Why good-faith estimates weighed most on the therapist’s office
From January 1, 2022, every state-licensed provider owed uninsured and self-pay patients a written estimate before scheduled care. Hospitals had revenue cycle teams to absorb it. Therapists and small practices, where self-pay is common and treatment has no fixed end, did not.
Looking Back revisits one week at a time, from January 2020 to today, and asks what it meant for the banks, health systems and public agencies we serve. The series was written in 2026, with the benefit of hindsight, and each article says which week it looks back on.
The week
On January 1, 2022, the main consumer protections of the No Surprises Act took effect. The law, enacted in December 2020, protects insured patients from most surprise out-of-network bills for emergency care, for certain care by out-of-network clinicians at in-network facilities, and for air ambulance services. It also created obligations toward patients who are uninsured or choose not to use insurance. Providers and facilities must give these patients a good-faith estimate of expected charges when care is scheduled at least three business days ahead, or when a patient asks. If the final bill exceeds the estimate by $400 or more, the patient can use a federal patient-provider dispute resolution process. The same day, higher penalties under the federal hospital price transparency rule took effect.
Earlier in this series we looked at the No Surprises Act as a set of integration problems inside hospitals and between providers and plans. The good-faith estimate had a different center of gravity. It applied to every state-licensed provider and facility, not just hospitals, and it applied whenever a patient was uninsured or chose to pay directly. In hospitals, those patients are a minority. In psychotherapy, counseling and many small specialty practices, they are common, because many clinicians do not join insurance networks and many patients prefer not to bill their plan. Those practices rarely had a revenue cycle function at all. Three features made the requirement heaviest for them: care with no fixed endpoint, compliance work with no back office, and a patient remedy that changed the first conversation.
Care with no fixed endpoint
A hospital estimate prices a defined episode: an MRI, a colonoscopy, a knee replacement. Psychotherapy and other ongoing treatment do not work that way. A course of therapy may run eight sessions or eighty, and its length depends on what happens in the room. The rule still required an estimate of expected items and services, with charges, diagnosis codes where known and service codes, delivered in writing before the first scheduled visit.
Federal guidance allowed recurring services to be covered by a single estimate spanning up to 12 months, with a new one issued if the expected scope changed. That helped, but it moved the hard part into clinical judgment. The clinician had to state an expected frequency and duration at intake, before a full assessment, and document the basis. Estimating too low risked a later bill exceeding the estimate by $400 or more. Estimating too high could alarm a patient deciding whether to start care at all. Practices settled on approaches such as estimating an initial block of sessions with a stated review date, then issuing a revised estimate at that review. That is defensible, but it requires a calendar reminder and a template, which brings the second problem.
Compliance work with no back office
In a hospital, the estimate lands on patient access staff with scheduling systems, chargemasters and estimate tools. In a solo or small group practice, it lands on the clinician, or on one administrator who also answers the phone. Many practices ran on a practice management product chosen for scheduling and notes, with no estimate function. In the first months, the work was done in word processing templates and email.
The requirement was more than one document. Practices had to identify which patients were uninsured or self-pay, a question that changes when a patient decides mid-treatment to stop using insurance. They had to deliver the estimate within set timeframes after scheduling, keep a copy for six years, and post a notice of the right to an estimate in the office and on the website. Where another provider would be part of the care, such as a psychiatrist prescribing alongside a therapist, the rule anticipated a combined estimate. Regulators deferred enforcement of that part because no standard way existed to exchange the data.
Vendors responded. Practice management and electronic record products aimed at small practices added estimate templates, recurring-service fields and delivery through patient portals, often within a year. For the practice, the choice of tool became partly a compliance decision. The useful test was simple: can the system flag self-pay patients, generate the estimate from the appointment, track its review date, and store the delivered copy with proof of delivery. If any step happens outside the system, it will eventually be missed.
A patient remedy that changed the first conversation
The rule gave self-pay patients a concrete remedy. If a bill exceeded the estimate by $400 or more, the patient could start federal patient-provider dispute resolution within 120 days of receiving the bill, for a $25 fee. A selected dispute resolution entity would then decide the amount owed. The process was little used in its early years, but its existence changed the economics of a careless estimate. A practice that could not show why a bill rose had a weak position.
The larger effect was on the first contact between patient and practice. Price talk had often been informal: a session rate on a website, a sliding scale discussed on the phone. The estimate made it written, specific and early. For many patients, especially in mental health, that was welcome. It told them what a course of care might cost before they committed, and it opened a conversation about frequency, sliding fees or referral to lower-cost options. For clinicians, it raised a concern. Some worried that a written projection of months of sessions, delivered before a first meeting, could discourage a hesitant patient from starting.
Practices that handled this well treated the estimate as part of informed consent rather than as a billing form. They explained it in plain language, framed duration as an expectation to be reviewed together, and made clear how to ask questions about cost. That kept a regulatory document from becoming a barrier to care.
With hindsight
Good-faith estimates for uninsured and self-pay patients settled into routine practice, and estimate features became standard in practice management software for small and behavioral health practices. Quality still varies. The provisions requiring estimates to combine charges from several providers, and the advanced explanation of benefits for insured patients, were deferred while regulators worked on data exchange standards, and they remained unfinished years later. The provider-insurer dispute process drew heavy volume and litigation, which overshadowed the patient-facing remedy. By this point in 2026, the estimate is a normal part of intake at most small practices. Those that built it into their scheduling and consent workflow, rather than handling it as a separate form, have absorbed it with the least friction for patients.