Thursday, December 27, 2007

The Patient Who Wouldn't Pay

I posted the latest poll on the sidebar and I thought there would be hands-down winner, that everyone would agree, the hardest thing to talk about in therapy is MONEY. Payment. Fees.

Maybe it's just from the therapist's side, but I HATE TALKING ABOUT MONEY. I really hate it. How much do I hate it? A lot.

On the phone before I meet someone, I'm very clear about a bunch of money things-- I hate this, it turns me off, but people have the right to know what they're getting into and if it isn't clear there are a lot of misunderstandings. So I don't participate with insurance companies, the patient needs to pay up front and then submit the bill so the insurance company will reimburse him directly. He needs to call the insurance company before he even comes in-- it's called "preauthorization" and if you don't jump through this hoop, some companies will refuse to reimburse at all. Many companies have a separate managed care component for mental health and ask for a treatment plan. The patient needs to find out how many visits he has before a treatment plan needs to be submitted (it may be 1, it may be 8, it may be 11, it may be never) and he has to to tell me Where to send the treatment plan to. Then he has to count the appointments so I know when the next treatment plan is due (--oh, actually I have a system for doing this, but it doesn't hurt to have a back up reminder). I tell the patient the cost of the evaluation and the cost of a regular 50 minute session. I tell them to expect to pay at the time of the visit-- that's the most comfortable way I've found to say it. A lot of people say "no thanks, I'll find someone in my network," and that's fine. I say a few other things too, like how to find my office and what to expect, and that it's fine to bring someone if that will be helpful, and definitely bring your medications.

I hate talking about money (did I mention that?). What I don't do is ask for payment during the session, it feels tacky. Most people write a check at the end---they were told this is the policy on the phone. If they don't, I send a bill at the end of the month, with all the other bills. The majority of people mail or bring a check, and it's just not a problem. Here and there, someone just doesn't pay. I hate asking. Eventually, I ask. Usually I don't, and eventually the patient pays, but I've been stiffed by a few people.

There was once a woman who'd seen me for years, payed at every session, and then had an unexpected financial crisis and now was really struggling. I didn't ask her to pay for the full session, instead, I nagged her to submit to her insurance company and at least pay the portion they would pay. Should I mention that the reason for her unexpected crisis was that she outspent her excessive standard of living? I've had this happen a few times, and I tell people to catch up at they rate that they can. In the case of people who have had true crises (lost jobs with few assets any way), I will slide their fee. But I'm not so comfortable doing that when the patient drives a late model luxury car or owns a vacation home. I'm sympathetic to their sudden financial plight, but I need to make a living, too. My hardest is the patient who struggles and struggles just to make a living, sleeps on the couches of friends, every purchase is a hardship, and I would say "forget it," I'll see you for free, but for that little drug habit--- if you can swing upwards of $50/week on your habit, another $50 for your cigarettes, a few bottles of wine, then maybe it's good to make a minimal payment on your shrink bill to that shrink who calls around to get you free samples.

Do you want to hear about the surgeon who came twice and never paid the bill? Or the patient who moans about every dime of the bill and the struggles to get reimbursed, but spends in a way most people wouldn't dream of spending on luxury trips, 5-star restaurants, homes so big the utility bills are bigger than his medical bills? Or the few patients I've seen who simply didn't pay at all--even after being asked, uncomfortably, repeatedly, just said "next time," or "I'll send a check" or "I did send a check." The odd thing is these aren't people who are talking about their financial hardships, they're people who are talking about their vacations and boats. The reality is they make a profit by not paying, because they get reimbursed by their insurance companies (often these same patients will ask to have the statements regenerated two or three times), but they never pass along the fee. This is called fraud, I believe.

Uncomfortably, I've been left to say on a few occasions, "Why don't you catch up and then call to schedule the next appointment." I hate talking about money.

I'm sorry, I sound bitter and this is an issue with so very few people. Most people, if they fall behind, they say something and I'm happy to have them catch up at their own pace, and they do. Nothing specific set me off tonight, I just was surprised that more people have trouble talking about sex than money. Maybe I'm feeling a little Grinchy. You can guess which I'd rather talk about.


The Shrink said...

At least on this side of the pond, within the NHS, it's simply not an issue.

It's something we invariably take for granted here, that clinicians principally are clinicians and not participating in or running an income generating system. It must be a significant reduction in stress for us that we're not truly appreciative of.

Anonymous said...

I suppose that money would be a more difficult topic if I was a shrink or a patient who habitually didn't pay. But I was responding to this poll from the point of view of a patient who always pays with a cheque at the end of this session. I don't hate talking about money because there is nothing to talk about :)

Anonymous said...

