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.  

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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? 

20 comments:

Alison Cummins said...

Don’t you do psychotherapy? My impression is that the traditional way for psychotherapists to deal with that is to decide that the topic of psychotherapy is the client’s reluctance to pay. Eventually the client gets fed up and either pays so that they can talk about things of interest to them or quits.

Some psychotherapists abuse this, seemingly for their own amusement or because they feel more in control of sessions this way, but most probably just have it as part of their bag of tricks.

L said...

I've had therapists who wanted to be paid at each session and therapists who give a monthly statement. I don't have a particular preference. Those who gave me a statement received checks I sent from my online bank, so usually about 10 days after getting the statement. No one's ever complained. I had one therapist who wanted payment at each session but gave me a statement to send to my insurance only once a month. To her, I requested that she either give me a statement at the time of payment or have me pay her monthly because I can't be paying her huge sums of money while waiting for reimbursement. She opted that I pay her monthly because she didn't want to make up weekly statements. I pay my therapist's bill the same way I pay my electric bill. Oh, and by the way, my therapist uses a sliding scale with me and I still pay every month. I don't really get why others don't.

jesse said...

Alison has the right idea, in my book. I myself am also quite easy going about payment, and yes there are a few patients who abuse it, but not many. Yet to say "it is the topic of psychotherapy" begs the question of how this is to be understood. It is not "look, all we can talk about now is why you do not pay" as an ultimatum but rather it is a thoughtful listening to the total context in which it occurs, and how the patient addresses it (or does not address it). For instance, how does the nonpayment fit in with the other ways the patient views or treats the therapist? Does the patient feel that others treat him that way? Does he feel resentful of you, or does he feel angry that you are not seeing him as frequently or quickly as he might wish? Is the nonpayment an expression of sadistic wishes towards the therapist? Or could it even be that the patient is so embarrassed at not being able to pay the whole amount that he sees the partial payment he agreed to as inconsequential? One needs to keep in mind the transference and ask how the nonpayment is an expression of it.

So when the patient comes in next and talks only about his distress, the therapist might say "you are not bringing anything up about the past balance you owe. What is keeping you from discussing it?" This can lead to a fruitful discussion.

jesse said...

And L, you are right on.

Dinah said...

Allison: Perhaps I need to go to therapy to better understand why I find the topic difficult to bring up.

L: I think others don't because they don't have the money or there is something else they would rather spend it on?

Jesse: Invariably when I take that approach the response is that the patient does not have the funds. They've let the balance pile up, if the insurance paid, well there were creditors hounding them, so the money went to that, and Okay, I can say,"What is keeping you from discussing it?" but I may well get "I don't have the money" or "I will send you a check which then won't come." When I bring this up with people with large balances who have the money, they typically say "Oops, sorry" and a check comes 2 days later. If there is a way to have the patient use this to discuss their sadistic impulses towards me, I missed that technique. I imagine there are many people who simply pay their bills who also have issues of resentment or sadistic thoughts. My guess is that a willingness to reduce a fee implies I don't really need the money and it makes my bill less urgent then the hairdresser who just won't put in those highlights without payment and who simply doesn't see hair styling as a necessity or reason to slide a fee.

jesse said...

The thought that reduction in fee could mean to the patient that you don't need the money may well be true in many cases, but it still leaves open discussing it. The sadistic impulses are being acted on - the therapist does not say "you are being sadistic" but realizes this may be part of the determinant for what the patient does. And yes, too, it is important to not let the bill get too high before one brings it up. It begs the question of what kept the therapist from discussing it earlier (for example, the therapist want the patient to like him and/or feels that calling attention to money is less than professional. In this regard, too, not discussing it can be a message to the patient that the therapist indeed does not need the money, and thus can reinforce whatever presuppositions the patient has.

In my way of working, everything that occurs is something that might be utilized to help the patient. There is nothing that is necessarily irrelevant.

jesse said...

