Beginning January 1st, 2022, health care providers will need to provide Estimated Costs of Services prior to beginning treatment. This is part of The No Surprises Act.

In medicine, it is meant to protect patients from “unforeseen superbills.”


And, this also applies to psychologists, therapists, counselors, etc.

The link to the related American Psychological Association article can be found by clicking here.

What Does This Mean in Mental Health?

In mental health, this means that anyone you see for services should address the following information before starting treatment.

Accordingly, this must be provided in both oral and written form:

  • The cost per session
  • An estimated number of sessions/length of time in therapy
  • How the client will pay for sessions (e.g. out of pocket or insurance claim)

The Act also stipulates that the client/patient should receive this information:

  • No later than 3 business days prior to the first appointment
  • If the first appointment is scheduled in less than 3 business days, then no later than 1 business day after scheduling the appointment
  • No later than 3 business days after a client/patient overtly requests an appointment

How Are Some Therapy Consumers Reacting?

I’m noticing these themes in consumer reactions:

  • Confusion that this wasn’t already a law
  • Relief
  • Renewed hope and faith in therapy after previous disappointments

How Are Some Therapy Providers Reacting?

I am noticing mixed reactions.

Some people are happy and some people are not.

In commentary from the seemingly unhappy, I am perceiving anger, bother, frustration, and confusion.

In that commentary, the following reasons are being offered:

  • This equals more work for healthcare providers
  • It is not possible to predict how long someone will be in therapy
  • Feeling legally exposed
  • Being unclear about diagnoses are required
  • Feeling unsure about Informed Consent changes
  • Wishing they knew sooner*

*Of Note: this information has been available since it was enacted as a part of The Consolidated Appropriations Act of 2021 on December 27th, 2020. The No Surprises Act is a part of The Consolidated Appropriations Act of 2021. It states that The No Surprises Act would take effect on January 1st, 2022.

My Reaction to Negative Therapy Provider Reactions


Disappointed, confused, and alarmed.

As such, I’d like to share with you an op-ed I penned on a professional psychologist listserv.

Here it is:

Subject: No Surprises Opinion

Hello Readers,

I’ve informed myself and wish to share my opinion and reaction. Take what you like and leave the rest.

I find myself wondering if there’s a correlation between years in practice and frustration/anger over this.

I wonder who is bothered why and the differences between those who are not.
Maybe there will be a study 😉

This law does the opposite of bother me.

In fact, I think it is largely overdue, most especially in Psychology.

Without expressly writing “the treatment duration” in my Informed Consent (IC), I most definitely verbally expressly address immediately upon engagement.

This is what every initial consultation is about in my practice.

I also feel safe, and I believe my clients feel safe, when we discuss things like, “it is often the case that the reason a client comes in is not the reason they choose to stay on and sometimes clients enjoy the process longer than they realized they might.”

I’ve never had a client not get that or report feeling uncomfortable.

I check in with every client about what we are doing – often! Especially because they pay me out of pocket. And I did the same when I worked with insurance-based clients as well.

Not a single one of my clients would likely ever report being “surprised” – I’m going to poll them after I return in the New Year. I’ll let you know if any said they ever felt surprised.

Given that they also have to prepay their sessions, there’s nothing to feel surprised about.

If I’m working with someone longer than one year, we are definitely talking about why and I am getting their expressed consent on “no definitive end date” and their desire (and right!) to choose, inclusive of my recommendations.

I’ll be adding this to my paperwork, as well.

Along with a waiver, perhaps something like “I have been offered a good faith estimate and I have signed off on the organic quality of the work and prefer it to be fluid than my provider to give me a certain number of sessions” or something that sounds like that.

My clients will sign that. And that will stand up legally.

It reminds me of when I go to the dentist and I say, “No thanks, I don’t need x-rays every five minutes, and yes, I’ll sign a paper that says if something happens – I said I didn’t want x-rays.”

For me, this is not that much more work. This is adding a section to an IC and maybe having a follow up signature later in the process.

Private practice has been a gorgeous gift in my life. I have never felt that just being “licensed” gave my clients any true insurance of anything.

I see all of this as my job as a business owner and I find that I feel in deep integrity when I overtly discuss all of this, anyway.

I also think it’s worth remembering that not every licensed MH person operates with deep integrity.

If you work in an “if a client doesn’t show, I don’t get paid” field, and it involves the HIGHEST (arguably) possible ethics, then this is checks and balances.

Admittedly, I am a skeptic in life. I am suspicious, often. Upbringing, immigrant family, poverty, I’m sure all the reasons apply.

But I know for certain that there are licensed MH people collecting weekly checks who shouldn’t be. No governing body is investigating this. And for those cases, a law like this brings me great joy.

I am very dynamic in my approach and still think this is not just okay, but overdue.

A good faith estimate is not a promise of outcomes. In fact, we aren’t supposed to promise outcomes. I do not believe this requires us to do anything we shouldn’t already be doing.

Deep respect for all,

I Share This Because

I think my perspective is important to articulate (if I do say so myself). And because I want consumers (and colleagues) to be aware that my reaction is similar to others who are also happy about this.

A Similar, And Different Perspective

A good friend, colleague, and fellow clinical psychologist is the person who brought all of this to my attention. While she prefers anonymity, she consented to my sharing her deeply worthwhile feedback and additional points to my blind spots.

(Truthfully, she told me to just paraphrase and add the points to my article because I loved them so much… but I could never take that credit. And I feel it important to illustrate the process between us).

Please see her reply to this article:

From Another Licensed Psychologist

I too, like the spirit of the law, as I have had clients and family members experience receiving surprise bills from medical procedures.

I do like the part in your letter about letting clients sign a statement of preference for a more organic process.

I agree ethical practice is important, as is informed consent and accountability.

I too, keep my clients very well informed about costs per session, treatment approach, goals, and inform them about diagnosis which many say they have not had before.

They are aware of the cost and treatment approach prior to the first session.

Most of the details of diagnosis when applicable occurs at the first session. However, while I am still processing this, I am one of those providers that do see some problems with the law.

I do believe there are socio-economic/demographic issues overlooked.

My biggest issues are:

  • The requirement to provide a diagnosis and length of treatment before meeting with a client
  • The way insurance companies will use this law to further dictate treatment
  • Ongoing disadvantages for those at lower socio-economic levels

Despite the spirit of the law, this is sure to come.

Especially as the article identified that insurance companies are working on how they will implement their process.

I also believe the ease of implementation will differ based on the provider’s population served.

I’m interested to see how my dentist will be able to tell me the diagnosis and treatment, without an examination, from my call to schedule an appointment about a toothache.

I’m sure many healthcare providers will disclaimer their way out of any legal issues, and then what was the whole point, still no real accountability.

I couldn’t appreciate, or agree more, with this perspective and these ideas.

This person comes from an insurance-based practice and her feedback is extremely relevant to providers who are working with insurance company reimbursement for client treatment.

Thank you for reading.

There are still many questions to be answered.

There is no need for panic.

I sincerely hope this was informative and provoked critical thought.

Please do not hesitate to reach out to me with questions or comments.

And please, do share.

Respectfully yours,

Dena DiNardo, Psy.D, LMFT