Paying for Nothing

News Type: Other — Fri Dec 22, 2006 1:37 PM EST

health, psychology, psychotherapy, social-work

Some years back I had situation that forced me to examine a common practice of mental health professionals i.e. to make patients pay for sessions that they did not keep or did not provide ample cancellation notice.

The situation was simple enough. A patient celled mid-day to say that something came up at work and could not make their 6: PM session that day. My office policy which is similar to that of many mental health practitioners was that if you did not provide 24 hour notice to cancel a session you will be charged for the session. My rationale was impeccable or so I thought as well as consistent with that of my colleagues.

First, I reserved time for my patients. They are paying for my time. If they choose not to use it, that is their choice but since they reserved it they are responsible for paying for the time uses or otherwise.

Then of course there is the commitment to therapy. If patients break or cancel too many sessions it shows a lack of commitment or motivation etc. Charging such patients helps keep them motivated or so the argument goes.

This patient however said, Nonsense. He actually used stronger language but nonsense is a fair translation. He said, I am not paying for something I never received. You can bill me all you want, I am not paying. I pay only for services received. If you chose not to see me over a few silly dollars that is your choice and you have to live with that decision and take full responsibility for your actions. But I am not paying for what I did not get.

Well, this was in interesting stand off. What was I to do? I consulted with colleagues who for the most part supported the standards position. I should insist on charging them for the cancelled appointment. Some colleagues suggested it was a transference issue. One suggested that I may have misdiagnoses my patient who seemed clearly a Borderline Personality, a term often used to describe patients we don't like or who are difficult. And of course there are always some who make all kinds of other analogies such as non refundable theater tickets.

Yet despite the sage advice from my colleagues I was troubled. My patient was otherwise motivated for treatment and was actually making progress. He always paid his portion, the co-pay, on time and never gave any indication of having a personality disorder. He came from a working class background with what might be traditional values who paid his bills but on principle did not wish to be charged for what he did not get. So writing him off as some kind of nut case a term sometimes synonymous with borderline personality did not seem to hold.

Nor did the theater ticket analogy hold much weight either. When one goes to a theater one is a passive observer in the audience. The performers are the main event. A great performance can take place who a full house or empty seats. No one ticket need be sold or seat filled. With therapy however it can not take place without the patient. Therapists tend to forget that too often. Their presence is necessary. Also, it is possible for a ticket holder to sell their tickets to another and sometimes make a profit so. Can one sell their therapy session or put it on e-Bay. That analogy falls flat.

So what could I do?

Refusing to see my patient until they paid the disputed fee could work only if they really did not need the therapy in the first place. In fact often times when patients break or cancel sessions they may be telling their therapist that it time for them to move on when the therapy has been resistant to let them go.

However in this case I recently written a treatment report to the patient's managed care company indicating that I thought continued treatment was medically necessary. So to fail to continue treatment over a couple of dollars would easily put me in a position looking like I was abandoning my patient for no other reason than money and a paltry sum at that. That was out of the question.

But for me the clincher was the fact that the patient's insurance company as are most insurance companies was very clear they would not pay for broken or cancelled appointments. Why? Well they had the same reasoning as my patient. Why should they pay for something that was never received? In addition some even stipulate in their contracts that you may not charge the patient in such circumstances but most are silent on that matter of whether you can bill the patient directly.

But why is it OK to make a patient pay for something they never received and not their agent the insurance company? The reason is simple. The insurance company has the clout to set the terms with providers and we in most cases have the clout to demand that patient's pay. It's a matter of power. We charge patients for what we did not provide simply because most of the time we can. We have the power. They are vulnerable. The relationship between therapist ands patient is not equal. But does that make it right? And is it really good business?

Since that experience of a patient having the courage to stand up to my unreasonable demand I have changed my policy. I have not charged for late canceled sessions since. And it turned out to be one of the best business decisions I ever made.

Patients who normally would have dropped out or treatment or grudgingly paid only to bad mouth me to family and friends later stayed in treatment and referred their friends.

It 's similar to companies that have liberal return or refund policies on their products. Sure it may cost you a little in the short run but in the long run it is worth a fortune in good will.

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{"commentId":442563,"authorDomain":"vicaxp"}

vicaxp

Good article and refreshing new policy!

