The No Surprises Act of 2022 (H.R. 133) and the Good Faith Estimate (GFE) are important changes in how patients are informed about the costs of health care treatment. Consumers have a right to an estimate of costs involved in medical treatment and to be able to advocate for themselves if they dispute charges. As providers of medical treatment, we need to be transparent about what we charge and bill for.
The act has resulted in an uproar from many health care practitioners. Hospitals, small medical practices, and emergency medicine providers worry that they will be forced out of business because it will lead to unreasonably low rates. Practitioners worry that medical billing arbiters will decide the fair price that they can charge for health care services.
When psychologist groups got wind of this new rule requiring that we explicitly state—verbally and in writing—the cost for a course of therapy it engendered animated discussion about how unrealistic and cumbersome it will be. For many therapists, the change seems unnecessary when we already state our fees in our consent forms or on our websites and we discuss payment policies with clients when we schedule their first session.
The Reasons Behind the No Surprises Act
First, a bit of background about why this is a good thing for patients and will not harm our practices. For years private equity firms have been clawing their way into healthcare practices, venturing into hospitals, youth wilderness camps, dentistry, nursing homes, substance abuse clinics, and even veterinary practices. Some of their biggest investments have been in emergency medicine, radiology, and anesthesiology—practices that generate the largest surprise bills. Ultimately the surprise costs come from out-of-network charges that are unnecessarily inflated and don’t go to the providers of care but into the deep pockets of private equity groups. Studies have found that 20 percent of patients who had emergency services were treated by someone outside their insurance network. Therefore, this bill primarily targets out-of-network providers.
As the bill’s cosponsors, Rep. Katie Porter (D-Calif.) and Sen. Tina Smith (D-Minn.) learned, these practices are not only creating financial hardships for patients but also pressuring providers to recommend nefarious and unnecessary treatment, like recommending that babies get root canals. Legislators on both sides of the aisle voiced support of the bill.
An investigation by The New York Times revealed who was behind the multimillion-dollar campaign to resist ending surprise medical billing: a shadowy dark money group called Doctor-Patient Unity that is spearheaded by some of the largest culprits of surprise medical billing.
Doctor-Patient Unity is comprised of Team Health and Envision Healthcare, which are owned and controlled by private equity firms. The group engaged in a $28 million advertising campaign that claimed the proposed legislation was ‘government rate setting’ and would affect patients’ access to medical care. This is misinformation. It is disconcerting that the Wall Street firms reaping excessive profits from surprise medical billing are the primary opponents of legislation designed to protect patients.
I am grateful that my graduate school required courses in research design, statistics, and test construction. Those classes were necessary for the literature reviews and studies we did for our dissertations. They seem more important to me now 25 years post-grad school. Yet most people have not had that background. Facebook ads, Google advertising, and mass direct mail campaigns have profound influence, as we have seen too often these last few years.
The No Surprises Act for mental health professionals asks that we provide a Good Faith Estimate (GFE) of what clients are likely to pay over the course of their treatment when we schedule our first appointment with self-pay or uninsured patients. It is a reasonable estimate based on clinical judgment and experience. The legislation is not singling out private practice psychologists. We are necessarily caught in this because we are healthcare providers.
This bill’s requirements are intended for clients who are private pay or not using insurance for their care. It is just an estimate, as in many cases that involve mental health it can be difficult to know how much treatment is needed when we schedule the first appointment.
The mental health field is undergoing a paradigm shift, and we are on the front lines. The pandemic has moved much of our work online and has concurrently created a greater need for our services while at the same time destigmatizing mental illness and psychotherapy. Therapy services are in high demand, and many of us have long waiting lists. This is not lost on big business. Companies are swooping in by offering online therapy with big enough panels to meet the need. Here in California, tech companies have begun offering their employees services like Lyra among others. By now we have all been bombarded by ads recruiting us to join teletherapy panels and seen the countless ads targeting potential patients. The good news is that this increases access to care which has been sorely needed.
