Good Faith Estimate

GOOD FAITH ESTIMATE OF EXPECTED CHARGES

You have the right to receive a Good Faith Estimate explaining how much your medical care will cost before you receive services.

Who This Applies To Under federal law, health care providers must give patients who are uninsured or who choose not to use their insurance a written estimate of expected costs for medical items and services.

What’s Included You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services, including related costs such as medical tests, prescription drugs, equipment, and facility fees.

When You’ll Receive It

  • If you schedule a service 3 or more business days in advance, you must receive your Good Faith Estimate at least 3 business days before your appointment.
  • If you schedule a service less than 3 business days in advance, you must receive your Good Faith Estimate at least 1 business day before your appointment.
  • You may also request a Good Faith Estimate at any time before scheduling a service. Any question or discussion about the expected cost of your care is considered a request for a Good Faith Estimate.

How to Request One Ask your KOH Physical Therapy provider or front desk staff for a Good Faith Estimate before scheduling any item or service. Requests can be made in person, by phone, or in writing.

If Your Bill Is Higher Than Your Estimate If you receive a bill that is $400 or more above the amount on your Good Faith Estimate, you have the right to dispute the bill through the Patient-Provider Dispute Resolution (PPDR) process.

To use the dispute process:

  • Save a copy of your Good Faith Estimate when you receive it.
  • There is a $25 fee to initiate the dispute process.
  • If the Selected Dispute Resolution Entity (SDRE) reviewing your dispute agrees with you, you will pay the amount on the Good Faith Estimate, reduced by the $25 filing fee.
  • If the SDRE agrees with the provider, you will pay the higher billed amount.
  • Initiating the dispute process will never affect the quality of care you receive at KOH Physical Therapy.

Important Disclaimers

  • A Good Faith Estimate is not a contract. It does not obligate you to obtain services from KOH Physical Therapy or any provider listed in the estimate.
  • Actual charges may vary based on the specific services rendered during your visit.
  • A Good Faith Estimate does not include charges for services that cannot be anticipated at the time the estimate is prepared.

Questions? For more information about your rights under federal law, visit www.cms.gov/nosurprises or call 1-800-985-3059.