Good Faith Estimate

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)

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. 

Fourth Trimester Wellness does not take part in surprise billing. Additionally, Fourth Trimester Wellness is an out of network provider. Payment is due at the time of service, with each visit costing $125 for virtual visits, $170 for clinic visits, and $225 for home visits regardless of diagnosis, performed services, or clinician providing treatment. Fourth Trimester Wellness' NPI number is 1578162780 and billed CPT codes include Therapeutic Exercise (97110), Neuromuscular Reeducation (97112), Manual Therapy (97140), Gait Training (97116), Therapeutic Activity (97530) Reevaluation (97164), Physical Therapy Evaluation (97161,97162, or 97163) each of which are billed for the cost of each type of visit (home, clinic or virtual) divided by 4 unless specified at the time of your appointment. Fourth Trimester Wellness 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. 

Fourth Trimester Wellness creates each patient's initial plan of care at the time of the initial evaluation. Given the nature of physical therapy, plans of care are reevaluated by your physical therapist at every subsequent visit. Due to this nature, it is challenging to offer an accurate estimates for full cost of care. On average, Fourth Trimester Wellness sees each patient for 5 visits, with some patients being seen significantly less or more. Each individual visit is $225, $170 or $125 dependent on location and due at the time of service. For example, 1 home visit costs $225. 2 home visits cost $225 x 2, or $450, 3 home visits cost $225 x 3 or $675, and so on. Each type of visit costs the same. You may pay for each visit using an HSA or FSA card, and Fourth Trimester Wellness can provide you with a superbill upon request for out of network insurance reimbursement.

The No Surprise Act requires that you receive this 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 813-336-1668.

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.