Even if the patient says what you are suggesting above, that they do not have the funds or that they are waiting for the insurance, that they do not talk about it can be a valuable clue, particularly to how they treat other people. The man tells you he treats his wife just beautifully, but the way he treats you gives you a window on to another part of the story he may not consciously realize....

L said...

If I didn't pay, I would not come. I would be too ashamed. It kind of blows my mind that other people would not pay and continue coming for treatment. And that this is okay with you guys. Seems to me that your not addressing it is what gives the impression that you don't need the money, not a sliding scale.

Tigermom said...

I take payment at the end of each session. I stopped having any outstanding balances when I began taking credit cards. Credit cards allow people to use their health saving account funds as well. And hecks are hard to remember to keep in one's wallet and people under a certain age just don't use them.

Anonymous said...

I don't pay my pdoc when I don't have money and he doesn't say anything, it's not a trick or bad feelings, just broke. When I have money I pay. He's nice and doesn't say anything, thank god. I have enough problems! Maybe we shouldn't look to far onto these matters. Broke I's broke. But, I always trying to come up w money;)

SJ said...

I am lucky to have good mental health coverage with my health insurance that allows me unlimited appointments with my psychiatrist because of my bipolar diagnosis. I see my shrink twice a week for therapy and have done so for over a year now. He literally saved my life once and I would be devastated if suddenly he refused to see me because my insurance ran out and I couldn't afford to pay anymore. I understand that he is running a business, has bills to pay, and deserves to be paid for the use of his set of skills, but in my mind it would almost negate the care he has provided over all this time if the end of our relationship was financially based. Like he was only ever in it for the money and I was interchangeable with any other patient passing through his office.

Nathan said...

Getting paid to talk about getting paid, sounds like a good deal for a therapist.

I think clarity about payment upfront is super important, including noting expected length of time of treatment, or noting that that length of time cannot be given, so people know they are entering a professional relationship with increasing cost over time. If folks don't have money, they shouldn't start such treatment in the first place and professionals who expect a certain amount of payment should not agree to enter them either.

Folks shouldn't forget that relationships with professionals are financially based. That's with every professional. Professionals are in it for the money (not necessarily to rake in the big bucks, but their income is based on what clients pay). I don't know of many psychiatrists who practice voluntary simplicity in their lives. At the very least, they have a lot of student debt. If therapists aren't getting paid, they aren't going to like treating you.

L said...

It's hard for me to understand the rationale of I'll pay if I have money and I won't if I don't. Would you go to a manicurist if you couldn't pay? Or a bookstore? Hire painters for your house? Buy a porsche? Of course not.
I don't understand the sense of entitlement, just because a person in mentally ill. My therapist uses a sliding scale with me based on what I can afford, but if for some reason she stopped doing that, I would have to find someone who took my insurance or a sliding scale clinic, not continue seeing her without paying. It just wouldn't be acceptable to me to simply not pay because I didn't have the money. Truthfully, I think there are two problems - 1 is this apparent sense of entitlement, which really shocks me, and 2 is that therapists permit this.

Anonymous said...

As a patient, I recognize that my relationship with my psychiatrist and therapist is an emotional one as well as a professional one requiring a fee for services rendered. I negotiated with both members of my treatment team the amount of money I would pay them when I began treatment almost two years ago. The psychiatrist does not take any insurance and while the therapist does take some insurance plans, she does not take mine. I submit the bills to my insurance company to receive out of network benefits. I pay both psychiatrist and therapist by check at the end of the visit (they do not take credit cards).

Anonymous said...

I'm fortunate enough that my psychiatrist bulkbills, the Australian Medicare system reimburses him but I doubt its very much, I started seeing him in yr 12 through a govt clinic, but that was only short term and he offered to see me at his private practice, at first he did mention something like a token fee of $5 a session but I wasn't working yet so he never brought it up again, sometimes I feel bad for not paying him "properly" even though I'm still in uni, but i do work part time now and wonder if maybe I should pay him extra now?

