Why good-faith estimates weighed most on the therapist’s office

The week

On January 1, 2022, the main consumer protections of the No Surprises Act took effect, and with them a federal paperwork duty that hospitals had entire departments to handle. Among those about to inherit it in the last days of December 2021 was the counselor in a two-room office. She sees clients back to back, with a part-time administrator who answers the phone and books appointments.

Congress enacted the law in December 2020, as part of the Consolidated Appropriations Act, 2021, which was signed on December 27 of that year. The week this article covers was the law’s first anniversary and the last working days before its main provisions applied. It was written to deal with a familiar shock: the medical bill that arrives weeks after care, far larger than anyone expected, because someone involved turned out to be outside the patient’s insurance network. An insurance “network” is simply the list of doctors and hospitals that have agreed prices with a health plan; go outside it and the plan may pay little or nothing.

The law protects insured patients from most of those surprise out-of-network bills in three settings: emergency care, certain care by out-of-network clinicians working at in-network facilities, and air ambulance services. Those protections mostly played out between hospitals, physician groups and insurers.

But the law also reached a different group of people: patients who are uninsured, or who have insurance and choose not to use it. For them, providers and facilities now had to supply a good-faith estimate, a written statement of the charges the patient can expect. The estimate is due whenever care is scheduled at least three business days ahead, or whenever a patient asks for one.

The detailed rules had arrived only a few months earlier. The Departments of Health and Human Services, Labor and the Treasury, with the Office of Personnel Management, issued the second of their interim final rules in late September 2021. It was published in the Federal Register on October 7. An interim final rule takes effect without the usual round of public comment first. That left practices roughly twelve weeks between the published text and the start date.

The rule was specific about timing. If a service was scheduled at least three business days ahead, the estimate was due within one business day of scheduling. If it was scheduled at least ten business days ahead, the estimate was due within three business days. A patient who simply asked about cost was owed an estimate within three business days of asking. The estimate had to be in writing, on paper or electronically, as the patient preferred, and in a form the patient could save and print.

The rule came with teeth. If the final bill exceeds the estimate by $400 or more, the patient can turn to a federal patient-provider dispute resolution process. It is a formal route for challenging the bill, instead of arguing with the office manager.

The definition of who was owed an estimate had two parts. The first covered people with no coverage for the service at all. The second covered people who had coverage under an employer plan, an individual insurance policy or the federal employees’ program, but did not want a claim sent to it. People with benefits for the service under a federal health care program such as Medicare or Medicaid fell outside the definition. So the rule mattered most where private patients chose to pay directly, which is exactly the pattern in much of outpatient mental health.

Who counted as a provider was also broad. The rule reached any physician or other health care provider acting within the scope of a license or certification under state law. That took in licensed professional counselors, clinical social workers, psychologists, marriage and family therapists, physical therapists and dietitians, along with physicians. Hospitals and other facilities were covered as well. Many of those clinicians had never dealt with a federal billing rule written primarily for hospitals.

On paper, this looked like a modest consumer-protection measure, the sort of thing a hospital billing department could add to its checklist. In practice, it landed hardest on the smallest offices in health care: therapists, counselors and small specialty practices, where paying out of pocket is common and where the course of treatment rarely has a predictable end date. Those offices usually have no billing department at all. The person who would now write the estimate was, very often, the clinician.

Most of the No Surprises Act played out inside hospitals and between providers and plans, where claims data, network directories and billing systems had to talk to one another so that patients were protected. The good-faith estimate had a different center of gravity.

The requirement applied to every state-licensed provider and facility, hospitals among them. 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, sometimes for privacy, sometimes for simplicity. Those practices rarely had a revenue cycle function at all.

“Revenue cycle” is the hospital industry’s term for everything that turns care into collected money: checking insurance, pricing services, sending bills, chasing payments and handling disputes. A large health system may employ hundreds of people and run specialized software to do it. A solo therapist does it at the kitchen table on Sunday evening.