{"commentId":442563,"threadId":"63057","contentId":"492882","authorDomain":"vicaxp"}

2 votes

#1 - Fri Dec 22, 2006 1:54 PM EST

{"commentId":442885,"authorDomain":"DailyNewsRush"}

Daily News Rush

For the patients that did pay you for the missed appointments, can I have that time for FREE since you're not otherwise occupied during that time? (big toothy grin)

:) Just kidding.

It's tough - some people just won't stop to consider that your time is valuable, nor do they realize that you could be seeing other patients during this time and actually 'earning' the money.

For some, they may have legitimate reasons for missing an appointment with you (I would never miss an appointment with a psychologist or therapist or psychiatrist or mental health professional - they're way too much fun and very helpful...not that I've ever been to one...) that may have been beyond their control. By charging irate patients for missed appointments, you may lose a customer - by not charging them, you will have a customer for life (well, hopefully you're a good mental health professional and they won't need you quite that long....), plus you'll get recommendations. So I think you made a good choice.

Enjoyed hearing this from your perspective - I'm probably one of those people who would get upset if my Doctor charged me for a missed appointment, but I would have dutifully paid it. Now if they charge me, I'm just going to show them your article. :) Probably kidding there too.

{"commentId":442885,"threadId":"63057","contentId":"492882","authorDomain":"DailyNewsRush"}

2 votes

#2 - Fri Dec 22, 2006 4:48 PM EST

{"commentId":443202,"authorDomain":"drjohnriolo"}

Dr. John Riolo

Actually I hope you are not kidding. Show them my article.

Look whether a health professional charges for missed appointments is a matter of choice plus something contracts with insurers. I have found it helpful not to do so.

However, the BS and psychobabble rationalizations some of my colleagues give is laughable. If they had the guts to they simply wanted your money at least that would be honest.

{"commentId":443202,"threadId":"63057","contentId":"492882","authorDomain":"drjohnriolo"}

1 vote

#2.1 - Fri Dec 22, 2006 9:17 PM EST

{"commentId":450878,"authorDomain":"Nycam"}

Nycam

I personally would volunteer to have goreproter's head examined- on my terms. lol

{"commentId":450878,"threadId":"63057","contentId":"492882","authorDomain":"Nycam"}

#2.2 - Fri Dec 29, 2006 2:32 PM EST

{"commentId":443414,"authorDomain":"winsomecowboy"}

winsomecowboy

Bravo. I think you made a wise decision and am glad it is paying you dividends.
I have been in the position where the co-pay was $10 but a regrettably missed appointment cost me $75.
I felt punished. (you can read into that what you will :)

{"commentId":443414,"threadId":"63057","contentId":"492882","authorDomain":"winsomecowboy"}

#3 - Sat Dec 23, 2006 1:16 AM EST

{"commentId":443659,"authorDomain":"redruby"}

Redruby

I have this policy spelled out in my disclosure but I don't think I've ever used it. Most people do not miss an appointment without good reason but I think having the policy stated lets everyone know that in this business, a client is contracting for my time and I set aside that time just for them. If they aren't able to make it and give me enough notice, I can usually fill their spot. The policy for me is primarily an information item and helps the new client especially realize they are involved in making a serious investment in their health and well being. Like I said, I don't think I've ever charged anyone...no, maybe one person awhile back who didn't show up a couple of times and we talked about that and agreed it was not the right time for them to do their work.

{"commentId":443659,"threadId":"63057","contentId":"492882","authorDomain":"redruby"}

3 votes

#4 - Sat Dec 23, 2006 11:23 AM EST

{"commentId":450891,"authorDomain":"Nycam"}

Nycam

Excellent point and idea, redruby.

@ Dr. John R: I wonder these things-
[1] is the patient possibly being passive-aggressive, or arrogantly trying to demonstrate a new self-image of assertiveness?

[2] Did you spell out your no-show policy and have the patient sign off on it (contractually obligating him/her, regardless of insurance?

[3] Would you or your patient be open to an arbitrator, to save time, face and some of the monies due you?

Just a thought.

{"commentId":450891,"threadId":"63057","contentId":"492882","authorDomain":"Nycam"}

1 vote

#4.1 - Fri Dec 29, 2006 2:37 PM EST

{"commentId":451058,"authorDomain":"drjohnriolo"}

Dr. John Riolo

Nycan

You asked three questions.

First, it dose not matter whether they are being passive aggressive or not. Passive aggressive along with borderline is among the terms of endearments that therapist use to describes anyone who challenges them. It may once have had meaning beyond that but that meaning got lost with therapist using these terms to they advantage at the expense of patients.