Steven Reidbord MD said...

I mostly agree with Jesse on this, although in my mind it depends on the type of treatment. A "meds only" psychiatrist who is ok not being paid, whether out of altruism, charity, guilt, forgetfulness, or whatever, should feel free to practice that way. After all, some people volunteer professional services for free. I hope they do so consciously, but that's not for me to say.

In contrast, a psychiatrist doing any variation of dynamic psychotherapy does a disservice to his/her patient by tiptoeing around this issue. Yes, we're paid to talk about getting paid — and to talk about how patients feel about being in treatment at all, and whether they hate us or have erotic dreams about us, and countless other things — all in the service of helping them know themselves (and how they come across) better. More than once my broaching the "3rd rail" topic of unpaid bills has led to relief in a patient who was too embarrassed to bring it up himself. It's hard for me to imagine any scenario when NOT mentioning unpaid bills would be more helpful for a therapy patient.

Raising the topic doesn't require an ultimatum. instead it insists this behavior needs to be looked at, even if it results in an uncomfortable admission of poverty or the articulation of contempt toward the therapist. And, yes, at some point, fortunately with very few patients, I decide they're never going to look at this behavior, and I stop seeing them. Rewarding sadism isn't in any patient's best interest, not to mention mine.

Anonymous said...

Same anon as before, out of curiosity, how much does a psychiatrist usually charge for an hour of psychotherapy? And if anyone knows how much can a pdoc claim from a system like Medicare or insurance?

Skizzy said...

I am obviously schizo so I forget things from one minute to the next. If there is not an alert on it for my phone it doesn't happen except where money is concerned. I have the best psychiatrist ever and would gladly be a mob goon who breaks kneecaps to make people pay him. I always pay cashat the beginning of the session because he knows I am paranoid about paper trails about me seeing him so I drop $300 on him upfront . I have to keep it in my hand so I don't forget. I really wish he took insurance. It would make my life a lot less stressful trying not to forget, but if I do he asks if I want to pay with my debit card and he knows that will widen my eyes to realize I forgot to pay when I got there. That is a polite way to remind. You have to remember that really jacked up people can be very distracted and forgetful but I blame excessive or habitual non-payment on this new era of"gimme my free stuff" The world expects everything for free .

seti said...

I don't work in healthcare, but If the patient was getting reimbursed by insurance and then not reimbursing me, I would fire them and then report it as insurance fraud.

I think the second stealing comes into the picture, the professional relationship is over. I actually apply this rule to doctors. If they overcharge and don't reimburse me after I notify them, then I just assume that they didn't want my business and I don't go back. I am going to report one soon to the insurance company for overcharging.

Anonymous said...

I've never missed a payment (in fact I think I overpaid my first year because I didn't realize my therapist gave me vacation days). But, at one point I thought my company was going to be sold and my job in jeopardy. I brought up my ability to afford therapy, and my therapist immediately made it clear she'd see me no matter what. I'll never forget that gesture, but I'm glad (knock on wood) I never had to test that. In fact, I don't think I could go to therapy for free and feel okay about it. Paying my therapist is my ONLY real world obligation in the relationship. It would be criminal to take the service and not pay (unless other arrangements were mutually agreed upon). I also own a business that extends a great deal of credit to a great deal of small businesses. I rarely get stiffed, but when I do, I've noticed there is always some major character flaws with the people who stiff you without honest efforts to proactively rectify the situation but continue to operate their business (aka they didn't go bankrupt and close their doors). And, they are habitual about it. I'm definitely not the only business they have screwed over. I think this is a HUGE area for you to explore with clients -- both because you are rightly owed your due, and because there is a very high chance you are not the only person that has been taken advantage of (it's just a matter of how extreme the pathology is). Not paying you is a form of abuse, in my opinion.