The privacy reason for paying directly is worth understanding, because it explains why self-pay is so common in mental health. HIPAA gives patients the right to ask a provider not to tell their health plan about a service they have paid for in full out of pocket. With narrow exceptions, the provider must agree. Some patients want no diagnosis in an insurer’s file at all. Others want to avoid limits a plan places on the number of sessions or the type of therapy. For these patients, paying directly is a deliberate choice, and the estimate rule followed them into it.

Three features made the estimate requirement heaviest for these small practices: care with no fixed endpoint, compliance work with no back office, and a patient remedy that changed the very first conversation between patient and clinician. Together they show something familiar well beyond health care: a rule written with one kind of organization in mind can fall very differently on another. We start with what the estimate actually required, then take the three features in turn, then look at how the pattern shows up in larger organizations and what the practices that adapted did.

A written quote in the language of claims

Strip away the regulatory language and a good-faith estimate is a written quote, the same idea as the estimate a contractor gives before renovating a kitchen. It tells the patient, in advance, what the provider expects to do and roughly what it will cost.

The rule asked for more detail than a typical contractor’s quote, though. The estimate had to list the expected items and services, with their charges, and include diagnosis codes where known and service codes. Those codes are worth a moment of explanation, because they are part of what made the job feel technical to a small office.

• Diagnosis codes come from a standard catalog used across health care to describe what condition a patient has. Each condition has a short alphanumeric code, so that every payer and provider means the same thing.
• Service codes describe what the clinician actually does: a first diagnostic evaluation, a standard-length therapy session, a family session and so on. Again, each has a standard code.

Hospitals and insurers live in this coding world every day. A therapist who has never billed insurance may barely have touched it. Suddenly, the estimate required them to speak the language of claims processing, for patients who had specifically chosen to stay outside that system.

What else the document had to say

The codes were only part of it. The regulation also required the patient’s name and date of birth, a description of the primary service in clear language, and the scheduled date. Each provider listed needed its name, National Provider Identifier, tax identification number and the location where care would happen. The National Provider Identifier is a ten-digit number every health care provider who bills electronically must have. Many self-pay therapists had one; some had never needed it.

The estimate also had to carry several disclaimers. It had to say that it was an estimate and that actual charges could differ. It had to explain that the patient could start the dispute process if the bill came in substantially higher, and that doing so would not affect their care. It had to state that the estimate was not a contract and did not oblige the patient to use the providers listed. CMS published an example form and a model notice that practices could adapt, which helped. But adapting a federal form still meant reading it, deciding which fields applied and making it fit the practice’s own services.

Federal floor, state additions

The estimate was a federal requirement, but it did not displace state law on privacy, security or access to records. A practice still had to follow its state’s rules on who may see a patient’s records and how they must be protected. The regulation was also explicit that an estimate issued under a state process that did not meet the federal requirements would not count. A practice could not rely on a state form alone unless it covered every federal element.

For clinicians who see clients in more than one state by telehealth, that meant one federal standard with possible state additions on top. Practices in that position needed to confirm the rules in each state where their clients were located, as well as the state where the clinician practiced.

The diagnosis code problem

Diagnosis codes caused particular unease in mental health. An estimate is issued before the first session, often before the clinician has assessed the patient. The rule asked for diagnosis codes where known, which gave room to leave them out when no diagnosis existed yet. But it also raised a question clinicians care about. A provisional diagnosis written on a cost document, before assessment, may stick to the patient’s record. The estimate became part of the medical record, so whatever code went on it stayed.

Practices handled this in different ways. Some left the diagnosis blank on initial estimates and added it to revised ones after assessment. Others used a code for the reason for the visit rather than a diagnosis. Either choice needed a written rationale, because a practice that later had to defend an estimate would want to show it had applied a consistent approach. Clinicians unsure how to handle codes for their profession were well advised to check guidance from their licensing board, their professional association or a health care attorney.

The clock on every booking

The estimate also had to arrive on time. It was required when care was scheduled at least three business days ahead, or on request. If the appointment was three to nine business days away, the estimate was due within one business day of booking. If it was ten or more business days away, the practice had three business days. For a practice that books a first appointment by phone on a Monday for the following week, the estimate became a task with a deadline attached to every new booking.

