GOOD FAITH ESTIMATE

Dr. Brad A. MacNeil Psychological Services, PLLC

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This is the total cost estimate of what you may be asked to pay for services at Dr. Brad A. MacNeil Psychological Services, PLLC. It is your ethical right as a patient or client to determine your goals for assessment and therapy, as well as how long you would like to remain in therapy (i.e., unless you are pursuing mandated treatment). A full breakdown of possible fees for all services rendered will be provided to you as part of the Good Faith Estimate. We will collaborate with you throughout your assessment and therapy sessions to determine the number of sessions required to receive the most benefit from the evidence-based treatment for the diagnosis or presenting concern you may be struggling with. Service charges are the same for in person or telepsychology services (i.e., in office versus telemental health services). 

 

All patients will have an opportunity to review the detailed Good Faith Estimate. We will recommend that you call your health plan as they may have better information about how much of these services will be reimbursed if you are filing for this. If a patient has any questions about the Good Faith Estimate you can ask us directly. For questions about your rights as a patient you can contact the Arizona Secretary of State (https://azsos.gov or (602) 542-4285).. Please note that a patients health plan, except in an emergency (See No Surprises Act below), may require prior authorization for certain  services and you may need approval by your plan that it will cover a service before you receive it. If prior authorization is required, ask your health plan about what information is needed by them for you to receive the coverage.

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NO SURPRISES ACT 

(OMB Control #: 0938-1401)

 

PATIENT RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

As a patient you are protected from surprise billing and balance billing in the case of needing emergency care or or receiving treatment from an out-of-network provider at an in-network hospital or ambulatory surgical center.

 

BALANCE BILLING AND SURPRISE BILLING

When a patient sees a doctor (or other health care provider), they may owe specific out-of-pocket costs (e.g., copayment, coinsurance, or a deductible) based on their specific coverage. Patients may have additional costs or be required to pay the entire bill from the doctor or healthcare provider if that provider is at a health care facility that is not in their health plans network. Out-of-network includes doctors, healthcare providers, or facilities that have not signed a contract with the patients health plan. These out-of-network providers may be permitted to bill you directly for the difference between what your health plan agreed to pay them and the full amount charged for a  specific service. This is referred to as balance billing and this amount can be more than in-network costs for the same service or may not count toward your annual out-of-pocket limit as a patient with your provider.

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Patients should also be aware of surprise billing which is an unexpected balance on a bill. This occurs when a patient cannot control who (i.e., doctor, other healthcare providers, facility) that is involved in their care. This occurs typically when patients either require emergency services or book an appointment with an in-network facility but unexpectedly receive services from an out-of-network provider. As a patient you are protected from balance billing in the following instances:

 

(1) Emergency services

In the event of an emergency medical issue where a patient receives emergency services from an out-of-network provider or facility, the provider or facility may bill a patient a cost-sharing amount including copayments and coinsurance. Patients cannot be balance billed for these types of emergency services including services received after a patient is in a stable  condition unless the patient gave  written consent and gave up their protections not to be balanced billed for these services.

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(2) Specific services at an in-network hospital or ambulatory center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections  not to be balance billed.

 

(3) Other services at an in-network facility

Out-of-network providers cannot balance  bill a patient unless written consent is given or a patient has given up their protections. Patients are never required to give up their protection from balance billing or required to get care out-of-network. 

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When balance billing isn’t allowed patients are only responsible for paying their share of the cost (e.g., copayments, coinsurance, and deductibles). The patients health plan will pay out-of-network providers and facilities directly.

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Patients health plans generally must cover:

• Emergency services without requiring approval for services in advance (i.e., prior authorization)

• Emergency services by out-of-network providers

• Base what a patient owes  as part of cost-sharing on what it would pay an in-network provider or facility and show that amount in the explanation of benefits

• Count any amount a patient pays for emergency services or out-of-network services toward the deductible and out-of-pocket coverage limit.

 

If a patient believes that they have been wrongly billed they can contact the Arizona Secretary of State (https://azsos.gov or (602) 542-4285).

 

Know your rights under federal law:

 https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.