No Surprise Act
Your Right to Receive a Good Faith Estimate of Expected Charges
Under the No Surprises Act
Thrive Wellness Physical Therapy and Personal Pilates will provide a “Good Faith Estimate” (“GFE”) of how much our services will likely cost you upon request. If you are paying us directly for your services and you schedule at least 3 days in advance, we will provide a written GFE within 1 day of scheduling.
We will inform you in advance with a new GFE if we plan to increase our fees or we anticipate your costs exceeding your original GFE. If we don’t and we bill you more than $400 in excess of your GFE without informing you in advance, you will have a right to dispute our bill through a federal dispute resolution process. You will need to provide a copy of your GFE to open a dispute, so we recommend that you save and/or print your GFE for future reference.
To request a GFE, please contact us at email@example.com or call at 513-600-5164.
Example of our Good Faith Estimate:
Our Clinic Information:
Jenny Stollmaier, Physical Therapist, 9882
Thrive Wellness Physical Therapy and Personal Pilates
1110 Main Street
Milford, Ohio 45150
Contact person: Jenny Stollmaier
National Provider Identifier (NPI): 1245437862
Taxpayer Identification Number (TIN): 88-1759438
Details of Services and Items for Thrive Wellness Physical Therapy and Personal Pilates
Services patient is seeking:
Our fees per visit are:
$175 First Examination visit of 55 minutes and any visit occurring after a 60 day lapse in treatment time or for a new unrelated diagnosis (inclusive of all CPT codes provided except the additional option of a $25 add on dry needling service fee)
$145 Each 55 minute follow up visit (inclusive of all CPT codes provided except the additional option of a $25 add on dry needling service fee)
$200 Each 85 minute follow up visit (inclusive of all CPT codes provided except the additional option of a $25 add on dry needling service fee)
Our fees are per visit with a discount of $17.50 per recurring 85 minute session scheduled in lieu of a 55 minute scheduled session.
An add on service fee of $25 will be charged to your normally scheduled session fee if you and your provider choose to add this service onto your treatment session. This service will occur during the same time frame of your scheduled appointment time.
If you cancel with less than a 24 hour notice or you are more than 15 minutes late to your appointment and you have not reached out to your providing PT that you are running late and that you are on your way, you will be responsible for paying our cancellation fee of $100. We cannot estimate your cost for cancellation fees. You are in control of that. We reserve the right to waive this fee at our discretion for good reason.
Total Expected Charges from Thrive Wellness Physical Therapy and Personal Pilates:
Your total cost will depend on how many visits you choose to receive from us. Multiply our recurring visit cost estimate by the number of visits you choose to receive from us plus any additional dry needling sessions that you choose to add onto your sessions plus the initial evaluation fee estimate, plus any late cancellation fees that you incur due to late notice of less than 24 hours or no show of over 15 minutes without providing notice to the practitioner that you are running late and are on your way to get the total amount.
Your charges will not be more than the fees listed above unless we give you advance notice that our fees are increasing. Since we require payment at the time of service for all self pay clients we do not expect any payment disputes. If you do not agree to pay the above charges, do not schedule services with us. Your total fees will depend on what services you choose to receive and how many visits you purchase. Therefore, YOU are in control of how much you choose to spend on our services.
Common Service Codes:
PT Evaluation Low Complexity: 97161
PT Evaluation: Moderate Complexity: 97162
PT Evaluation: High Complexity: 97163
PT Re-evaluation: 97164
Therapeutic Exercise: 97110
Neuromuscular Re-education: 97112
Manual Therapy: 97140
Gait Training: 97116
Needle Insertion(s) without injection(s); 3 or more muscles: 20561
Common Diagnostic Codes:
Sacroiliac Joint Dysfunction: M53.3
Low Back Pain: M54,50
Iliotibial band syndrome (IT band): M76.32
Myofascial Muscle Pain: M79.18
Muscular Skeletal Pain: M79.18
Intercostal Pain: R07.82
Shoulder Pain: M25.519
Lateral Epicondylitis: M77.11
Medial Epicondylitis: M77.00
Pain in Wrist: M25.53
Ankle Sprain: S93.4
Knee Pain M25.569
Hip Pain: M25.55
Achilles Tendonitis: M76.6
Plantar Fasciitis: M72.2
Osteochondrosis (juvenile) of proximal tibial tubercle (Osgood-Schlatter): M92
Heel Pain: M79.671
Tempromadibular Joint Disorder (TMJ) M26.80
Carpal Tunnel: G56.0
Other abnormalities of gait and mobility: R26.89
Loss of Coordination: R27.8
Generalized Muscle Weakness: M62.81
Abnormal Posture: R29.3
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created and does not include any unknown or unexpected costs that may arise during treatment.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.
If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059.Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.