Business days are what count. A booking made on a Friday afternoon for the following Wednesday owes an estimate by the end of Monday. Practices that offered online self-scheduling met a further twist: a client could book at midnight, and the clock started without anyone in the office knowing. Scheduling tools that sent the estimate automatically at booking, or at least flagged each new self-pay appointment the next morning, closed that gap.

A change to the plan triggered the clock again. If the expected services, charges or providers changed before the appointment, the rule required a new estimate no later than one business day before the scheduled service. A therapist who decided after a phone screening that a longer first session was needed, at a higher rate, owed the patient a revised document.

Care with no fixed endpoint

A hospital estimate prices a defined episode: an MRI, a colonoscopy, a knee replacement. These have a beginning and an end. The hospital knows, within a range, which services go into them and what it charges for each. Its estimate tools can assemble a quote from those known parts.

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. A patient may arrive for help with a single stressful event and stay for a year working through something deeper. Another may feel better after a handful of visits and stop. Neither the clinician nor the patient can know at the outset.

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. So a clinician who had not yet met the patient had to put a projected course of care on paper.

Federal guidance offered some relief. Recurring services could 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 for that expectation.

Here the practice faced a genuine dilemma, with risk on both sides:

• Estimate too low, and a later bill could exceed the estimate by $400 or more, opening the door to a federal dispute.
• Estimate too high, and a patient deciding whether to start care at all could be alarmed by a long and costly projection before they had even met the therapist.

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. Say a counselor meets a new self-pay client. Rather than guessing at a year of weekly sessions, she estimates an initial block of sessions at her standard rate. She notes that the plan will be reviewed together on a specific date, and explains that a new estimate will follow if they agree to continue. The patient sees an honest, bounded number. The counselor has a defensible basis for it. If treatment continues, the next estimate reflects what both now know.

That approach is sound, but it creates an obligation that is easy to miss: someone has to remember the review date, produce the revised estimate and deliver it. It requires a calendar reminder and a template, which a practice with no back office has to maintain itself.

Errors, corrections and other people’s information

The regulation allowed for honest mistakes. A provider that made an error in an estimate in good faith, and corrected it as soon as practicable, did not fail to comply on that account alone. A provider that relied in good faith on information from another party was also generally protected, unless it knew or should have known the information was wrong. Once it learned of the problem, it had to correct it.

That protection has a practical edge. A correction has to be visible. A practice that spots an error should issue a corrected estimate, note in the record what changed and why, and keep both versions. Services already delivered before a correction can still be disputed, so speed matters. A correction issued the day an error is noticed is much easier to defend than one issued after the patient complains.

How the $400 threshold interacts with session fees

The arithmetic of the threshold matters more in therapy than in surgery. The $400 is measured against the total expected charges listed for that provider. For a single expensive procedure, a modest overrun rarely reaches it. For weekly therapy, it can be reached by a few extra sessions. At a session fee in the range many private practices charge, three or four sessions beyond the estimated block could cross the line.

That arithmetic points to a simple control. A practice can track sessions delivered against the number estimated, and issue a revised estimate before the count runs past it. The trigger for a revision is then a number in the schedule, not a clinician’s memory. The same logic applies to fee changes. A practice that raises its rates at the start of a year should check which open estimates were based on the old rate.

Where the block approach strains

The block approach has limits worth naming. Some treatment models have a defined length, such as certain structured therapies delivered over a set number of sessions. For those, a single estimate for the full course is more honest than a short block. Other situations are far less predictable, such as crisis work, where a patient may need several sessions in one week and then none for a month. For those, a block based on a typical month, with a clear explanation, may serve better than a count of sessions.

Group therapy, couples therapy and family sessions add another wrinkle. The estimate is issued to the individual who is uninsured or self-pay. A practice seeing a couple in which one partner uses insurance and the other does not has to decide who receives the estimate and for what share. There is no single right answer, and a practice should write down the approach it takes and apply it consistently.

Compliance work with no back office

In a hospital, the estimate lands on patient access staff, the people who register patients and check coverage, supported by scheduling systems, chargemasters and estimate tools. A chargemaster is a hospital’s master price list, a large database of every service and supply it bills for and the standard charge for each. Estimate tools draw on it automatically.

