Why Your Therapist Is Suddenly Presenting You With A Huge Billing Estimate…And Why We’re All Confused By This

a couple who is shocked by something they're reading

Joe Borders, MFT

By Joe Borders, MFT

Therapist in Sacramento and Roseville

December 30th, 2021

Why Your Therapist Is Suddenly Presenting You With A Huge Billing Estimate
…And Why We’re All Confused By This

If you’re in therapy you may have recently received a huge billing estimate from your therapist. Or if you’re a prospective client looking for a new therapist, you may have been surprised when the person you talked to mentioned a huge potential cost for therapy. This may have…..surprised you!…welcome to the crazy, completely confusing, and yes, surprising world of the No Surprises Act!


  • There’s a new law coming into effect on 1/1/22 that is supposed to help reduce surprise medical bills.
  • In spirit this is a great idea! But it’s affecting private practice therapists in a weird way.
  • Everyone is confused.
  • No one heard about this until 1-2 weeks before it went into effect.
  • Therapists now have to diagnose you before they meet you *we think?
  • Your therapist now has to provide you with a “good faith estimate” of how much therapy will cost you.
  • Its impossible to estimate this so we are being told to tell prospective clients that we estimate their treatment will cost our session rate x 50 (52 weeks in a year minus vacation time).
  • This amounts to people receiving a 4 to 6 page document from their therapist, before even meeting them, that contains a diagnosis, and a potential price tag of $7,000+.
  • Sticker shock is real and this is going to hurt a lot of people.
  • This new law applies to all licensed medical providers…except dentists….because reasons.

You may have heard about this somewhere in the news or on social media, but on January 1, 2022, the “No Surprises Act” is going into effect. The spirit of this law is to prevent crazy, terrible situations like people going to an in network hospital and receiving services from an out of network doctor who then bills them $50,000 or some such astronomical number.

This is all well and good…..but the way the law is written is….very confusing, broad, and unfortunately puts private practice therapists in a very awkward and confusing position.

We Are All Surprised

For the first part, none of us heard of this before December 10th. It is quite literally a surprise to all of us. I’m a member of a Facebook group for therapists trying to figure out the No Surprises Act. The page was created on Christmas day and in the 5 days since then the group has amassed almost ten thousand confused and frustrated therapists. One thing that is immediately clear when reading through the comments in this group is that nobody saw this coming, and many are rightfully angry about it. From all accounts I have read, the earliest anyone received any notification from any of our professional organizations was an article put out by the American Psychological Association on the 1oth of December, only 20 days before it goes into effect! I, and many others only heard about this thing through Facebook this week and I’ve seen dozens of accounts of therapists on Christmas break or on vacation somewhere trying to figure out how to accommodate this thing before it goes into effect!

So What Is It?

The No Surprises Act is intended to prevent surprise billing: people getting unexpected, huge charges for medical services after the fact. How the act actually does this is….hugely debated and extremely confusing. When I first found out about it I went straight to the source, found the bill, and immediately gave up upon seeing that it is over 130 pages of legalese.

In spirit this law is a great idea, and in some ways I’m sure it will really help people and reduce surprise billing. But it starts to make a lot less sense and get really complicated when applied to something outside of a hospital or a strictly medical setting. This article is about how its playing out with private practice counselors and therapists.

Before I explain what exactly is going on, its important to note again:

We Are All Confused

Everything I’m about to tell you is largely uncertain and up for speculation. Everyone is confused and bouncing around between different answers, conclusions, and speculations. There are several trainings being offered on the subject and they are presenting conflicting information. Multiple people have reported having called their malpractice insurance and been told their lawyers can’t help because this is “a billing issue” and some have been told by their lawyers that they are just as confused as the rest of us.

An acronym I’ve seen thrown around a lot in the last couple of days is CYA…I thought this was a legal term, but it turns out it means cover your ass! :-p

So enough complaining, here’s the deets:

The stuff we know for sure:

  1. Therapists are now required to assess if their clients have insurance and ask them if they intend to use it.
  2. If a therapist is out of network they must inform potential clients that they have the option to find an in network therapist.
  3. If a prospective client chooses to schedule with an out of network therapist, then the therapist must have them fill out and sign a 4 to 6 page document attesting that they are choosing not to see an in network provider.
  4. If a client schedules or requests therapy, therapists must provide them with a “good faith estimate” of how much services will cost.

Number four is where things get really crazy and confusing. The law requires that this “good faith estimate” (GFE) is to be given to clients before the first session. The major problem with this is that the law also requires that the GFE contain a diagnosis.

