Good Faith Estimate

The following information is being presented to you due to the new federal law called the “No Surprises Act” which went into effect 1/1/2022. This law requires us to provide you with a “good faith estimate” of the TOTAL COST of your treatment FOR AN ENTIRE CALENDAR YEAR. Estimating the total cost of psychiatric and psychotherapy treatment is very difficult because the course of treatment varies for everyone. The law requires us to make this estimate even prior to completing an initial assessment which further complicates things. The cost of services will always be made clear to you before you consent to participate, and estimates can easily be calculated by multiplying the cost of the service x the frequency, which will always be discussed and agreed upon by you and Isha as the treatment progresses. 

You have a right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

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.

You’re getting this notice because this physician is not in your health plan’s network. This means the physician and the facility do not have an agreement with your plan. Getting care from this physician/facility could cost you more. Ask your health care provider if you need help knowing if these protections 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. This means that the final cost of services may be different than this estimate. You and your clinicians 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.

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▶ Review your detailed estimate.

▶ Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.

▶ Questions about this notice and estimate? Call Isha directly. 

▶ Questions about your rights? Call this federal phone number for information and complaints: 1-800-985-3059.

You may also visit: www.cms.gov./nosurprises

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Details about your estimate

The amount below is only an estimate; it isn’t an offer or contract for services. This is only an

estimate regarding the items or services reasonably expected to be furnished and actual items,

services, or charges may differ. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.

Contact your health plan to find out if your plan will pay any portion of these costs, and how much you may have to pay out-of-pocket.

There may be additional items or services the provider recommends as part of the course of care that must be scheduled or requested separately and are not included in the Good Faith Estimate.

The rates for uninsured or those who are insured and do not plan on submitting their own claim to insurance are as follows, and are based on the length of time the appointment was booked for, even if the visit ends early. You may also be responsible for fees submitted to your insurance if your insurance does not pay your doctor.

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Appointment Fees:

Unless otherwise noted in writing the current fee schedule is:

$350 for comprehensive 60-minute initial assessment

$350 for 30-minute follow up integrative medical appointments

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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 Isha:

Intake Appointment: 90205

Follow up Appointments:  99214 or 99215

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:

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F31-F31.9: Bipolar Affective Disorder

F32-F33.42: Depressive Disorders

F39: Unspecified Mood (Affective) 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 (includes PTSD)

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

F11-F11.9: Opioid Related Disorders

F12-F12.9: Cannabis Related Disorders

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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 your doctor.

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 given year of treatment.

PLEASE NOTE: The number of sessions differ for each person based on their needs. You and your doctor 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. If your visits are more frequent, the total cost for the year will be more. If your visits are less frequent, the total cost for the year will be less.

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 48 BUSINESS HOURS of the appointment time. This may also affect your GOOD FAITH ESTIMATE.

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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.

If there is a difference of $400 or more in the good faith estimate you received and the amount you are billed, 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 or get a form to start the process, go to www.cms.gov/nosurprises.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises. The initiation of a patient-provider dispute resolution process will not adversely affect the quality of healthcare services furnished to you as a patient.

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.