In a solo or small group practice, the estimate 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 at all. Practice management software runs the business side of a small office: it keeps the appointment calendar, client contact details, clinical notes and invoices. If it had no estimate feature, the estimate happened somewhere else. In the first months, that somewhere else was usually word processing templates and email.

And the requirement was more than one document. Look at the full list of what a practice had to do:

1. Identify who qualifies. Practices had to know which patients were uninsured or self-pay. That question can change: a patient may decide mid-treatment to stop using insurance, and at that point becomes someone owed an estimate.
2. Deliver on time. The estimate had to reach the patient within set timeframes after scheduling.
3. Keep it as a record. The estimate became part of the patient’s medical record, not a loose billing note.
4. Produce history on request. Practices had to supply copies of estimates issued in the past six years when asked.
5. Tell people about the right. A notice of the right to an estimate had to be posted in the office and on the practice’s website.

There was also a harder piece. Where another provider would be part of the care, such as a psychiatrist prescribing medication alongside a therapist who provides talk therapy, the rule anticipated a combined estimate covering both. That would require two independent offices, often using different software, to share pricing and scheduling information with each other on a deadline. Regulators deferred enforcement of that part because no standard way existed to exchange the data. That is a telling detail: even the government recognized that some of what it asked for could not yet be done reliably without shared technical plumbing.

Vendors began to respond. Practice management and electronic record products aimed at small practices started adding estimate templates, fields for recurring services, and delivery through patient portals, the secure websites where patients can see appointments, messages and documents. For the practice, the choice of software became partly a compliance decision.

The useful test was simple. Can the system:

• flag self-pay patients automatically;
• generate the estimate directly from the appointment;
• track the estimate’s review date; and
• store the delivered copy with proof of delivery?

If any step happens outside the system, it will eventually be missed. That says nothing against busy people; manual processes behave this way over time: the template lives on one person’s laptop, the reminder lives in one person’s head, and the first time that person is on vacation or leaves, the chain breaks.

The notice is a duty of its own

The posting requirement was easy to underestimate. The rule required information about the right to an estimate to be displayed prominently on the practice’s website, in the office and wherever scheduling or questions about cost happened on site. It also had to be given orally when a patient scheduled care or asked about cost, and offered in accessible formats and in the languages patients spoke.

For a practice whose “website” was a profile on a therapist directory, and whose “office” was a room in a shared building, each of those places needed thought. The oral piece needed a short script for whoever answered the phone. A practice that served clients in Spanish needed the notice in Spanish. None of it was expensive. All of it was easy to forget in the first week of January.

Six years of records on a small practice’s systems

The six-year retrieval duty has a technical consequence. A small practice changes software more often than a hospital, sometimes because a product is discontinued or a vendor raises prices. When it moves, the estimates stored in the old system have to come along or remain retrievable. A practice choosing a new product should confirm that past estimates, and proof of delivery, can be exported and imported, or plan to keep a read-only archive.

Storage also brings security duties. An estimate contains a patient’s name, date of birth and possibly a diagnosis code. It is protected health information for any practice covered by HIPAA. Estimates sent as unencrypted email attachments or kept in a personal cloud folder raise the same concerns as any other record handled that way. A patient portal or the practice management system is usually the safer route.

How the burden differed by type of practice

The weight of the requirement depended on the practice’s mix of patients. A solo therapist who accepts no insurance owes an estimate to nearly every new client. A group practice that is in-network with several plans owes estimates only to the minority who pay directly, but has to identify them reliably among everyone else. A community mental health center that mostly serves Medicaid enrollees sees fewer cases still. People who have benefits for a service under a federal health care program such as Medicaid fall outside the regulation’s definition of an uninsured individual.

Hospitals faced the requirement too, and some found it hard. Outpatient behavioral health programs inside a health system had the system’s estimate tools, but those tools were built for procedures, not for a twelve-week intensive outpatient program. The gap between tool and service appeared there too, just with more staff to absorb it.

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 administrative fee. A selected dispute resolution entity, an independent organization approved to decide these cases, would then determine the amount owed.

