Which leaves the question most therapists actually struggle with: who counts as self-pay when much of a caseload submits superbills?

What will matter most for Good Faith Estimates over the next 12 to 24 months?

Over the next 12 to 24 months, the enforceable core stays simple: each practice estimates its own charges for self-pay clients, while the multi-provider layer waits on federal rulemaking.

Three shifts are already visible in the evidence. Each one changes what your front office does at intake, not what your therapists do in session.

Why does the first row lead? Because it decides how complicated your estimate stays. In 2022, hospital and medical group associations asked CMS for more time on the estimate rule, warning that providers had no realistic electronic way to exchange estimate data with one another. Waystar later reported that HHS itself said compliance with the co-provider piece "is likely not possible."

Until HHS acts, a client who also sees a psychiatrist gets separate estimates from each provider, and yours lists only your sessions. That is simpler for you today. It is also less complete for the client.

What the evidence cannot settle is timing. None of it says when, or whether, that rulemaking will finish, and I would rather admit the gap than guess at a date.

Two developments would change the picture fast: HHS finalizing the co-provider requirement, or finalizing the Advanced Explanation of Benefits for insured patients, which a 2026 consumer guide still described as in rulemaking. Either would push practices from templates toward real systems.

The same December 2022 analysis read enforcement as largely complaint-driven. So a frustrated client, not an auditor, is the likeliest trigger.

One carve-out belongs in your intake script now: Medicare patients sit outside the estimate rule, and an Advance Beneficiary Notice applies to them instead.

Where do therapy practices get Good Faith Estimates wrong?

Therapy practices usually go wrong in three places: deciding which out-of-network clients get an estimate, projecting a year of sessions, and proving the estimate actually went out.

The rule reads cleanly on paper. Inside a real practice, it lands on whoever answers the phone, and in a solo therapy office that person may well be the clinician. A 2022 survey by the Medical Group Management Association (MGMA) put numbers on the strain: 70% of practice executives rated the GFE requirement very or extremely burdensome, second only to prior authorization. 82% said it increased their administrative burden, 74% lacked the technical infrastructure for the expanded requirements then due in 2023, and 78% wanted more help creating estimates.

Those figures came from medical practices. A solo therapist doing intake between sessions has even less room. Left alone with the rule, clinicians turn to each other, and the answers conflict.

Out-of-network and superbill clients

This is the biggest gray zone. One therapist who dropped insurance panels had been offering an estimate as a separate document in intake paperwork, then worried that every out-of-network client should have received one automatically. Peers split. One insisted "all self-pay clients are required to receive a GFE." Another believed no estimate was needed when the client submits a superbill or the provider files out-of-network claims on the client's behalf. Nobody settled it.

My recommendation is to issue the estimate. A superbill client pays your fee directly, and nothing guarantees they ever file for reimbursement. One extra document is cheap. A missing one is not.

Annual session projections

The second error is the projection itself. In 2023, a therapist in an r/therapists thread described a worksheet that multiplies the full fee by 52 weeks, assuming weekly sessions without interruption for a full year. The stated reason was "to avoid the penalty of underestimating fees." The same therapist called the worksheet "a bit of a joke." In 2024, another clinician described a template with lines for CPT 90791 and CPT 90837, the rate for each code, the expected number of sessions and a total, costed as weekly visits for 52 weeks even for clients seen every other week. Sample language that circulated among therapists in late 2021 projected 50 weeks instead, allowing for vacations and holidays.

Which number is right? Neither extreme. A deliberate maximum protects the practice on paper, yet it tells the client very little about what therapy will really cost. Good faith means a realistic number, revised when reality changes.

Proof that the estimate went out

The third error is documentation. In that same 2023 discussion, one clinician reviewed fees with every client and had each one sign a form confirming they understood. They used the conversation to cover late-cancellation and no-show fees too, insured clients included, because those clients owe cancellation fees as well. Another admitted, "Frankly, I'm only marginally compliant." Elsewhere, a clinician keeps a record of each estimate and the related communication in the EHR.

