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.

Tags: Choice, Contract, Courage, Ethics, Managed Care, Packaging

Earlier this month, I was asked to speak to a group of new professionals interning at Aurora Mental Health Center.  The topic was on why it’s important to join your state and national professional associations.  Just in case you are hesitating, here are 23 reasons that I believe you should join your professional associations today.

1. This is your number one career development tool.
2. This is how mental health professionals get things done.
3. Often there are special resources available to you.
4. This is where you go to learn how to be a professional.
5. This is how you stay informed about your profession’s standards of practice.
6. This is where you learn about professional trends and mandated changes in practice.
7. This is where you can build relationships and expand your network.
8. This is where you get continuing education at affordable prices via conferences, workshops, and forums.
9. Often those continuing education opportunities include a free breakfast, lunch or dinner.
10. This is how you protect and promote your own profession.
11. This is where you increase others awareness of your practice or your employer’s visibility in the community.
12. Student memberships are often reduced or no fee.
13. There are always opportunities here to give back to / build up your profession by your volunteer efforts within the organization.
14. There are often opportunities for community service.
15. This is where you go to stretch your own thinking and stay creative in your work.
16. This is where you learn what others in your profession are doing.
17. This is where you can easily establish yourself as a leader.
18. This organization may choose to sponsor your work, research, or workshop.
19. Many organizations offer members free listings and links on their websites.
20. This is who negotiates for the best and most affordable liability insurance.
21. This is where you get free advice on ethics issues.
22. Many organizations offer job placement services.
23. This will allow you to know other professionals to consult with and refer to (and vice versa) as your needs dictate.

I’m sure there are more benefits / reasons to join.  Can you tell me why you’ve joined your professional associations?

Tags: Ethics, Insurance, Relationships, Workshop

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.

Tags: Closing Your Practice, Ethics, HIPAA, Records & Documentation, Relocation, The Unexpected

"Looking Out" by Tyler Neu / Neuski

According to the American Counseling Association’s Code of Ethics, counselors are not required to diagnose a client if they believe that to do so would cause harm to the client.  Here is an online article in Counseling Today that addresses some of the ways that diagnosing may be harmful to your client.

Tags: Diagnosis, Ethics

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 following items are often included:

• Contact info
• Your qualifications including training, experience, licensure, and certifications
• Professional associations that you belong to
• Services offered
• Your theoretical foundation and counseling approach
• Fee structure including broken appointments and cancellation policy
• Whether or not you will file insurance / provide documentation for your client to file insurance
• How you handle emergencies and client needs after business hours
• Confidentiality and exceptions to confidentiality
• Client rights and responsibilities
• 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.

Tags: Disclosure Statement, Ethics, Informed Consent, Professional Association, Rights & Responsibilities

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?"]

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Tags: Diagnosis, Documentation, Ethics, Fraud, Standard of Care

I was checking out posts at one of my favorite blogs,  Shrink Rap , when I ran across this little jewel.  Oh, ok, it’s not directly about building your private practice but it is about critical thinking and moral decision making and that is what we are called to do and to help our clients do on a daily basis.

"Justice" by YO lXl YNTL

What I’m talking about is . . . Justice with Michael Sandel, one of Harvard’s most popular courses.  This twelve class series is now available on line at no cost to you – complete with an episode guide, reading assignments and discussion guides.

Take a peek and see if this is something that can enrich your professional life.  If so, drop back in here at Private Practice from the Inside Out and let’s talk about it!

Tags: Critical Thinking, Decision Making, Ethics

Carla read my post here and wrote in asking:

What do you do when as a result of finding out that you are a counselor, your church now wants you to provide counseling services to members of the congregation? Or the fact that you have taught classes at ministry events, and as a result some of the participants want to come see you?”

"Nice, Small Church" by Speediakal

How flattering!  But, here are 9 things that I consider before deciding whether or not to see members of my own church . . . .