Yes I Did spell out my no-show policy and the patient signed off in it. However more often than not when someone comes in for help with a mental health problem they can be made to sign just about anything. It means nothing unless you have true informed consent.

And why would I need an arbitrator in this case. I agreed with the patient. Nine times out of ten when patients do not keep appointments they are telling you that either they no longer need you which is a good thing or that you are not helping them. It it the former I concluded I did a good job and look forward to the next patient. If it was the later I need to understand why the patient is not satisfied . I could not do that if I am preoccupied with collecting money from someone for services I never preformed.

In a business where if you have to force people to pay you, something is wrong. Fact is in 30 years very few people broke appointments. Imagine how many times you went to a store and said I be back and never returned. Imagine getting a bill for no showing up.

A call to cancel would be nice but it should not be mandatory.

{"commentId":451058,"threadId":"63057","contentId":"492882","authorDomain":"drjohnriolo"}

3 votes

#4.2 - Fri Dec 29, 2006 4:09 PM EST

{"commentId":443838,"authorDomain":"megamiddlemyth"}

megamiddlemyth

My point of view on this is:

I have indeed reserved my time, this day, for this particular person. As I tell clients when I discuss this with them, I can't very well go out into the parking lot and go up to someone and say, "you look troubled; I have a free hour, would you like to hire me?". So if someone cancels without reasonable notice (which by professional consensus is 24 hours, except for psychoanalysis, where it appears to be six months) it is costing me money - and I am quite prepared to be say this to clients.

On the other hand, things happen. Things come up at work and people feel (often rightly) that it's appropriate to stay late and deal with them. Babysitters get sick. Children get sick. And it does indeed feel punitive - to me as the therapist, and often to the client - if I insist that they pay the full session fee for missing a session under these circumstances.

What I have done in my practice is to have two levels of financial consequence for missed appointments and late cancellations.

For a missed appointment - the client doesn't show up at all, and does not give me prior notice at all - the client is charged the full fee for the session (currently $110). This doesn't happen too often. Sometimes people are really forgetful - I know, a ridiculously nonclinical phrase - but these are folks who live in the community - they manage to get to their jobs, or school, or whatever on time (or at least more or less on time) - so while the full fee may be a steep price to pay for forgetting about their appointment, they really are capable of routinely responsible behavior (e.g., calling to cancel, even if at the last minute), and I think it's 1) fair to me and 2) supportive of the reality principle in general , to charge full fee for absolute no-shows. (It is, of course, true that someone who is dropping out of therapy will sometimes no-show as a way of telling me they are quitting - usually someone who has just started - often at someone else's request that they get help - and not really engaged in treatment , but occaisionally someone who is avoiding dealing with an issue (transferential or otherwise). I don't chase these folks for the money; if they don't pay the bill, that's that as far as the financial issues go.

The other level of financial consequence is the "late cancellation fee". This is spelled out in my intake-policy agreement, as being a charge (currently $35) made when the client cancels, but gives me less than 24 hours notice. If you give me notice that you can't come, I can do something useful with the time, even if I can't make money during it (I can do paperwork, make phone calls, read, nap go out for a walk; I'm not sitting in the office waiting for the client to show up, unable to engage in any activity requiring sustained attention). And I've been treated respectfully by the person having cancelled. Still, I have reserved the time, and realistically can't (usually) fill it on short notice like that. So some compensation to me seems fair, and clients almost always think it's fair too. There are, of course, judgement calls that need to be made. If a client is sick, or the child is sick do they still have to pay if they cancel? (Usually not in my practice, but it can depend on the client and circumstances).

There are always judgement issues that come up, but having a "late cancel fee" that is significantly less than the full session fee has worked for me.

{"commentId":443838,"threadId":"63057","contentId":"492882","authorDomain":"megamiddlemyth"}

1 vote

#5 - Sat Dec 23, 2006 2:18 PM EST

{"commentId":446859,"authorDomain":"stolte-sawa"}

Ryan Stolte-Sawa

Thanks for this enlightening article on a progressive position. I have always contended that a patient is not paying for a doctor's time, but for their expertise. Anyone can expertly waste an hour.

{"commentId":446859,"threadId":"63057","contentId":"492882","authorDomain":"stolte-sawa"}

3 votes

#6 - Tue Dec 26, 2006 11:54 PM EST

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DR. JOHN RIOLO

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Paying for Nothing

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