I couldn't vote on the poll because my problem spans two options. I have trouble talking about the payment fees for sex. Hmm, and afterwards, it is difficult talking about our "therapeutic" relationship.

So, can I pick all of the above?

Gerbil said...

Anon(2): I sincerely hope you are joking--or, at least, not talking about your therapist!

I've never been in the position of taking payment from a client, but I have been in the position of knowing more about my insurance company than my in-network therapist. Of course, that could also be because I worked for my insurance company...

Midwife with a Knife said...

anon2: hah hah hah hah! :)

Money's the toughest thing to talk about. Sometimes I know patients are not planning on paying their copays for my care, and I've never figured out how to address it.

NeoNurseChic said...

sounds like money is the hardest thing to talk about for those providing the service rather than those paying and that's understandable. I don't like having to bug someone for money if they owe me for some reason! However money is definitely not the most difficult thing for me to talk about. For me its the therapeutic relationship and sex - one having nothing to do with the other. So I didn't vote bc it was too difficult for me to choose which was the most difficult to talk about! I have issues with both of those topics for different reasons.

Anyway my comments are going to be short now if I keep using my iPod touch! LOL I actually have more to say on the financial topic but will comment again when at a computer!

Take care,

jcat said...

Most pdocs here have opted out of insurance, and work on a direct payment system.

With my pdoc talking about money is never required - he has front office staff who do that for him - so he can pretty much be sure that when he sees you, the account is either up to date or arrangements have been made for it to be paid.

And there is no way in hell I'd discuss sex with him, so that one's ruled out as well!

Anonymous said...

I am suprised that you don't have somebody else to pester your non-payers. Also, I don't understand why you would see somebody who is not paying. No money=no service. How about a retainer required for 2008 for any customer who has had a history of late payment?

I used to work for a public library where asking people to pay bills was everyday work, and done face to face. A suggestion if you want this taken care of: You could inquire at your local library and ask if somebody there is available to work a few odd extra hours on a contract basis. Talk to the director to get a bead on who is their reliable bean counter. Most library staff are underpaid and well-educated and could use a little extra cash.

Alison Cummins said...

Is sex a big problem for lots of people? I thought it was such a public topic of discussion these days - in magazines, newspapers, television - that much of the taboo would have dissipated.

I suppose I shouldn't be that surprised: I saw a couples therapist who refused to talk about sex. I brought it up three times and each time she changed the subject without acknowledging what I'd said. Then when I asked her if the fact that we were older than she was was what was making her uncomfortable talking about sex with us, she denied being uncomfortable. She said she was fine talking about sex and that we should bring it up any time we felt like it. When I pointed out that I'd brought it up three times already, she looked uncomfortable and said "then there must have been something more important I wanted to talk about." Um, yes, my point. I stopped trying to talk about sex and she never brought it up on her own.

This was an unsuccessful therapeutic relationship on many levels. I also tried to talk about the therapeutic relationship - in every session. I would ask what approach she was using. "I'm here to help you." I would ask what a particular exercise was about. "I'm here to help you." I would say that I cried all day before seeing her because it was so unpleasant. "I'm here to help you." I'd ask why she'd ask if I were comfortable in the room and if I said no, ignore my answer and go straight on as if the question and answer had never happened. "I can't tell you that. Only you can answer that. I'm just here to help you." I'd tell her that I was much worse since starting to see her, that I was much more unhappy and that my beloved and I would spend four days not talking before sessions, that we would hug before going in, exchange endearments and expressions of encouragement, then be so miserable in the one hour with her that we wouldn't talk again for four more days. (And we had completely stopped having sex since seeing her. We had been having sex before.) "I'm here to help you."

Really upsetting. Cognitive dissonance up the yin-yang.

That's why I'm totally spooked about seeing therapists. The therapeutic relationship really frightens me. I have a psychiatrist and a talk therapist, and I trust them, but it can still be hard. It helps that my talk therapist is willing to discuss the therapeutic relationship, and tells me it's ok not to trust her. It helps a lot. But it's still scary.

Anonymous said...

Apatient who refuses to pay you is speaking volumes abt the relationship.u shouuld know that by now.

Anonymous said...

I definitely chose sex. I refuse to talk about sex in marriage counseling even though my husband and I will talk about it freely. I just won't talk about it with a stranger. I won't talk about it with my personal therapist either, even though she as tried to approach it several times. I had an extremely difficult time bringing it up with a shrink when my meds were causing problems with libido, dryness, pain, etc. I've just come to accept those side effects of a fact of life now because it seems to be a side effect of everything I take (it's almost as bad as weight gain).