1. Size matters.  I have found that it is difficult to be active in a church whose congregation numbers only 200 and still maintain my privacy.  That, in turn, colors my professional relationship with my client.  He knows more about me (and I know more him) than is always best.  If, on the other hand, my congregation numbers 1000, then it may be relatively easy for me to maintain my privacy and to minimize personal interactions outside of the counseling office.
2. I consider how I will handle it if I discover that my client is sexually or romantically involved with one of the leaders in my church (who happens to be married).  As far fetched as that may sound to you, it is not all that uncommon and it may very well change how you feel about your church home.  It did for me.  And, that’s before my client AND my church leader both wanted to vent to me, wanted me to choose sides, and then wanted me to publicly condone their behaviors to others!
3. I also consider how my own unforeseen weaknesses / foibles in my personal or church life (challenges in relationships, lapses in judgement, my own spiritual practices, etc.) might negatively impact my relationship with my client . . . .  Unanticipated exposure of those things can actually color what happens in my church and with my client.
4. I also consider the possibility that my partner / spouse / friend / child / sibling / parent may want to befriend my client.  That’s a mess in and of itself! And, what will I do if I believe (from my  clinical work) that the relationships with my client might not be good for my loved one?
5. I’ve had clients catch me before I could dash off from church services to “catch me up” on the latest chapter of their weekend disaster.  Do I want to do therapy in the parking lot?  Do I want to act disinterested?  Or, do I want to dread seeing that client every time I enter the church door?
6. I also have to consider if / how I am going to interact with my clients when I see them.  Am I going to speak to my clients when I see them at church?  Am I going to ignore them?  What if my new client sits down beside me on the pew?  Wants to hug me?  Asks me to take communion with her — or just “conveniently” times it so that it happens that way?
7. What if I sign up for a church dinner club and get assigned to the one that my client attends?  Am I going to explain to the host why I had to leave abruptly when my client showed up?  Am I just going to let the host think I’ve lost my mind?  (Yep, that’s exactly what I did as I ran out the back door.)
8. What if I agree to host a Bible study and my client shows up . . . or his wife . . . or someone who eventually becomes his spouse?  Am I really going to ask my client to leave because there’s a dual relationship if he stays?
9. Sometimes clients can be possessive of their therapists (and you won’t always know this ahead of time).  I’ve had Client A  show up “hurt” or mad at his therapy appointment because he had seen me talking to someone else at church.

OK, so I could go on and on . . . . My point is this . . . .  While much of this can make for great grist for the clinical work that you do with a client, do you really REALLY want to contaminate your personal life (and the lives of your loved ones), your spiritual home, and your professional life with this stuff?  Just think about it and, if you do, consult, consult, consult.

Can you think of other questions / situations / concerns to consider before jumping in to provide therapy within your own religious community?

Tags: Boundaries, Consultation, Ethics, Policies and Protocols, Reputation

This is part of an episodic series, The Therapist’s Networking Guide.
To see the previous post in this series, click here.

Donna loves Yorkies.  She has decided that a good way to make new friends is to organize a Yorkie Meetup Group.  That will get her out in the community as well as allow her to meet other Yorkie-lovers.

Donna is also a Licensed Clinical Social Worker who wants to build her private practice. Is the Yorkie MeetUp Group a good way for her to get clients?”

Definitely YES! Meetup Groups, as well as support groups and other special interest venues can be great ways to network.  At these groups you will find other folks with similar interests who are interested in meeting other people.

It’s here that you can really get to know individuals (and, more importantly, they can get to know you).  As other Halloween-lovers get to know you and run across clients of their own in need of your services, they will likely refer directly to you!

Definitely NO! On the other hand, as a mental health professional, you cannot ethically or legally hang out with the Yorkie Group, exchange dog stories, go have breakfast together, and then see someone from the Yorkie Group (now or later) as a client.  Neither can you see their family member or close friend as a client.

How to do it right? Be clear . . . very clear about what your purpose is when you venture out into the community and maintain the appropriate boundaries that go with that particular role.  Whether it is at church, . . . at a support group meeting, . . . at a fundraiser, . . .or at a formal business networking event, it is very likely that you cannot ethically or legally sit on a board of directors alongside your client.  You cannot go to Bible study with your client.  And, you cannot attend a brunch that is hosted by one of your favorite referral sources if your client is also attending.  

