Good Faith Estimates
As mandated by the 2022 No Surprises Act
Good Faith Estimate
Effective January 1, 2022, a ruling went into effect called the “No Surprises Act,” which requires mental health practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care to any patient who is uninsured or who is insured but does not plan to use their insurance benefits to pay for health care items and/ or services, whether it is because they do not wish to use insurance or because their provider does not accept their insurance.
Under the No Surprises Act, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
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.
● 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 healthcare 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.
Riverbend Counseling and Behavioral Health’s Good Faith Estimate:
The following is a detailed list of expected charges.
Provider estimates: *Maximum does not include late cancellation/no-show fees, non-therapeutic charges e.g. documentation fees, banking fees, anger management, life skill services, or other financial arrangements based on a case-by-case basis. See ‘Practice Policies, Disclosure, and Financial Responsibility” for complete details regarding this fee scheduled.
Psychotherapy:
00000- Initial Consultation, 20 minutes - $0.00
90791 – Intake Session – Individual/Group/Families 50 minutes - $165
90832- Individual Psychotherapy, 16-30 minutes- $70
90834- Individual Psychotherapy, 30-45 minutes- $100
90837- Individual Psychotherapy, 50 minutes - $130
90847- Family Psychotherapy, conjoint psychotherapy w/ patient present, 50 minutes -$130
90846- Family Psychotherapy, conjoint psychotherapy w/o patient present, 50 minutes -$130
90839- Psychotherapy Crisis, 60 minutes- $130
90840- Additional Psychotherapy, 30 minutes -$60
90853- Group psychotherapy, 45-60 minutes- $60
90849- Multiple-family group psychotherapy, 45-60 minutes- $60
75- minute psychootherapy esssion - $165.00
SM Individual Intensives: $150.00 for every 60 minutes scheduled. For example, a 4-hour intensive scheduled from 1:00pm - 5:00pm would be $600.00
Non-Therapeutic/Other Fees:
Cancellation Fee: $100.00
Chargebacks - $30.00
Non-sufficient funds (NSF) - $30.00
Documentation fee- $30.00
Phone calls outside of session: $30.00 for every 15 minutes.
Emails outside of session: $30.00 per email
Other written communication between sessions: $30.00 per written reply
Court/Litigation:
Retainer for court services due in advance: $1500.00
Communications (phone, text/SMS/email, written letters, ect.) - $150 per hour
Deposition/Testimony- $150 per hour
Travel and mileage- $150 per hour plus $0.56 per mile
Court filing – $100 plus associate fees
Express service (less than 72 business hours)- $200
Reset fee (Less than 72 business hours) - $400
Riverbend Counseling and Behavioral Health, LLC Estimated Total Psychotherapy Intake Fee:
Individual and Couple/Family Intake Session Fee: $165.00
Riverbend Counseling and Behavioral Health, LLC Estimated Total for weekly/bi-weekly/monthly psychotherapy sessions:
Individual/Couple/Family Weekly Session Fee: $130.00
Total Estimated Psychotherapy Cost*:
Below are examples of a Maximum Total Estimated Psychotherapy Cost, depending on the services you choose. Please bear in mind that these estimates assume I work 52 weeks a year, which is unlikely due to scheduled time off and/or sick leave:
For Weekly Individual/Couple/Family Session Fee: Maximum= $6795.00 (for one intake session + 51 50-minute sessions).
For Bi-weekly (2x/week) individual/couple/family session fee: Maximum= $13425.00 (based on 2x/week for 51 weeks x @ $130.00 + 1 intake appointment at $165.00)
For weekly group therapy fee: Maximum= $3225.00 (based on 51 weeks @$60.00/group session + one intake appointment at $165.00)
Length of Services:
Psychotherapy services can range from one or two days to two months, to a year or more. The length of time you will need to be in therapy is based on your therapeutic goals, your overall wants/needs, and any psychosocial/financial barriers may arise. With that being said, communication is key to any healthy relationship. Should a financial hardship occur, you are encouraged to discuss your situation with Riverbend Counseling and Behavioral Health, LLC to determine the best resolution as it pertains to your continuity of care and the therapeutic relationship.
Should more time be required to meet your therapeutic goals, Riverbend Counseling and Behavioral Health, LLC will discuss your options with you at which time a new Good Faith Estimate will be created, your therapeutic services will end, or you are referred to another provider.