Whatever its volume, the existence of that remedy changed the economics of a careless estimate. A practice that could not show why a bill rose had a weak position. A practice that had documented its original reasoning, issued a revised estimate when the plan changed, and kept proof that the patient received it was in a far stronger one. The paperwork was also the practice’s evidence.

How a dispute is decided

The mechanics show why documentation carries so much weight. Once a dispute starts, the provider has ten business days to send the reviewer the estimate, the bill and any documentation of what changed. The reviewer looks at each item separately. For an item billed above its estimate, the question is whether the provider has credible information that the extra cost reflects medically necessary care and circumstances it could not reasonably have foreseen.

If the provider cannot show that, the patient pays the estimated amount for that item. If it can, the payment is set at the lower of the billed charge and a typical amount paid for that service in the area, and not below the estimate. A service that was never on the estimate at all can be reduced to zero without credible information. Meanwhile the provider must not send the bill to collections or threaten to, and late fees stop accruing until the matter is resolved.

For a therapist, the implication is direct. A session added without a revised estimate, and without a note explaining why it was needed and unforeseen, is a session the practice may not be paid for if a dispute arises. The clinical note and the revised estimate are the practice’s defense.

Settlement and its incentives

Many disputes need not run to a decision. If the patient and provider agree on an amount after a dispute begins, the provider must reduce the bill by at least half of the patient’s $25 administrative fee. It must also tell the reviewer about the settlement. If the reviewer decides in the patient’s favor, the fee is subtracted from what the patient owes. Those rules give practices a reason to settle early when the record is weak, and to fix the process that produced the dispute.

For a small practice, the bigger cost of a dispute is time. Gathering documents, writing an explanation and waiting for a decision take hours from a clinician’s week. A practice that keeps estimates, revisions, delivery records and clinical notes in one system can answer in minutes. A practice that has to search inboxes and laptops cannot.

The first conversation

The larger effect, though, 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. People who have avoided care because they feared an open-ended bill had something concrete to plan around.

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 at all. Anyone who has worked in mental health knows how fragile that first step can be. A person who has finally decided to call a therapist may be easily turned back by a document that looks like a large bill.

Practices that handled this well treated the estimate as part of informed consent rather than as a billing form. Informed consent is the clinical practice of making sure a patient understands what treatment involves before agreeing to it. Framed that way, the estimate becomes one more thing the clinician explains, alongside confidentiality and how sessions work. These practices explained the estimate in everyday 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.

The case against the rule, and why it still helped

Critics in the profession made a fair argument. Therapy is not a commodity, and a rule designed to price procedures fits it awkwardly. The estimate added administrative time that small practices could otherwise spend with clients, and for clinicians who already posted flat session fees, it added little information the patient did not have.

Much of that is right. The rule was a blunt instrument for ongoing care, and the deferred co-provider piece shows that its designers had not fully worked out how it would apply to care spread across several offices. But the rule also addressed a real harm. Patients in mental health often start care without knowing how long it will run, and a session fee alone says little about total cost. A clear, bounded estimate with a review date gave patients a way to plan, and gave them a remedy if a practice billed far beyond what it had told them. The burden was real, and so was the benefit.

The same pattern in larger organizations

Large organizations meet the same five lessons whenever their service depends on independent clinicians, local agencies, contractors or franchisees.

Rules travel down to the smallest participant. A requirement designed with hospitals in view applied to every state-licensed provider. Any leader whose organization relies on small partners, such as independent clinicians, local agencies, contractors or franchisees, should expect that new obligations will hit those partners harder than the organization itself. If your service depends on them, their compliance burden can become your service problem.

Consider a health system that refers patients to independent therapists, or a county behavioral health department that contracts with small providers. Both depend on those small partners for the service their own patients receive. When a new rule arrives, the larger organization can offer templates, training or shared tools. It costs little and protects the service its own patients receive.

Compliance is a workflow, not a document. The good-faith estimate looked like a form. In reality it was a chain of steps: identify the patient, generate the quote, deliver it on time, store it, revisit it, produce it again years later. Organizations that treat a new rule as “a new form to fill in” tend to discover the hidden steps when something goes wrong.

A useful habit is to map a new obligation as a sequence before deciding who owns it. Each step needs a trigger, an owner, a system and a record. Steps without all four are where failures happen.

