Suicide seems like a strong metaphor to use, I know, but the implication of choosing to contract with managed care can be life threatening to both your client and your business. Take time to read and ask questions so that you can make an informed choice.
You can thrive without compromising your values, your clients, and your business.
One of the choices every practitioner in private practice has to make is how to set your fees.
Karlaye from Arizona writes . . .
. . . I set my base fee at $ 125 per hour . . . but the insurance companies that I work for set it at $85-95. If I have a private patient, its fine, but when I have a client that wants to use their insurance, I can only set it at that price. Is that correct?”
And, Jason from Colorado asks . . .
Is it OK to charge my cash-paying clients $85 / hour and charge my insurance- paying clients $100 / hour? It’s the only way I can see surviving in this economy.”
When setting your fees, you need to be careful. Health care providers are the most common perpetrators of insurance fraud. Sometimes such fraud occurs out of greed; however, it is much more likely that you may be engaging in fee-related practices that are illegal and not even know it.
If you have chosen to work with insurance companies, make sure that you are not charging you cash-paying clients a different rate than those who are filing on their insurance. Regardless of your intent, charging different clients different fees for the same service (based only on whether or not your client pays cash / uses insurance) is not OK.
Look for a future post when I discuss reduced fees and sliding scale fees.
If you are a regular member of our community here, you already know that my practice is a
"Money Fight" by HikingArtist.com
fee-for-service-only practice. However, if you are a provider who bills insurance companies for your services and you are having difficulty recouping your fees, check out this post about a doctor in Florida who got his money back by taking an insurance company to small claims court.
And, if you have had success in working with insurance / managed care companies and recouping your fees, I hope you’ll drop in here to share your insights / experiences.
I have made the choice not to contract
with managed care companies
for my professional services.
Here’s the 8 reasons why . . . .
Conflicts of Interest
As a Licensed Professional Counselor, I am required to avoid potential conflicts of interest. My primary concern is for my client’s well-being. Therapists working under the constraints of managed care companies are sometimes put in the position of having to choose between what is in their own best interest and what is in their client’s best interest. I do not want to be put in that position.
Managed care companies were created to “manage” and contain escalating health care costs. Their bottom line is to reduce costs and raise profits; it is not to increase the quality of care or quality of life for my client. In many cases, therapists who contract with MCC are actually paid to NOT see clients.
Restricted Choice
Often managed care companies restrict the client’s choice of therapist by offering only short term / brief therapy that I refer to as “drive-by” therapy. Such therapy meets the financial criteria of managed care companies but may fail to afford my client the opportunity to get the information / therapy that s/he wants / needs. It is my belief that this often results in my client’s quality of care being compromised. And, this, of course, can result in the possibility of my client’s needs going unmet.
Managed care companies often choose to limit what therapies are offered, can restrict what is discussed in therapy, and decide which clients can be seen and for how long. Some managed care companies have even included “gag clauses” in their contracts to prevent therapists from suggesting more effective treatments.
Professional Expertise
I believe that my client should be able to access the full range of mental health professionals according to client needs. Often managed care companies restrict the professionals that clients are allowed to work with – preferring to refer clients to therapists who have a record of providing short term therapy rather than to other therapists who may provide better results or offer a different packaging of services.
Contractual Limitations
I believe that a client has the right to full disclosure of any arrangements, agreements, contracts, or restrictions between any third party and me that could interfere with or impact your treatment. Managed care companies may label counselors’ choices to advocate for clients in this manner as “Managed Care Unfriendly Behaviors” and take such actions as they deem fit. Typically “violations” such as these result in therapists being removed from provider panels or censured in other ways.
Privacy / Confidentiality
By contracting with managed care companies, it is likely that I would be required to share my client’s deeply personal information with gatekeepers and utilization review professionals; it would mean potentially allowing literally hundreds of other to have access to my client’s personal information.
Medication
Research has consistently shown that medication for problems with mood is most effective when combined with psychotherapy. Nevertheless, managed care companies frequently approve medication only for their members rather than permitting them to also work with a mental health counselor. Again, the appearance is that of being more concerned about money rather than my client’s needs.
Time
Managed care companies usually require therapists to justify and convince Utilization Review professionals before treatment is approved / continued. This is time consuming for the therapist and for the client who is required to continue his / her therapy in “fits and starts.”
Diagnosis and Stigma
Managed care companies typically cover only those services deemed medically necessary which is defined as being literally about life and death and the treatment of illness. This means that they require a diagnosis of mental illness for my clients.
My practice is solution- focused on quality of life and personal goals. My work with clients focuses on prevention, exploration, and personal growth rather than simply survival. We typically talk in terms of possibility and resourcefulness, gratitude and integrity, commitment and personal responsibility. Working with managed care companies is not a choice that I can ethically make.
I Know Better
I have mental health professionals declare on a regular basis that you “can’t survive in private practice without participating in managed care.” But, I know better. What I know is that you can’t thrive – both personally and professionally – while participating in managed care.