The above listed total estimated psychotherapy cost is based on a 52-week structure at the individual/family rate of $130.00 per one session a week and intake fee of $165.00 equating to $6795.00. These totals DO NOT account for no show/late cancellation fees, bank charges, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, anger management, life skill services, or other financial arrangements based on a case-by-case basis. You are encouraged to carefully read the ‘Practice Policies, disclosure, and financial responsibility for complete details regarding fee schedule.
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. This 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 the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them 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 HHS at (800) 368-1019.
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) 368-1019.
Provider Estimate
Please review the 'Practice Policies, Disclosure, and Financial Responsibility' for the complete details regarding Riverbend Counseling and Behavioral Health, LLC fee schedule. *Maximum DOES NOT account for no show/late cancelation fees, bank charges, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, anger management, life skill services, or other financial arrangements based on a case-by-case basis.
Provider name: Riverbend Counseling and Behavioral Health, LLC
Provider/facility type: Outpatient Mental Health Clinic
Street address: 11 Davis Keats Drive
City: Greenville
State: South Carolina
ZIP code: 29607
Contact person: Madison Crook
Phone: 864-581-2458
Email: madison@riverbendcounselingllc.com
National Provider Identifier (NPI): 1356865976
Taxpayer Identification Number (TIN): 67761088
Details of Services and Items for Riverbend Counseling and Behavioral Health, LLC
Address where service/item will be provided: 11 Davis Keats Drive, Greenville, SC 29607 or a secure Telehealth platform
Diagnosis code will not be provided before first appointment.
Service code(s):
00000- Initial Consultation, 20 minutes - $0.00
90791 – Intake Session – Individual/Group/Families 50 minutes - $165.00
90832- Individual Psychotherapy, 16-30 minutes- $70.00
90834- Individual Psychotherapy, 30-45 minutes- $100.00
90837- Individual Psychotherapy, 50 minutes - $130.00
90847- Family Psychotherapy, conjoint psychotherapy w/ patient present, 50 minutes –$130.00
90846- Family Psychotherapy, conjoint psychotherapy w/o patient present, 50 minutes –$130.00
90839- Psychotherapy Crisis, 60 minutes- –$130.00
90840- Additional Psychotherapy, 30 minutes -$50
90853- Group psychotherapy, 45-60 minutes- $60.00
90849- Multiple-family group psychotherapy, 45-60 minutes- $60.00
75 minute sessions: $165.00
Quantity (For meeting once per month)
1 intake session @ $165.00 = $160.00
12 16-30 minute sessions (1 session x 1 month x 12 months) @ $70.00 = $840.00 (PENDING NEED)
12 30–45-minute sessions (1 session x 1 month x 12 months) @ $100.00 = $1200.00 (PENDING NEED).
12 50-minute sessions (1 session x 1 month x 12 months) @ $130.00 = $1560.00
12 50-minute Group Therapy sessions (1 session x 1 month x 12 months) @ 50.00 = $600
Quantity (For meeting biweekly/twice per month)
1 intake session @ $130.00 = $1650.00
24 16-30 minute sessions (1 session x 2 month x 12 months) @ $70.00 = $1680.00 (PENDING NEED)
24 30–45-minute sessions (1 session x 2 month x 12 months) @ $100.00 = $2400.00 (PENDING NEED).
24 50-minute sessions (1 session x 2 month x 12 months) @ $130.00 = $3120.00
24 50-minute Group Therapy sessions (1 session x 2 month x 12 months) @ $60.00= $1200.00
Quantity (Meeting once per week/ four times per month):
1 intake session @ $165.00 = $165.00
52 16-30 minute sessions (1 session x 2 month x 12 months) @ $70.00 = $3640.00 (PENDING NEED)
52 30–45-minute sessions (1 session x 2 month x 12 months) @ $10000 = $5200.00 (PENDING NEED).
52 50-minute sessions (1 session x 2 month x 12 months) @ $130.00 = $6760.00
52 50-minute Group Therapy sessions (1 session x 2 month x 12 months) @ $60.00 = $3120.00
*Maximum does not include late cancelation/no show fees, crisis sessions, non- therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, anger management, life skill services, or other financial arrangements based on a case-by-case basis.
*Please note that the cost of total services will be in part dependent on the services you choose, and that it is extremely uncommon to meet for all 52 weeks in a year due to planned time off, sick leave, and/or other scheduling conflicts. These are examples of totals. Your total cost in a year may be calculated by using the cost of service codes described above and multiplying them by the frequency you use them.**
**This estimate does not take in account for sliding fee benefits as those benefits are based on clients income and fall under "other financial arrangements". Estimate is based on fees quoted at time of initial contact and confirmed in consultation appointment.