Good Faith Estimate Notice
Your Right to a Good Faith Estimate
Under the federal No Surprises Act, effective January 1, 2022, individuals who do not have health insurance or who choose not to use their insurance to pay for healthcare services have the right to receive a Good Faith Estimate of expected charges, including psychotherapy services.
A Good Faith Estimate provides information about anticipated treatment costs before services begin. You may request one before scheduling an appointment or at any time during treatment.
A Good Faith Estimate is not a bill or a contract and does not require you to receive services.
Provider Information
Provider: Ellie Doherty, LMFT
California LMFT License: #15712
Email: Elliemdoherty@gmail.com
Phone: (323) 372-6855
Services: Virtual psychotherapy throughout California
Services and Estimated Costs
Ellie Doherty Therapy is a private-pay practice. Session fees are due at the time of services.
Services:
Individual Therapy: 50-55 minutes session | $225 per session
Couples Therapy: 50-55 minute session | $275 per session
Family Therapy: 50-55 minute session | $275 per session
CPT Codes: Applicable procedure codes will be included in individualized Good Faith Estimates and superbills, as appropriate.
90837 (53+ minute session), 90847 (50 minute couples therapy), 90834 (50 minute session)
Estimated Annual Cost
The total cost of treatment depends on the type, frequency, and duration of services received. Treatment frequency is determined collaboratively based on clinical needs and therapeutic goals.
The following examples are provided for financial planning purposes:
Services:
Weekly Individual Therapy (52 sessions x $225) = $11,700
Bi-Weekly Individual Therapy (26 sessions x $225) = $5,850
Weekly Couples Therapy (52 sessions x $275) = $14,300
Bi-Weekly Couples Therapy (26 sessions x $275) = $7,150
Weekly Family Therapy (52 sessions x $275) = $14,300
Bi-Weekly Family Therapy (26 sessions x $275) = $7,150
These estimates assume the listed number of sessions and do not represent a required treatment commitment. Actual treatment frequency and costs may vary.
Most clients attend therapy weekly or biweekly, although frequency may change throughout treatment. There is no minimum or maximum number of sessions required.
Insurance and Reimbursement
Ellie Doherty Therapy does not bill insurance directly and is considered an out-of-network provider.
Clients are responsible for paying the full session fee at the time of service.
Upon request, I can provide a superbill, an itemized receipt containing relevant billing information, including applicable CPT and diagnosis codes, which you may submit to your insurance provider for possible out-of-network reimbursement.
Reimbursement is not guaranteed and depends on your individual insurance plan. I recommend contacting your insurance provider before beginning treatment to confirm your benefits.
Your Rights Under the No Surprises Act
You have the right to:
Receive a written Good Faith Estimate when eligible under federal law.
Request an estimate before scheduling services.
Ask questions about expected treatment costs.
Potentially dispute a bill that is at least $400 more than the applicable Good Faith Estimate.
If you receive a bill that is at least $400 more than your estimate, you may qualify for the federal patient-provider dispute resolution process. Generally, disputes must be initiated within 120 calendar days of receiving the initial bill.
For more information, visit:
https://www.cms.gov/medical-bill-rights
Or call the No Surprises Help Desk at 1-800-985-3059.
Initiating an eligible billing dispute will not adversely affect the quality of healthcare services you receive.
Important Information
A Good Faith Estimate reflects the services and charges reasonably anticipated when it is prepared. Actual services, treatment duration, and charges may differ as clinical needs change.
Additional services that were not anticipated or require separate scheduling may not be included in an initial estimate. Separate estimates may be provided when applicable.
A Good Faith Estimate does not obligate you to receive treatment or require the provider to deliver services beyond those considered clinically appropriate.
Questions or Requests
If you would like to request an individualized Good Faith Estimate or discuss anticipated treatment costs, please contact me.
Ellie Doherty, LMFT
Email: Elliemdoherty@gmail.com
Phone: (323) 372-6855
I am happy to answer questions about fees and expected costs before beginning treatment.