Sunday, September 01, 2013

When Patients Don't Pay

Before we start, some housekeeping issues:

First, I want to say that I was misled.  I was told that gazpacho freezes well, and following such advice, I can say with impunity that fresh gazpacho is far better than defrosted gazpacho.

Second, I want to say that when I deactived my personal Facebook account, I lost access to the ShrinkRapBook Facebook account where I post new Shrink Rap articles and other links to Shrinky Things of Interest.  Instead, please follow us on Twitter: ShrinkRapDinah, ShrinkRapRoy, and ClinkShrink.  I'm slowly transferring my social media addiction.  

Third, ClinkShrink and I will be doing the kickoff lecture for the Hopkins Odyssey Mini-Med School Series on the evening of September 12th.  There is a reception, followed by our talk where apparently we will be teaching everything you want to know about psychiatry in one hour, with time for questions.  While I speak, Clink will be fashioning the shingles in the back of the room, so you'll be ready to hang them soon after.  While Clink talks, I'll be distributing the new Psychiatrist shingles.  It should be a fun evening, so if you're in town, do register.  


Now for the post.   Before I start rambling, let me say that it's rare that patients don't pay.  It happens in every business, and some people are more aggressive about being sure they are paid, but I am not.  I ask for payment at the time of service before the first session, and maybe half of people pay at each visit.  If someone doesn't pay, at the end of the month, I send a statement.  The large majority of people then send a check.  Some don't, and the following month, I send another statement.  Some people let them build up and send payment irregularly, but most people stay up to date, and nearly everyone pays at some point.  Since I'm not living on a pay-check to pay-check basis, it doesn't bother me if someone waits a bit -- perhaps they're waiting for the insurance to reimburse them to have the cash available, or perhaps they are lazy about bills, but I'm not a stickler for this, I hate nagging people about payment because I don't want them to feel like all I care about is the money (and that is what people think) and that I don't care about them.  Talking about money is the hardest part of psychiatric practice, especially if I'm the one to bring it up and not the patient.  Much harder than  talking about sex or suicide, or the routine stuff of psychiatric sessions.

So I'm not a stickler for being paid at a precise time, and I would never send a patient away who forgot their checkbook (in some practices: No payment, No treatment) and for the most part, it's not a problem, most people pay, if not now, then later.

But this is a post because sometimes people don't pay.  Sometimes  keep coming and building up a balance, and acknowledge this and say they intend to pay.  Sometimes they disappear with an unpaid balance, never to be seen again, or later they want to return and send in the check for the unpaid balance before calling for another appointment.  But every few years there is someone who just doesn't pay, doesn't address it, and continues to request services, emergency care, repeat requests for medications to be called in, or duplicate statements to be sent for insurance reimbursement (which does not turn in to payment for the doctor).  Rare-- I could probably count on my fingers how many times this has happened in 20 years, but still, I find it troubling on several levels:
-- I feel I can't turn someone away if they are in distress.  Actually, I'm not much for turning anyone away once they are an established patient.  As one psychiatrist told me, "Once a patient, always a patient."  Forget 'in distress.'  If someone requests an appointment, I'm not good at saying, Hey you owe me big bucks, what's the deal?
-- If the patient is submitting to insurance and then not paying me, this is insurance fraud. They are turning a profit on coming to treatment.  Even if the money is going to pay their mortgage, it still feels wrong.
-- At some level, the issue starts to impact care: there is a large unpaid, unaddressed bill, and then a call with a crisis on a weekend.  To me, it never feels right to say "I'm sorry you're suicidal, but you know you last paid me 6 months ago."  I deal with the crisis, but I'm not happy about it.
-- I'm not in insurance networks, so people have the option of getting less expensive care by going in-network; I'm no one's only option for treatment.

So what is reasonable?  I don't want to say to people, if you haven't paid by the 15th of the month, then I won't see you until you pay up.  Some people pay irregularly, but I've seen them for years and I know they will pay and there is no issue.  Others, I just don't know.  And sometimes I will agree to a reduced fee for someone in a rough place who has been in treatment with me for a time, but ironically, these are the people who are most likely not to pay. I suppose they figure that if I can afford to discount the fee, I must be rolling in the bucks.  Which then might beg the question, should a wealthy physician who doesn't need the money to survive because he inherited a trust fund from grandpa be charging people with financial problems for necessary medical or surgical care?  Well of course, his time/training/expertise have value, but patients sometime resent paying rich doctors.  (P.S. I didn't inherit a trust fund, but I wish I did, and I'm still open to being a beneficiary). 

What's your experience been?  Psychiatrists: what rules do you have for collecting payment: Pay at the door? Pay when you get your bill? And when do you start saying you won't schedule another appointment -- when a bill is unpaid for one session? One month? 90 days?  Six months?  What overdue balance can you live with and not feel taken advantage of?  $100?  $500? $1,000? $1,500?  If someone is in a regular on-going psychotherapy, it's not hard to get to those numbers.  Patients/Clients/"Consumers": How does your shrink deal with this?