Once I realized the ethical implications of working with managed care companies, I terminated all of my contracts with managed care. It’s not a decision that is right or necessary for all therapists but it was the best decision that I’ve made to date.
I am now celebrating 10 years of being an insurance-and- managed-care-free private practice. I’m thriving and you can, too! All it requires is courage.
If you, too, run a practice without managed-care, I hope you’ll drop in here to chat about your experiences. And, if you have yet to make the choice to opt out of managed care, I would be happy to help you find your courage and to help you create a path to a fee-for-service only practice.
Early in my career,I naively believed that the way to build a strong and independent practice was to contract with both insurance and managed care companies. I spent hours filling out the lengthy applications for each company. I followed up with phone calls and sent in supportive documentation just trying to get on the companies’ panels as a provider.
"Paperwork" by Luxomedia
Once I was approved to get referrals from the managed care companies, I had more paperwork to do and more phone calls to make. And, did I mention that the fee that I contracted for was significantly reduced from my usual and customary fee?
When counseling was not deemed medically necessary by the Utilization Review professionals, my reimbursement was abruptly cut off. My clients were unprepared to suddenly be financially responsible for my full fee. And, neither were they prepared to discontinue treatment with me.
As a therapist in private practice, you have many potentially practice-altering choices to make. Deciding whether or not to contract with managed care companies is one of them.
Make sure you take the time to consider the implications of working with managed care before you ever contract to do so.
When you get ready to close your private practice, for whatever reason, you can’t just shut the door and walk away. Did you know that? Attorney Richard S. Leslie has written a thoughtful article in the January 2010 issue of the Avoiding Liability Bulletin. In it he details some of the following for your consideration when you decide to close up shop:
Ask yourself who needs to be notified – clients, former clients, insurance panels, landlords, supervisees, colleagues and business associates, referral sources, and your licensing boards;
"You Couldn't Have Planned This if You Tried" by Ken Douglas / Today is a Good Day
Consider the possible circumstances that might result in you closing your door – retirement, geographical relocation, health emergencies, financial circumstances, your own death, your spouse’ or partner’s death,and other unforeseen circumstances;
Your state may dictate certain actions that you must take when you close your practice;
Your professional code of ethics and HIPPA will certainly have standards that you must adhere to when closing your practice;
How to notify existing clients;
Subsequent maintenance, storage, and access to records;
How to provide public notice of the closing;
When and how to notify former clients;
Why you may not want to terminate liability insurance policies when you close your practice;
And, in the event of your death or incapacity to handle these things, who does it for you?
Every mental health professional and every professional coach is required to responsibly close their private practice – regardless of whether their closing is planned or unforeseen. Whether you’ve been in business for years or you are just now getting started, now is the time to take the steps necessary to prepare for the eventual closure of your practice.
Part of what helps you to build a strong private practice is to become a
"Knots" by Dan Allison
resource for your clients.
If you have clients who may be losing their jobs,
you’ll want to take a look at this article in the New York Times written by Walecia Konrad. Help your clients make wise decisions concerning their COBRA health insurance coverage. Don’t wait until they need COBRA benefits. Read it now.
. . . Has anyone customized a general billing software like QuickBooks?”
[Update 01-28-09] Another reader, Sandy Jardine, in Phoenix, Arizona also wrote in asking for help.
I am a long-time user of Therapist Helper software. I have just been informed that when I switch to Windows 7 my ancient version of Therapy Helper will be useless. I need to get new software. I am looking for something SIMPLE. I have a completely self pay practice, do no direct billing to insurance, submit no electronic claims and need no scheduler. I provide my clients statements they can submit directly to their insurance for reimbursement. I also use it for keeping track of my income receivables, client lists, etc.
Can you please recommend what you have found helpful, affordable, simple and windows 7 compatible.”
If you have experience and opinions about billing software, please introduce yourself, tell us what you’ve used (and for how long) and let us benefit from what you know!
Parity, as it relates to mental health and substance abuse, prohibits insurers or health care service plans from discriminating between coverage offered for mental illness, serious mental illness, substance abuse, and other physical disorders and diseases. In short, parity requires insurers to provide the same level of benefits for mental illness, serious mental illness or substance abuse as for other physical disorders and diseases. These benefits include visit limits, deductibles, copayments, and lifetime and annual limits.”
~ National Conference of State Legislators ~
Every therapist in private practice should know how to access information about the laws concerning mental health and the insurance industry. Here is an explanation and a link to parity across the United States.
I’ve mentioned in the past that one of the ways that I keep my marketing fresh is that I borrow ideas from other professions.
This morning I was reading Erika Trimble’s blog, Physical Therapy Biz Success, when I ran across a great little post on setting priorities. She recommends the A-B-C-D-E Method for setting better priorities.
A = Critical and Urgent
These are the things that if you put off, will cost you your practice.
