No Surprises Act

The No Surprises Act is a federal law that went into effect on January 1, 2022. It protects patients from unexpected medical bills, also known as "surprise bills," that can occur when you unknowingly receive care from out-of-network providers. This law applies to emergency services, certain non-emergency services at in-network facilities, and air ambulance services.

At Empathy Health Clinic, we are committed to transparent billing practices and want you to understand your rights under this important federal protection.

If You Have Health Insurance

When you receive mental health or psychiatric services, you are protected from:

• Surprise billing: If you receive care from an out-of-network provider at an in-network facility without prior knowledge, you cannot be billed more than your in-network cost-sharing amount.
• Balance billing: Out-of-network providers generally cannot bill you for the difference between the billed charge and what your insurance pays (known as "balance billing") in protected situations.
• Emergency services: Emergency mental health services are protected regardless of whether the provider or facility is in-network.

If You Are Uninsured or Self-Pay

If you do not have insurance or choose not to use your insurance, you have the right to receive a Good Faith Estimate of the cost of your care before your appointment.

Under the No Surprises Act, health care providers are required to give patients who do not have insurance or who are not using insurance an estimate of expected charges for medical services, including psychiatric and mental health services.

Your Right to a Good Faith Estimate

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency health care services, including psychiatric evaluations, therapy sessions, medication management, and related services.
• You can request a Good Faith Estimate before you schedule a service, or at any time during your treatment.
• If you schedule a service at least 3 business days in advance, we will provide you with a Good Faith Estimate within 1 business day after scheduling. If you schedule a service at least 10 business days in advance, we will provide the estimate within 3 business days after scheduling.
• The Good Faith Estimate will include the expected charges for the primary service and any other services you may reasonably be expected to receive as part of that care (such as lab work, assessments, or follow-up visits).

If Your Bill Is Substantially Higher Than Your Good Faith Estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. You have the right to initiate a patient-provider dispute resolution process. 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 (800) 985-3059.

At Empathy Health Clinic, we are committed to the following practices in compliance with the No Surprises Act:

• We provide Good Faith Estimates to all uninsured and self-pay patients before scheduled services.
• We clearly communicate our fees and billing practices during the scheduling process.
• We verify your insurance coverage and inform you of any potential out-of-network costs before your appointment.
• We provide clear, itemized bills for all services rendered.
• We have a patient-friendly billing dispute process in place.

In certain situations, if you choose to see an out-of-network provider, you may be asked to sign a consent form acknowledging that you understand you may be billed at higher, out-of-network rates. This consent must:

• Be provided to you at least 72 hours before the scheduled service (or on the day of service for services scheduled fewer than 72 hours in advance)
• Include a Good Faith Estimate of the charges
• Clearly state that you are giving up your surprise billing protections
• Not be required as a condition of receiving care

You always have the right to refuse to sign this consent and instead seek care from an in-network provider.

If you have questions about the No Surprises Act or your billing rights, please contact us:

Empathy Health Clinic
1850 Lee Road, Suite 215
Winter Park, FL 32789
Phone: (407) 745-5915
Email: contact@empathyhealthclinic.com

For more information about the No Surprises Act, visit the Centers for Medicare & Medicaid Services at www.cms.gov/nosurprises.