Good Faith Agreement
The No Surprises Act is a law which went into effect 1/1/2022, and requires us to provide you with a Good Faith Estimate of the *total cost* of your treatment *for an entire calendar year*. The law requires us to make this estimate prior to completing an initial assessment; in addition, the course of treatment varies for each person.
Under the law, health care 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. The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care. If you plan to use your out-of-network
benefits, this does not apply to you.
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover for out-of-network providers, including Dr. Bojarski.
This means that the final cost of services may be different than this estimate. You and Dr. Bojarski will determine the frequency of appointments together based on your needs. This may vary depending on whether you receive services for medication management, therapy, or both.
Billing Codes:
The Good Faith Estimate also requires us to provide you with expected diagnostic codes. This can vary depending on the complexity of a given appointment and can only be finalized at the completion of the appointment. Below are the potential diagnostic codes used by Equilibrium Behavioral Health.
Primary service requested/scheduled, with CPT billing code:
Psychotherapy, 50 minutes (90838)
Psychotherapy, 75 minutes (90837)
Medication visit in conjunction with psychotherapy services, 25 minutes (99214 plus 90833)
Medication visit in conjunction with psychotherapy services, 50 minutes (99214 plus 90838)
Initial Psychiatric Evaluation to assess for mental health/substance use disorder, 75 minutes (90792)
Diagnostic Codes:
The Good Faith Estimate also requires us to provide a diagnostic code. This is not a complete list and is subject to change. Your diagnosis or diagnoses may or may not be included in this list. The diagnosis codes for each service are dependent on each individual's condition and you may have more than one. Diagnoses for some disorders vary over time. Some of the most commonly used diagnosis codes include, but are not limited to the following:
Primary diagnosis, with ICD:
F31-F31.9: Bipolar Affective Disorder
F32-F33.42: Depressive Disorders
F39: Unspecified Mood Disorder
F40-F40.9: Phobic Anxiety Disorders
F41-F41.9: Other Anxiety Disorders
F42-F42.9: Obsessive Compulsive Disorders
F43-F43.9: Reaction to Severe Stress and Adjustment Disorders
F50-F50.9: Eating Disorders
F32.81 PMDD
F25-F25.9: Schizoaffective Disorders
F20-F20.9: Schizophrenia
F60-60.9: Specific Personality Disorders
F90-F90.9: Attention-Deficit Hyperactivity Disorders
F17.20: Nicotine Dependence
F10-10.9: Alcohol Related Disorders
F12-F12.9: Cannabis Related Disorders
List of Fees including applicable CPT codes:
Psychotherapy, 50 minutes (90838) - $450
Psychotherapy, 75 minutes (90837) - $675
Medication visit with psychotherapy services, 25 minutes (99214 plus 90833) - $300
Medication visit with psychotherapy services, 50 minutes (99214 plus 90838) - $450
Initial Psychiatric Evaluation, 75 minutes (90792) - $800
There may be multiple diagnoses and/or other codes involved in a visit. If you have any questions about what your diagnosis is please contact Dr. Bojarski.
Please be advised that this is an estimate for a person who may have a complex course of treatment
which may require frequent appointments. Many people will need shorter visits and/or fewer visits over time, and will therefore have a LOWER COST for a first year of treatment.
PLEASE NOTE: The number of sessions differ for each person based on their needs.
You and Dr. Bojarski will determine the necessary frequency and length of appointments together. This will vary depending on whether you receive services for medication management, therapy, or both. Please keep in mind this estimate does NOT account for any potential out-of-network reimbursements from your insurance carrier you may receive.
You should also be aware that, since we charge for “other professional services” (described in the new client contract), this may add additional out-of-pocket costs. In addition, we charge the FULL FEE for missed appointments OR appointments that are not canceled within 24 HOURSof the appointment time. This may also affect your Good Faith Estimate.
Date of Good Faith Estimate (GFE): Estimated cost: As noted above, it is difficult to correctly estimate the frequency and therefore, total costs.
Weekly therapy without cancellations or vacation would cost, per year:
450$ x 52 = $23400
Monthly Medication management without cancellations would cost, per year:
$300 x 12 = $3600
Provider name and National Provider Identifier (NPI): Emeric Bojarski, MD, NPI: 1669715090 Tax Identification Number: 84-3009610
Disclaimers:
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. The 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 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.