Professional licenses and certifications
The rent for your office
Your mental – physical – emotional – spiritual health
Transportation to and from work
A way for your clients to contact you
Securing your client records (to protect confidentiality)
B = Important
These are the things that really need to be done but they are not critical. If you don’t do them in the short term, there are only minor consequences. However, if you put them off indefinitely, the cumulative effect can bump these into the A = Critical and Urgent category.
Vacuuming the office
Networking
Emptying the trash can
Cleaning the windows
Upgrading your computer to the most current Windows settings
C = Nice to do
These include all the niceties and, often, fun-to-do’s that can so easily distract you from your business-building tasks. They may be of added benefit to you or your clients but if they don’t get done, you don’t incur negative consequences.
Sending birthday / holiday greetings to your clients
Heating up the coffee / tea pot for your clients
Lighting the candle in your office
Writing a new blog post
Facebook chats
Returning friends phone calls
D = Delegate
If you don’t do it easily and well, you need to give serious thought to delegating or contracting to get the task accomplished.
Designing artwork for your new project’s marketing campaign (unless you are artistically inclined)
Writing the copy for your website
Billing clients / insurance companies
Janitorial / building maintenance services
E = Eliminate when possible
These are often acts of repetition or 100% time wasters.
Surfing the Internet
Creating handouts for your clients over and over again
Explaining your policies for payment, no shows, and late arrivals
Some correspondence including letters of introduction, marketing letters, and reminder letters
As you are gearing up for 2010, make sure you take some time to re-think your priorities. Assign each of your to-do’s an A, B, C, D, or E using Erika’s method of prioritizing and then let me know what changes for you.
What is it that you think is important . . . to attend to, to delegate, and to eliminate as you build your private practice?
The purpose of a professional disclosure statement is to inform clients about your professional background and the limitations of your professional relationship. It is sometimes referred to as a document of informed consent.
It is important to note that the state you practice in may dictate what must be included in your statement of disclosure.
The professional code(s) of ethics that you adhere to
How to file a complaint against you
Your professional disclosure statement is a living document. By that I mean that it will grow and change as your experience, training, and practice changes. It’s a good idea to review (and amend as needed) your disclosure statement at least annually.
When writing your disclosure statement, you may find it helpful to gather samples of other professionals statements. You will find a copy of my disclosure statement here at my counseling website.
Everything you do for your client matters. If and how you choose to diagnose your client matters a lot. Amanda B. wrote in asking if it is OK to routinely give a diagnosis of Adjustment Disorder to her clients if they do not exhibit symptoms warranting a more serious diagnosis. (She was trying to help them get reimbursed by their health insurance companies.)
The short answer is “No it’s not.” As tempting as it may be to slap an Adjustment Disorder diagnosis on to every client who is dealing with normal life transitions, it’s not wise and it’s not OK — clinically, ethically, or legally.
"Worried Woman" by HikingArtist.com / Frits Ahlefeldt-Laurvig
The clinical implication is this . . . by intentionally giving your client the wrong diagnosis, in this case a more serious diagnosis than is truly warranted, you pathologize your client. This is like going to your primary care doctor for a mosquito bite and him diagnosing you with an infection. Mosquito bites happen just like life happens. Misdiagnosing does nothing to empower your client. Nor does it inform her about the real nature of what’s going on or lead her toward useful strategies for managing the transition at hand.
Ethically you’ve failed . . . to provide honest, accurate and useful information to your client if you’ve told her she has something different than what is true. You’ve also set yourself up to provide inaccurate information to others i.e. physicians, lawyers, etch. that may gain access to your records later on.
And, legally, you’re setting yourself up for big trouble. When you choose to list an inaccurate diagnosis on health insurance claims forms and submit them, you have just committed insurance fraud. Should you choose to put the inaccurate diagnosis into your clinical record, you have falsified documents and failed to meet the professional standard of care.
If knowing all of this you are still tempted (perhaps you believe with good intentions) to misdiagnose a client, seek clinical, ethical, and legal consultation.
[Update 10 Dec. 2009 5:54 pm - Of course, mental health professionals are not the only one fudging on diagnoses. Check out The Last Psychiatrist blog post, "How Am I Going To Get Paid If It Isn't Autism?"]
Did you know that insurance companies sometimes consider being a victim of domestic violence as a pre-existing and exclusionary condition? In eight different states (ID, MS, NC, ND,
"The Cost of Domestic Violence" by The Advocacy Project
OK, SD, SC, and WY) plus the District of Columbia, that designation satisfies an option to exclude coverage under health, life or disability insurance.
Tamara G. Suttle, M.Ed., LPC has maintained a private clinical practice since 1991 and founded Private Practice from the Inside Out in 2003. She has spent almost 20 years consulting and teaching marketing strategies to health care professionals like you. You can learn more about her clinical practice at her website.
Email Tamara
Today I ran across another post written by Rand Partridge, Ph.D. about the conflicts of interest inherent in contracting to work with managed care.
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