Note that ALL of these situations have come up for me.

Tags: Board of Directors, Boundaries, Brunch, Conflict of Interest, Ethics, Fundraiser, Liability, Meetup Group, Network, Purpose, Religious Community, Special Interest Group, Support Group

The American Counseling Association is currently seeking a full time Director, Ethics & Professional Standards to work at our Headquarters office in Alexandria, VA.

Responsibilities include serving as ACA’s Ethics Officer and providing ethics consultation on the ACA Code of  Ethics, directing and monitoring the ethical adjudication process, advising and assisting the Chair or Co-Chairs of ACA’s Ethics Committee as appropriate, maintaining accurate and appropriate records, serving as the central resource for inquiries related to state licensure and developing materials to assist counselors in the advocacy of the counseling profession.

Requirements include a graduate degree in counseling (state license and/or national certification a plus),  experience as a practitioner and an identity as a professional counselor. Publications/presentations in the area of
ethics and professional standards are a plus.

The ideal candidate will have knowledge of the 2005 ACA Code of Ethics plus knowledge of professional counseling, licensure and reimbursement issues. You will also possess an ability and interest in helping professional counselors from all specialties and have excellent written and verbal skills, along with superior organizational abilities.

To apply send letter of application, vita, complete contact information of three references and salary history to Cindy Welch, Chief of Staff, ACA, 5999 Stevenson Avenue, Alexandria, VA 22304; cwelch@counseling.org; fax 703-823-0953.

Background checks are required. ACA is an AA/EOE organization and encourages minorities and women to apply. The position will be filled when the appropriate candidate is identified.

Tags: Ethics

For those of you who are new to the health care professions and take advertising for granted, you might be surprised to learn that not so long ago advertising was considered to be unethical for many health care professionals.  Last month John Riolo, Ph.D. was writing on the Counselors at Yahoo discussion list about the controversial history of advertising in the mental health professions.  He noted that it took the Federal Trade Commission stepping in before social workers were allowed to advertise!

If you are considering print advertising as part of your overall marketing strategy, here are a few things you will want to consider before you hand over your money:

• Whether you are taking out a listing in the phone directory, the local paper, or a program for a community event, actual placement on the page matters.  Research has shown that ideal placement for your ad is in the upper right hand corner of the right hand page.  That’s where our eyes normally travel first and linger longest (in cultures where we read from left to right, top to bottom).

On the rare occasion that I purchase advertising I always ask for that choice position.

When dealing with less sophisticated staff for advertising, they often accomodate my request at no charge.  However, those that are more informed about the advertising services being offered will typically charge me a surcharge (maybe 10% more) and I am always happy to pay it because I know it will be seen and read more often.

• For advertising to be effective in a newspaper or similar recurring publication, it must be seen repeatedly over time.  One shot advertising is rarely effective.  In order for your ad to work for you, you will need to advertise over a prolonged period of time at a predictable frequency i.e weekly or every other week.  The reason for this is that it is unlikely that readers will need your services on the very day the newspaper comes out.  However, if they see your ad every other week (in the same upper right corner of a right hand page), they are more likely to remember you when they are in need of your services.  If you can’t afford the recurring ad, then consider other options for marketing your practice.

• The exception to the above, is if you are advertising in a program for a community performance or charitable event like The Turtle Creek Chorale or Swallow Hill.  Of course, taking out ads for the entire season will still be more effective than a one time deal.  However,  if your budget doesn’t allow for the recurring ads, you may still find these community-based niches to be more closely read as well as more loyal patrons.
• Another way to tap into the patrons who are loyalty-driven, is to advertise within a specific subculture. This could be a religious community, the transgender community, or even a 12-step community.  Any group that tends to feel marginalized by the dominant community can be a more effective focus for your advertising.

So now that I’ve given you some strategies to maximize your advertising dollar, where will you decide to spend them?

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Tags: Ethics, Newspaper, Niche, Phone Directory, Subculture