Good faith estimates for self-pay therapy clients: when to send them and what goes on them

Most small practices meet the good faith estimate rule with a sheet they made once in 2022 and rarely look at. The rule is simple to follow once its two triggers are clear: the client pays for themselves, and a session is booked far enough ahead. What goes wrong is timing. The estimate has to reach the client within a business day or three of booking, which is easy to miss in a busy week unless it goes out with the booking itself.

Which clients get one

The rule covers an "uninsured (or self-pay) individual": someone with no coverage for the service, or someone who has coverage but does not want a claim submitted for it.¹ A client who uses insurance for some sessions and pays for others counts as self-pay for the sessions they pay for themselves.

The practice has to find out which clients these are. When scheduling, the rule asks you to ask whether the client has health coverage and, if they do, whether they want a claim submitted for the service.¹ Our recommendation is to make these two questions part of every booking, written into the booking form or the phone script, and to record the answer with the appointment.

The rule also asks for a notice that self-pay clients can get an estimate, in three places: on your website, where it is easy to find, in the office where people book or ask about prices, and said aloud when someone schedules or asks what a session costs.¹

When it has to go out

Those are the deadlines in 45 CFR 149.610(b)(1)(vi).¹ A client who books for tomorrow is not covered by the first two rows, but a request still is. The estimate must be written, on paper or electronically, and an electronic copy must be one the client can save and print.¹

Our recommendation is to send it the moment the first session is booked, whatever the notice period. One rule for the team is easier to keep than three, and the client gets the price before they come in.

What it has to list

For a therapist working alone, the list in the rule comes down to this:¹

• the client's name and date of birth;
• the service, described in plain words, and the date if one is booked;
• an itemized list of what is expected, with the service code, the diagnosis code and the expected charge for each item;
• your name, National Provider Identifier, Tax Identification Number and the place the service is given, in person or by telehealth;
• a line saying that anything else recommended later is not included and would need its own estimate;
• a line saying the estimate is only an estimate, and the charges may differ;
• a line on the client's right to dispute the bill if it is substantially more than the estimate, where to find out how, and that starting a dispute will not affect their care;
• a line saying the estimate is not a contract and does not oblige the client to have the service.

If the client will also be seen by someone else as part of the same care, the rule asks for their items and charges too.¹ CMS's training for providers walks through each part with examples.⁴

Weekly sessions: one estimate for up to 12 months

Therapy is usually a series, and the rule allows one estimate for recurring services. It must describe what is expected: the period, how often, and how many sessions in total. Its period cannot be longer than 12 months. If sessions are expected beyond that, a new estimate goes out, explaining what has changed.¹

When something changes after the estimate was sent, such as a move from weekly to twice-weekly sessions, a new fee or another provider joining the care, a new estimate must reach the client no later than 1 business day before the next session.¹ Our recommendation is to keep a renewal date with each self-pay client's file, 12 months from the first estimate, and to look at the expected number of sessions whenever the treatment plan is reviewed.

If the bill comes in higher

The client may start the patient-provider dispute process when the bill is at least $400 more than the total on the estimate. They have 120 calendar days from receiving the first bill with those charges.² CMS tells patients the same thing in plain words.³

The estimate is part of the client's record, and you must give a copy of any estimate from the last 6 years when asked.¹ Our recommendation is to file each estimate the day it is sent, next to the client's intake forms from our new patient intake checklist, so the copy is there if a question ever comes.

This is a summary of the federal rule, not legal advice. Your state's rules and your licensing board may ask for more.

Wording you can copy

Replace the words in brackets. The first is for your website and your front desk. The others go out with each booking.

The same booking messages can carry your cancellation terms from our late cancellation policy guide. For clients who do use insurance, the checks before the first session are in our insurance verification checklist.

What can run by itself

• The two questions at booking, on the form or in the scheduler, with the answer saved against the appointment.
• The estimate itself, filled in from the client's details and your fee schedule, and sent within the hour for every self-pay booking.
• The copy for the record, filed in the client's chart with the date it was sent.
• The renewal reminder, two weeks before an estimate's 12 months end, and a prompt to the clinician when a fee changes, as in our front desk automation guide.

What stays with your team

• The expected number of sessions. It is a clinical judgment, and an honest one protects both the client and the practice.
• Clients whose situation changes, such as losing insurance halfway through treatment, which needs a conversation as well as a new estimate.
• A bill that has gone over. Talking to the client early is better than waiting to see whether they dispute it.

More of what we write for practices is on the blog.

Questions practices ask