Another provision in the No Surprises Act requires insurance companies to update their provider panels on a regular basis. All too often I’ve heard stories of people who call dozens of therapists on their insurance panel to be told they will not take their insurance and in many cases, they never receive a return phone call. People in emotional pain finally muster the courage to make calls to therapists and no one calls them back! It is understandable that therapists must make hard decisions regarding how many patients they can take when reimbursement rates offered by insurance are in no way commensurate with our training and expertise.
It is not surprising for big business to find a way to profit in the mental health arena. We’ll have to wait and see how private equity and other Wall Street investment continues to shape our profession–hopefully in good ways.
How will all this affect psychologists?
For those of us with private pay patients, some clients will respond, ‘well, I already made a calculation of what my treatment with you will cost me, so I won’t be surprised”. Clients who are savvy about money will budget for their therapy and know exactly how much they can spend. These clients know their financial comfort level and know to ask for fewer sessions per month or a reduced fee. They may have made a deliberate choice to use that $1000 a month for their therapy rather than a monthly payment on a new Tesla. Still others are in an income bracket where costs are of no concern. And yet we will have clients who need our help but may not be realistic about how much they can afford or how quickly it adds up when paying without the help of insurance.
Our work is complex and multi-layered. Each client’s intrapsychic dynamics unfold over time affecting the way we work and the length of treatment. Unexpected life struggles will happen during our work. We are not soothsayers who can predict what may impact our treatment; a client becomes suicidal or discovers a scary medical diagnosis, there is substance abuse, a partner reveals an affair, a child is suddenly discovered to have been abused. Any number of situations and traumas can intrude during treatment. As therapists, we help patients cope with whatever comes into the therapy room and that includes the unknown, the unconscious, and the unfathomable. This is also what makes our work interesting—we must be both agile and vigilant as we endeavor to help those who come to us.
Conflicting Desires: Putting Money Front and Center in Therapy
The Good Faith Estimate provides a therapeutic opportunity for both client and therapist. Kachina Myers elucidates the conflicting desires of therapist and patient regarding money in the article Show me the Money: The Therapist’s Desire, Subjectivity, and Relationship to the Fee. She suggests that avoidance of fee discussions in therapy may be an avoidance of growth for both analyst and patient and can lead to treatment stagnation and analytic poverty. Therapists often fear and avoid getting into money discussions yet having these crucial conversations about fees can increase the client’s capacity with money and empower therapists who all too often are unable to ask for their desired fee.
As therapists, we often get into this work because we were caretakers in our families. We learned that other people’s needs were more important than our own, thus splitting off our needs to meet our family’s needs. The desire and the need to be paid for our caretaking create internal conflict. No matter where we are in our career, discussing fees can bring up anxiety because as soon as money is addressed with a client, the value of treatment is open for discussion. Therapists may be reluctant to raise fees or to pursue outstanding balances when we worry that there is something inadequate in the work we have done with patients.
How we implement our Good Faith Agreements for our clients is still evolving. It is clear which clients we need to give GFA to. APA is working with CMS and we’ll get more information over the next months. For information on the specific requirements please see this article.
In the meantime, I created my GFA and include it in my intake forms. I state the cost of sessions and the range of expected treatment during our first phone call. I give an actual dollar amount for low and high figures (6 sessions and up to 60 sessions depending on the presenting complaint). I have the client e- sign the document and ask that they take a photo or make a copy for their records. I have had no push-back so far and each client seems happy to do it.
APA: Understanding the No Surprises Act: How to provide estimates of your services. https://www.apaservices.org/practice/legal/managed/no-surprises-act
The No Surprises Act—New Resources. https://www.cpapsych.org/view.aspx?messageId=0bb7f7dad4ec456a88bdfad682982dd6
Myers, K. (2008). Show Me the Money:(the “Problem” of) the Therapist’s Desire, Subjectivity, and Relationship to the Fee (2008). Contemporary Psychoanalysis, 44:118-140