Software choices carry regulatory weight. A practice that chose its system for scheduling convenience found that the same choice now determined whether it could comply reliably. That holds at every scale. When a regulation arrives, the question “can our systems do this?” often decides the cost of compliance more than the rule itself.

For larger organizations, the implication is to ask vendors about regulatory change management during procurement. A vendor that can show how it shipped features for past rules on time is a safer bet than one that promises flexibility in general terms.

Disclosure shapes customer behavior. A price shown early changes what customers do. That can build trust or create anxiety, depending on how it is presented. The same estimate, handed over as a cold billing form or explained warmly as part of planning care together, produces very different reactions.

Banks, insurers and public agencies face the same dynamic with fee disclosures, benefit estimates and notices of eligibility. The words around a number matter as much as the number.

Missing data standards stall good policy. The combined estimate across providers was a sensible idea that could not be enforced because no standard way existed to exchange the data. Any leader pursuing coordination across organizations, whether in health, government or finance, should check early whether the shared plumbing exists, rather than assuming it will appear.

The same gap appears outside health care. A state benefits program that wants a county office, a nonprofit partner and a state agency to give an applicant one combined notice needs a shared case record or an agreed message format first. A bank that promises customers a single view of fees charged by itself and its partners needs those partners to send data in a consistent form. When the plumbing is missing, the policy either waits or falls back on manual work by the smallest participant, which is where the good-faith estimate began.

What the practices that adapted did differently

The practices that adapted well had several things in common.

• The estimate is generated from the appointment. When a self-pay patient is booked, the system produces the estimate from the scheduled service, rather than someone retyping details into a template.
• Insurance status is a live question. The practice rechecks whether a patient is using insurance during treatment, because a patient who stops using insurance becomes eligible for an estimate.
• Recurring care is estimated in reviewable blocks. An initial block of sessions with a stated review date, followed by a revised estimate at that review.
• Delivery is provable. The practice can show what was sent, when, and that it was received, and can retrieve estimates from the past six years on request.
• The conversation comes first. The estimate is introduced as part of informed consent, in everyday language, with a clear way to discuss cost and frequency.

The practices that struggled tended to make the opposite choices.

• Treating the estimate as a one-time form. Issuing it at intake and never revisiting it, even as the plan of care changes.
• Assuming insurance status is fixed. Missing the patient who switches to paying directly halfway through treatment.
• Keeping the process in one person’s head. A template on a laptop and a mental note to follow up are not a system.
• Leading with the number. Handing a hesitant patient a long projection without context, so that the estimate reads as a deterrent rather than as information.
• Ignoring the public notice. Forgetting that the right to an estimate had to be posted in the office and on the website.

Return to the counselor’s practice. In one version, the administrator keeps a word processing template, emails estimates when she remembers, and stores replies in her inbox. When a client disputes a bill a year later, nobody can find what was sent. In the other, the practice’s software flags the client as self-pay at booking, generates the estimate, records delivery through the patient portal and sets a reminder for the review date. The bill, the estimate and the revision are all kept in one place. The second practice is not more virtuous. It simply made the right step the default one.

A monthly check that takes an hour

Practices that kept the process healthy often used a short monthly review. The administrator, or the clinician in a solo practice, pulls a list of self-pay patients seen that month and checks three things for each. An estimate is on file and was delivered on time. Sessions delivered are within the estimated count. And a review date is set if treatment continues. Any gap is fixed that month, while the facts are fresh.

That review also produces evidence. A dated note that the check was done, with the gaps found and closed, shows a regulator or a dispute reviewer that the practice took the duty seriously. It costs an hour a month and catches problems before a patient does.

Where group practices and health systems differ

Larger practices and health systems can go further. They can assign estimate ownership to the front desk rather than the clinician, build the estimate into the scheduling workflow, and audit a sample of estimates each quarter. A health system with outpatient behavioral health services can adapt its existing estimate tool to handle recurring care, with a template for blocks of sessions and a review date field. The cost of these steps is mostly configuration and training. The risk they reduce is the one the rule created: a patient billed well beyond what they were told, with no record to explain why.