Signed or not, a dated record is what shows a practice met the rule. Without one, compliance is just a memory.

Most of this work is clerical. Asking the insurance question, filling the template and filing the record need consistency more than clinical judgment, so a trained medical virtual assistant can own them; HelpSquad staffs full-time support at $8-$13/hour. What matters next is the workflow around that person: who asks, who drafts, and who files.

How do you build a Good Faith Estimate workflow that holds up in 2026?

Assign the work to one HIPAA-trained front-office owner, like our virtual assistants certified through HIPAATraining.com, with a fixed script, one template, a deadline tracker and a filing rule.

Most GFE failures start at intake, not on the form. Fix the intake and the form gets much easier. Contrary to the instinct to make each therapist responsible for their own estimates, the rule behaves like a scheduling task with one or two clinical inputs.

Here is the sequence I'd hand to whoever owns the front desk:

1. Ask every new client two questions at first contact: do you have insurance, and will you use it for these sessions?
2. Treat any question about cost from an uninsured or self-pay client as a request for an estimate.
3. Draft the estimate from one standard template on the day the client books.
4. Send it in writing, in an accessible format and in the language the client speaks.
5. File a copy in the client's medical record, every time.
6. Reissue it at least 1 business day before any session affected by a change in frequency, number of sessions or duration.

Each step traces back to the rule itself. A 2022 provider guide from the law firm Burr & Forman spells out that the convening provider must ask about insurance when scheduling, that any cost discussion with an uninsured or self-pay patient counts as a request, and that every GFE "must be included as part of the patient's medical record." HHS has also published a GFE template and an informational notice. Nobody needs to design a form from scratch.

The deadlines depend on how far ahead the client books. In 2022, the same guide set them out this way:

Take a new self-pay client who calls on a Monday and books a weekly 90837 slot starting two weeks out. That booking falls in the 10-business-day row, so the practice has 3 business days. Send it that afternoon anyway. Issuing on the day of booking meets every deadline in the table with a single habit.

One piece sits outside the client file. Providers must display GFE availability prominently on the website, in the office, and wherever scheduling or cost questions come up. Post it once. Check it at every fee change.

Why does the record matter so much? If a bill lands $400 or more above the estimate, the client has 120 days from receiving it to file a Patient-Provider Dispute Resolution challenge. Collection efforts must stop while the dispute is pending, and an HHS-selected entity decides within 30 business days of receiving everything it needs. Your filed estimate is your side of that story.

Who should own all this? Not the therapist. The clinician supplies the diagnosis code and the expected session plan, and everything else is front-office work. Who fills that seat still matters: less than 3% of applicants clear every dimension of our screening, and those are the ones a practice meets.

If calls are the bottleneck, a healthcare call center team can take first contact and the insurance question, and HelpSquad offers a 14-day free trial to test that setup before a practice commits. Run the sequence for every new client and the estimate stops being a task a therapist remembers after the last session of the day.

What should therapy practices expect from Good Faith Estimates next?

Expect the written estimate to become routine front-office work: one owner, one template, sent at scheduling, so self-pay clients never meet a fee they did not see first.

The pressure behind that shift is real. In 2022, the federal health department's website stated that more than half of U.S. consumers reported an unexpectedly large bill after receiving medical care. That frustration is exactly what the estimate rule was written to answer.

Practices felt the cost from the other side. When MGMA surveyed practice leaders in 2022, they placed the estimate rule right behind prior authorization on their list of regulatory burdens. Claire Ernst, its director of government affairs, argued the rules force an unpaid "consultation prior to actually scheduling the service." Is she wrong? Not entirely.

My read is that the burden lands at the moment of scheduling, so that is where the fix belongs, with a trained front-office owner rather than a therapist squeezing paperwork between sessions. Clinical hours are too valuable for form filling.

Get that first call right, and dispute resolution stays something your clients read about rather than something they file.