Guidelines: Fees in Therapy
- People's relationships to time, money and sex are the three most revealing aspects of their lives in our time.
- Money is one of the more complex issues facing therapists and clients, especially at the beginning of treatment.
- As with issues of sex, many therapists tend to avoid exploring this important topic. As therapists, we choose to go to graduate school and study psychology or counseling rather than business, which is a reflection that our focus is on healing rather than on money and fees.
- Money is one of the parameters that defines and differentiates psychotherapy from friendship and other intimate relationships.
- Therapists' Office policies should articulate fee structure and policies regarding billing, missed and late canceled sessions, insurance billing, debt and debt collection, etc.
- The most common fee arrangement options are:
- Full fee
- Sliding scale
- No fee
- Bartering for goods or for services
- Therapists should try to come to an agreement with their clients as soon as possible as to the fee structure. They should then document it in the clinical records.
- Therapists are advised to keep a log of sessions, charges, and payments by clients, insurance or others, insurance billing, etc.
- The clinical records should include copies of billing, invoices, communication with third parties, debt forgiveness and any other information pertaining to fees.
- The sliding scale is a very common and acceptable form of fee arrangement. This allows clients to pay according to what they can afford in a flexible, individually tailored way. The concern with the sliding scale is that it can put therapists and clients in a conflict of interest where clients may have an investment in presenting a scaled down financial picture in order to pay at a lower rate. If this negotiation takes place at the beginning of therapy, it can contaminate the therapeutic relationship. Some factors, such as retirement investments, anticipated inheritance, etc. cannot be easily factored into the sliding scale calculations.
- For a summary of the Codes of Ethics of major professional organizations on fees and payment issues go to zurinstitute.com/ethicsoffee.html.
- The self serving belief by therapists that the more clients pay for the therapy the more likely they are to benefit from it is not supported by research.
- It is important for therapists to be flexible in regard to fees as sometimes patients' financial situations change in the course of therapy due to illness, lost of job, etc.
- Therapists should not engage in misdiagnosis in billing for the purpose of securing insurance reimbursement (e.g., give an individual DSM dx and CPT code for couple therapy.)
- Fees are also a clinical issue. Different fee arrangements have different meanings for different clients that should be explored when appropriate. For example, no fee arrangement can elicit in a client feelings of gratitude, indebtedness, entitlement, etc.
- Therapists should allow for some free or very low fee sessions in their practices.
- Different theoretical orientations sometimes guide the type and extent of discussion regarding fees. Psychodynamic psychotherapists are more likely to focus on unconscious, transferencial and counter-transferencial dynamics regarding fees. Feminist therapists may focus on issues of justice and reducing the power differential between therapists and clients by reducing the fee.
- Different settings, communities and clients may require different approaches to fee setting. Agricultural and rural communities are likely to be more accepting of bartering for goods and other creative ways to pay for therapy. Art-rich but cash-poor artists are often used to bartering arrangements.
- Bartering for goods, especially when one can assess their fair market value, is generally less complicated than bartering for services. Unlike bartering for goods, bartering for services is always a dual relationship. (For extensive articles on practices and ethics of bartering go to: zurinstitute.com/bartertherapy.html.)
- Therapists may choose to educate their clients about the benefits of private pay and the concerns and risks of managed care in regard to confidentiality, privacy, future eligibility for health and life insurance, employment, continuity and control of care.
- Therapists should be flexible about missed sessions and late cancellations due to illness, transportation problems, etc.
- Contrary to what is commonly believed, HIPAA does not mandate electronic billing. For a summary of billing options under HIPAA go to: zurinstitute.com/billing.html.
- Therapists should try to be careful of the accumulation of debt by clients. Large debts by clients tend to be clinically very complex and burdensome. If therapists let clients accumulate debt, they should document the reasons (e.g., sale is pending for patient's house) and consult in complex cases.
- Therapists are advised to avoid using collection agencies because it significantly increases the likelihood of clients filing complaints with the licensing boards.
- Payment for referrals and fee splitting are considered unethical by some professional organizations' codes of ethics.
- Several professional organizations' codes of ethics, including APA, state that it is unethical to withhold release of records that are needed for a patient's emergency treatment solely because payment has not been received.
- It is of the utmost importance that therapists should try to explore their own personal thoughts, feelings and issues in regard to money. Many clinical and ethical complications stem from therapists' ambivalence about money and lack of training and education about how to handle it.