Good Faith Estimate

INFORMATION FOR CLIENTS WHO DO NOT HAVE INSURANCE OR WHO ARE NOT USING INSURANCE:

Notice: You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 800-985-3059.

Village Wellness Family Counseling (VW) Good Faith Estimate

Federal laws regulating client care have been updated to include the “No Surprises” Act. Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services called a “Good Faith Estimate” (GFE) explaining how much your medical care will cost.

This regulation is designed to provide transparency to patients regarding their expected medical expenses and to protect them from surprises when they receive their medical bills. It allows patients to understand how much their health care will cost before they receive services.

There are several factors that make it challenging for VW to provide this estimate as treatment times vary for individuals in therapy depending on their goals and motivation for seeking treatment. Please remember that ultimately it is your decision when to terminate therapy services. 

At VW, we are required to provide a diagnosis for all clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act". A formal diagnosis occurs after an assessment has been completed. That will take place within the first 4 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, we will not update the GFE. It is within your rights to decline a diagnosis per state and federal guidelines. 

Common Diagnosis Codes at VW Below are some common diagnosis codes, please note that this list is not exhaustive. Diagnosis codes can change based on many factors. Please speak to your therapist with any questions or concerns.

• Adjustment Disorder (F43.23)

• Mental Disorder, Not Otherwise Specified (F99)

• Major depressive disorder (F32.9)

• Generalized anxiety disorder (F41.1)

• PTSD/Post Traumatic Stress Disorder (F43.10)

• Attention-Deficit Hyperactivity Disorder (F90.9)

VW recognizes everyone’s therapeutic journey is unique. 
Your length of treatment will be influenced by many factors including, but not limited to;

Your schedule and life circumstances; therapist availability; ongoing life challenges and previous commitments; the nature of your specific challenges and how you address them; personal finances; and more.

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change. 

According to the American Psychological Association, “on average 15 to 20 sessions are required for 50 percent of patients to recover as indicated by self-reported symptom measures”. Additionally, they state that through the working relationship between the client and counselor sometimes the preference is for “longer periods (e.g., 20 to 30 sessions over six months), to achieve more complete symptom remission and to feel confident in the skills needed to maintain treatment gains”.  

Whatever your number of sessions will be, we will work together to meet your needs.  

Common Services at VW

90791: Intake session ($220)

90834: 45-50 minute psychotherapy session ($220) 

90847/46: Family/Couples psychotherapy session ($250)   

90837: 53+ minute extended psychotherapy session ($220) 

Where services will be delivered. 

VW provides services in person in Thousand Oaks, California and via teletherapy throughout California

VW office location

516 Pennsfield Place, Suite 212, Thousand Oaks, CA 91360

Provider Information

Provider Name: Village Wellness Family Counseling, P.C. NPI2: 1649764648 TAX ID: 83-0731905 Email: info@villagewellnesscounseling.com Phone #: 818-917-6596

Good Faith Estimate

For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range. Out of an abundance of caution and transparency, we will only quote weekly appointments.

90791: Intake session ($220) +  90834: 45-50 minute psychotherapy session ($220) for 52 weeks: $11,440
90791: Intake session ($250) + 90847/46: Family/Couples psychotherapy session ($250) for 52 weeks: $13,000
90791: Intake session ($220) + 90837: 53+ minute extended psychotherapy session ($220) for 52 weeks: $11,440

The above examples are provided to give an idea of the financial expectations for a calendar year. The frequency and duration is dependent on your individual needs and goals and will vary.

We look forward to talking with you and answering any questions you may have about the “No Surprises” Act and Good Faith Estimates.

Good Faith Estimate 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. 

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. 

You may contact us at info@villagewellnesscounseling.com or call 818-917-6596 to let us know the billed charges are higher than the Good Faith Estimate. You can ask us 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 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. 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.

This is the public disclosure of the “Good Faith Estimate”

Village Wellness Family Counseling has always provided transparency in our billing practices by displaying our fee schedule within our Informed Consent. Please know that the Good Faith Estimate does not change any agreements you have already made with us with regard to self pay. Your review of this form and signature is required so that we can demonstrate our compliance with the mandate. Thank you!

If you have questions or concerns about the Good Faith Estimate or the No Surprises Act, please reach out to us at 818-917-6596 or email us at info@villagewellnesscounseling.com.