Where estimates break down

Whether you run a health system that works with independent clinicians, a payer, a government health agency, or any organization that must give customers prices before service, these questions are worth asking:

1. Which of our customers or patients are owed a written estimate or price disclosure, and how do we know, today, who they are?
2. If someone’s status changes partway through, for example they stop using insurance, what triggers a new estimate?
3. If a customer challenged a bill that ran well over the estimate, what evidence would we hand over, and how long would it take to find?
4. Where do our smallest partners struggle with obligations that our own organization handles easily, and does that affect the people we serve?

The questions need no technical expertise. Each points to a place where a modest-sounding rule turns into real operational work. A small gap in process there can become a dispute, a lost patient or an awkward conversation with a regulator.

Each also has an owner. The first belongs to whoever runs patient access or customer intake. The second belongs to the people who maintain the scheduling and billing systems. The third belongs to compliance, which should be able to produce the record. The fourth belongs to whoever manages the network of partners, and it is the one most often left without an answer.

With hindsight

The good-faith estimate has since settled into the ordinary rhythm of small practices. For uninsured and self-pay patients, it became part of routine intake for many offices, and estimate features spread through the software they use, though the quality of those features varies.

The spread of those features is the clearest sign of how the burden was absorbed. Software built for small therapy and counseling practices now commonly offers estimate templates, recurring-service fields and delivery through a client portal. A practice choosing a system in 2026 can treat the estimate as a standard feature to compare, much as it compares scheduling or note templates. In 2022 many practices were building the same thing by hand.

The more ambitious parts of the original design fared less well. HHS deferred enforcement of the requirement to combine charges from several providers while data exchange standards were worked out. The advanced explanation of benefits for insured patients, a parallel idea meant to give insured people a projected cost before care, was also put off. In September 2022 the departments published a request for information asking how the data exchange behind both could work. Both delays point to the same underlying truth: when policy depends on separate organizations sharing information on a deadline, the technical standards for that sharing have to exist first.

That remains the most transferable point of the whole episode. A therapist and a prescribing psychiatrist in separate offices, on different software, have no shared channel for estimates. Building one requires an agreed format, a way to find the other party, and rules about consent and privacy. Those are the same ingredients that took years to build for clinical records exchange. A policy that assumes them before they exist will wait for them.

Meanwhile, the part of the law that drew far more attention was the dispute process between providers and insurers over out-of-network payments. CMS counted more than seven million disputes initiated between April 2022 and July 2026. That figure is a reminder of where the money and the organizational muscle were concentrated: large providers and insurers had the teams and systems to contest payments at scale, while the patient-facing estimate became, with little fanfare, a matter of everyday office practice.

The provider and insurer side also produced the law’s main court fights. In February 2022 a federal court in Texas ruled in a suit brought by the Texas Medical Association. It set aside parts of the departments’ rules on how arbitrators should weigh the insurer’s median in-network rate. The departments rewrote those rules later that year. Those disputes concerned money between institutions. The patient-provider process for self-pay patients drew far less attention.

The wider push for price information continued in parallel. Hospitals had been required since January 2021 to publish their standard charges. The Transparency in Coverage rule required most group health plans and insurers to offer an online cost tool to members. It started with a set list of services in 2023 and expanded to all covered items and services in 2024. In February 2025 an executive order directed the departments to tighten enforcement of price transparency requirements. Those efforts mostly concern insured patients and large organizations. For the uninsured patient booking a therapist, the good-faith estimate remains the main federal price disclosure.

By this point in 2026, the practices that built the estimate into their scheduling and consent workflow, rather than handling it as a separate form, have absorbed it with the least friction for patients. When a new obligation arrives, the organizations that cope best, whatever their size, fold it into the work people already do, so it happens by default. They also present it to customers as part of good service rather than as a legal formality. A practice that explains the estimate at intake, alongside confidentiality and scheduling, has turned a federal requirement into part of how it welcomes new clients.

For any leader overseeing networks of small partners, the episode also offers a second warning. A rule that a large organization handles with a new field in an existing system can consume real hours in a two-person office. Knowing where that burden falls, and helping partners carry it, is part of serving the people at the end of the chain.