Making Sense of Good Faith Estimate (GFE) Compliance for Addiction Counselors in Private Practice - DON'T GET FINED!

Whether you're just setting up your private practice or you've been working in the field for years, there's one thing all addiction counselors need to be on top of: the Good Faith Estimate (GFE) requirement under the No Surprises Act. This regulation came into effect in January 2022, and it’s easy to overlook if you’re used to doing things the old way. But here's the deal—if you're not providing GFEs for uninsured or self-paying clients, you could be at risk for fines.

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Disclaimer: I am not an attorney and cannot provide legal advice, and this article should not be considered legal advice. I always recommend that addiction counselors in private practice seek out a trusted legal advisor who can partner with them to ensure compliance with the Good Faith Estimate (GFE) and other regulations specific to their jurisdiction.

This isn't just for new counselors. Even seasoned professionals need to get on board. Whether you've been in private practice for years or are just starting, this requirement applies to everyone. You need to be sure you’re giving clients a clear estimate of costs upfront, or you could face significant penalties.

If you're unsure about what to include in your Good Faith Estimate, don't worry! You can download your free GFE template right here on my website by following this link to help you stay compliant and confident.

For the Veterans: Are You Doing GFEs?

Many experienced counselors may think they’re in the clear because they've run their practices smoothly for years. But are you providing Good Faith Estimates to all your uninsured or self-paying clients? If not, it's time to make sure you're following this regulation, or you could face significant penalties. Here’s why this matters: the No Surprises Act was introduced to protect clients from unexpected medical bills, and if you're not complying, you're at risk of being fined, even if you've been practicing for decades.

Don’t let your experience or routine keep you from adapting to this change. Even if you’ve never had to deal with this before, you need to start now. No matter how long you've been in practice, this is a legal requirement—and no one is exempt.

What Is a Good Faith Estimate (GFE), and Why Does It Matter?

A Good Faith Estimate is a written document that provides an estimate of the costs for services your client will receive. Think of it like a detailed invoice—except it's given upfront before services are provided. It’s required for uninsured clients or those choosing to self-pay, helping them understand the potential financial obligations.

Here’s why this matters for you: if you’re working with people paying out-of-pocket (and you likely will be in private practice), you’re legally required to give them this information ahead of time. You’ll need to have systems in place to create these estimates and deliver them in a way that’s clear, professional, and transparent.

When Do You Need to Provide a GFE?

This isn’t something you can decide to do when you feel like it; there are specific times you must provide this estimate:

1. When a client requests one—Even if a client hasn’t scheduled their session yet, they may want to know what things will cost. You’re obligated to provide that estimate when asked.

2. When a client schedules a service—Once someone schedules a session with you, you have to provide a GFE at least one business day before their first appointment.

3. Updates to the GFE—You are also required to update the GFE at least one business day before scheduled care under specific circumstances. This is crucial to stay compliant, especially if any of the following situations arise:

   • Significant Changes to the Cost of Care: If there are changes to the services that affect the cost, you must update the GFE. The most critical aspect here is ensuring that the actual billing doesn’t exceed the GFE by more than $400. Any major changes in billing should trigger a new GFE.

   • Extended Treatment Time: If you continue to treat a patient beyond the timeframe covered by the original GFE, you’ll need to issue an updated estimate to cover the extended services.

   • Changes in Scope: Technically, you're required to issue an updated GFE if there are any anticipated changes to the “scope” of the GFE. This could include changes to expected charges, the services provided, frequency, duration, or other aspects of treatment. While it’s not always clear what constitutes a “change in scope,” it’s better to err on the side of caution and update the GFE if there’s any doubt.

   
   
   
   

It’s also worth noting that industry groups, like the APA, are pushing back against some of these burdensome requirements, particularly the need to update GFEs for changes that don’t affect the expected cost. But until there’s a change in the rules, it’s safest to issue updates whenever there’s a significant alteration to the treatment plan.

How to Stay Compliant (Without Losing Your Mind)

For those of you new to private practice, compliance can feel like a constant stressor, but it doesn’t have to be. Here’s how you can make the GFE process smooth and painless:

1. Have a System in Place for GFEs

   
   

   The easiest way to handle this is to automate it where possible. Whether you're using practice management software or a simple spreadsheet, ensure that creating and delivering these estimates becomes part of your routine process.

   
   

2. Include All Potential Costs

   
   

   Your GFE should cover all the services a client will receive. This means if they’re seeing you for an initial evaluation, plus ongoing sessions, include those in the estimate. If you charge differently for specific services (for example, group therapy vs. individual sessions), be sure that’s reflected in the estimate too.

   
   

3. Document Everything

   
   

   Keeping a record of every GFE you send is not just good practice, it’s crucial for compliance. If there’s ever a question or dispute, you want to be able to pull up the documented estimate and show that you provided this information upfront.

   
   

4. Update Your Estimates as Needed

   
   

   As mentioned above, life happens, and treatment plans often change. If your client requires more sessions or you add new services to their treatment plan, be sure to update their GFE so it accurately reflects any adjustments to the cost.

But What Happens If I Don’t Comply?

Failing to provide a GFE when required can lead to financial penalties, and more importantly, it can damage the trust you've worked to build with your clients. Private practice is all about relationships, and transparency is a big part of maintaining those. If clients feel blindsided by costs, it’s going to reflect poorly on you, which is not how you want to build your reputation in private practice.

What About Special Cases Like Medicaid or Insurance Clients?

If you’re new to private practice, it’s good to know that GFEs are only required for uninsured or self-pay clients. If you primarily work with Medicaid, Medicare, or insurance-based clients, you won’t need to worry about this for them. But if you start branching out into more private-pay work, make sure you’re on top of the GFE rules.

Keeping It Simple: A Step-by-Step Guide for Private Practice Addiction Counselors

1. Create your GFE template—Make a standard template that you can quickly customize for each client. It should list all potential services and their costs. You can download your free GFE template right here on my website by following this link.

2. Provide the GFE when requested—Remember, clients can ask for an estimate at any time, even before scheduling.

3. Send the GFE before the first session—Once a session is scheduled, send the estimate at least one business day before.

4. Update and store your records—Keep a copy of every GFE for your files, and update them if treatment plans change.

5. Ask for help when you need it—If you’re feeling overwhelmed or unsure about compliance, don’t hesitate to consult a legal or compliance professional. You don’t have to figure this all out on your own.

What to Do If a Client Disputes Their Bill Based on the GFE

Even with the best intentions, billing disputes can happen. The Good Faith Estimate (GFE) is designed to help avoid surprises, but there are cases where the actual charges may exceed what was listed in the GFE. If a client feels that they’ve been billed too much, especially if the charge is more than $400 higher than the GFE, they have rights under the No Surprises Act to dispute the bill.

Here’s what the process looks like:

1. Contact the Counselor or Practice

   
   

   If a client is billed for more than $400 above the amount listed in the GFE, their first step is to contact your practice. They can:

   
   

   • Ask you to update the bill to match the GFE.

   • Request to negotiate the bill or discuss any misunderstandings.

   • Inquire if any financial assistance is available to help lower the costs.

     
     

   Being approachable and transparent during this process is essential for maintaining trust and resolving disputes in a professional manner.

   
   

2. Start a Dispute Resolution Process

   
   

   If the client and the counselor cannot come to an agreement, the client has the right to initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS). The key points to remember are:

   
   

   • The client must initiate the dispute within 120 calendar days (about four months) of receiving the original bill.

   • There is a $25 fee