So problem #1…..are we being asked to diagnose people before we even meet them?

a facebook comment about the no surprises act and how it affects therapists

The biggest problem, and the focus of the title of this article

A “good faith estimate” makes sense when you’re talking about a relatively straight forward service like getting a cast for a broken arm. Not so much for therapy, which is hard to predetermine the length of. Every client is different and comes to therapy for different reasons. When people come to therapy for relatively straight forward things like specific phobias or life adjustments, therapy can sometimes be as short as 4 to 12 sessions. But on the other hand, a good number of people come to therapy for more deeply rooted issues that can take months and years to treat. Others come to therapy for introspection and self-actualization: striving towards becoming their best possible selves. This kind of work can take time and its impossible to define in advance, before meeting someone, how long they will need to be in therapy.

The consensus on the way the law is currently written seems to be that therapists need to provide a good faith estimate of expected charges up to 50 weeks (52 weeks minus vacation and sick time). So essentially what we’re being told is to provide all new and existing clients with a document that says something to the effect of:

My fee is $140 per session and I expect your treatment to consist of weekly sessions throughout the year for a total of $7,000.

Sticker Shock!

A big thing we’re all concerned about here is sticker shock! How many people are going to be immediately turned off by this and abandon the prospect of therapy when they are told before they even start, that therapy may cost them $7,000+ ?

Honestly, sometimes therapy does cost this much. Sometimes people stay in therapy for quite some time, but I would personally estimate a good 30% of the people I see come for 12 sessions or less, 40% come for 12 to 30 sessions, and the remaining 30% for something more than that. But we cannot predict how much therapy will cost any one person in the end, and giving a huge, up front prediction like this is going to scare people away.

One person in the Facebook group compared this to you getting sick and going to a doctor and before arriving for your appointment the doctor presents you with a good faith estimate of how much you will pay throughout the year based on the assumption that you get sick 5 times that year. That bill might hover around a thousand dollars or more depending on your coverage. We don’t do this. It doesn’t make sense. This would keep some people from seeking treatment.

I totally agree that people should know how much something is going to cost, but:

  1. Its impossible to effectively and ethically predefine treatment length.
  2. Therapists are already required to disclose their session fees before starting therapy.
  3. The installments argument: how many things do you purchase in life that you pay for on a monthly or per instance basis that would seem crazy and off putting when presented as a yearly cost? Your favorite coffee drink might cost $5 but what if the coffee house was required to label an estimate for how much it would cost if you got that drink 5 days a week for a year?….$1,300! You could apply this idea to many things you pay for and they would seem upsettingly expensive when calculated as a yearly expense.

One person in this Facebook group compared this whole thing to calorie listings on foods.
In theory this is supposed to help you make good nutritional choices.
……but nobody projects caloric values by years!

Some Concerns

So, you might say, then these people will just go to in network providers. We don’t have enough in network providers! Partially as an experiment, I recently tried to find a therapist in network to see myself. I spent 2 months searching through 100+ potential in network providers, emailed 30 of them, heard back from 9, and got scheduled with one after 4 months of struggling with it.

We don’t even have enough out of network providers! The website you’re on right now hosts a therapist directory I created for the greater Sacramento area here in California. I’ve had well over a hundred therapists leave the site over the last year and a half saying that they’re completely full and don’t need any advertising.

This all brings up so many questions people are scrambling to find answers to and we are all concerned about how the sticker shock is going to affect people. Personally, one of my specialties is working with trans and gender non conforming teens. I can’t tell you how many times I have reduced my fee because the cost is difficult for parents. These kids have my heart and I want them to get the help they need, so I lower my fees. But how is that going to work out now that I have to tell that reluctant parent that their kid’s treatment is going to cost up to 3,500 (half fee) or more?

A lot of this feels like rambling, but I had to get this out there somehow. Whenever I’m impassioned by something, I always find it helps to write about it. I hope this helps in some way and maybe explains some of the confusion around wtf is going on with this whole thing.

If you’re frustrated by this whole thing and want change, please sign this petition

Amend the No Surprises Act of 2022 regarding Private Practice Mental Health Clinicians

About the Author

Joe Borders, MFTJoe Borders is a marriage and family therapist located in Roseville and Sacramento. He is primarily a sex positive gender therapist, but also specializes in working with couples, teens, addiction, and the LGBTQ community. Joe is also the owner and founder of SacWellness. You can find out more about him by visiting his sacwellness listing or by visiting his website: therapy and counseling in Roseville and Sacramento

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