Good Faith Estimates

Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act

(For use by health care providers no later than January 1, 2022)

Instructions Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

You have the 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. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 512-766-2649.

Lady Bird Physical Therapy does not take part in surprise billing. Payment is due at the time of service, with each visit costing $225 regardless of diagnosis, performed services, or clinician providing treatment. Lady Bird Physical Therapy’s NPI number is 1598355901 and billed CPT include Therapeutic Exercise (97110), Neuromuscular Reeducation (97112), Manual Therapy (97140), Reevaluation (97164), Physical Therapy Evaluation (97161) each of which are billed for $56.25 unless specified at the time of your appointment. Lady Bird PT may recommend additional services or items as part of the course of care that must be scheduled or requested separately and are not reflected in this good faith estimate. This information is only an estimate of what is reasonably expected to be furnished at the time the good faith estimate is issued, and that actual services, items, or charges may differ. Your right to initiate a patient-provider dispute if the actual billed charges are substantially higher than the expected charges included in the good faith estimate. You can initiate the dispute resolution process and state that initiation of the process will not adversely affect the quality of the health care services you receive. Initiation can be started by submitting a notification to HHS within 120 calendar days of receiving the initial bill containing the excessive charges.