Money has never been an issue because I have insurance. Even when my insurance benefits ran out or I went out of network, I didn't have a problem. I was upfront about being poor. I told them I was able to pay out of pocket, but it meant I couldn't come as often. I let them choose whether they would sliding-scale me from there. One did, one left it as an option if my situation got worse.

I'm curious about why people find the therapeutic relationship difficult to talk about. I don't really have much of a therapeutic relationship with my shrink. I mostly just get med-checks for refills, but with my therapist, we talk about this quite a bit. We occasionally check in to see how well things are going or if she's about to get the axe (fired). Someday I'll have to take the mystery away and tell her I like her quite a bit (but I think she already knows that).

Alison Cummins said...

Michelle - you just talked about sex here, in front of seven billion strangers.

I would guess that the problem is more that a therapist is not a stranger?

FooFoo5 said...

My immediate reaction to the poll was "money," dismissing the other issues because we are all "adults" and should be able to talk about these things... Yikes! Yeah, I loved James Harriot, and even recall at age seven, when I had a seizure from a fever, my pediatrician, in a city reeking with ER's, actually came to the house in the middle of the night. Yet, such was, and perhaps for many remains, the image of "benevolence," which then seems incongruous with discussions of "fee for service." Further, it seems to me that the misperception that physicians, in general, are "outlandishly" wealthy (as opposed to simply paid commensurate with the level of education and experience, but more likely whatever managed care will allow) further distorts the image of benevolence and paves a path toward resentment.

My experience is that psychiatry, in specific, seems to suffer more from the accumulated "resentment" than other sub-specialties. I had an orthopedic surgeon cancel an elective procedure on me because there was a mix-up in communication with my insurance carrier. He didn't bat an eye. And my annoyance was directed at the insurance carrier. When I told clinic patients that we had to reach an understand regarding payment, they seemed to react as if I was rejecting them.

I don't want to be windy here, but I don't see "having someone else handling financial aspects" as the solution. Better that someone is angry at me specifically regarding this issue, rather than angry about this issue and at my lack of directness.

Anonymous said...

Money is not an issue for me either, because insurance pays for everything.

Talking about meds is only embarassing if I haven't been taking them!

I do find talking about sex uncomfortable, but that's because of me rather than any reaction on the part of the therapist. I get through these conversations by not looking at the therapist as I speak.

Talking about the therapeutic relationship is the hardest. I've always had a hard time letting people know how much they mean to me. The more they mean to me, the less I can express it. How could I tell my therapist that I love her?!!! I'm very dependent on her for a sense of security, but I can't tell her that because I'm afraid of appearing needy.

Alison Cummins said...

I've never had trouble talking about money when it's handled as a real-world issue. If a therapist tries to talk about what 'money really symbolises' I become very resentful.

At one point in my life my income dropped to around $400 per month. I was paying my talk therapist on a sliding scale, so $30 per weekly session or about 30% of my income. (Sliding scale for welfare recipients, who had an income of about $600 per month, would have been $25 per weekly session. Because I wasn't on welfare I paid more. I never questioned this policy.) My income had already been very low and I had absolutely no savings, so when this extremely poor period was coming up I paid my therapist for six weeks in advance as soon as I got my first $400 monthly cheque. Because otherwise I knew I would be wasting my cash on frills like food and I wanted to demonstrate to my therapist that I was taking therapy seriously, that I was willing to sacrifice to pay for it and was not waiting for it to be handed to me.

My therapist's reaction was to open a discussion about how I was asking her to take charge of my finances for me, and how infantile and dependent I was being. I was able to make my point and the discussion was not continued forever until I broke down and confessed to dependent personality disorder, but I resented having to go through this hoop when I was being direct and upfront and explaining the facts as they were.

Sometimes poverty is just poverty. (On $400 per month I was paying my rent and utilities and accepting charity food. I did not have a credit card or any debts. I did not use drugs or alcohol, or have a car. I was just poor. If I had not been suffering from major depression I wouldn't have been as poor, and if I hadn't been so poor I wouldn't have been as depressed, but I was managing as responsibly as I could under the circumstances and trying to keep my head up so I could look people in the eye. Being accused of bad behaviour and inappropriate neediness and abusing the therapeutic relationship really hurt. This was over 15 years ago and I still get all worked up just thinking about it.)

If my therapist had wanted to talk about money or budgeting or prioritising or my plans for the future, that would have been fine. Those are real-world things. I don't have a problem with the real world. But she didn't.

... Oh, and when I had to stop seeing her after the six weeks were up because I really couldn't pay her any more, she wanted to discuss what sort of issues I was avoiding by terminating therapy. Aaargh! What is it about money this lady does not understand?

So no, sex and money are both fine. They are what they are. But the therapeutic relationship is what the therapist says it is,* and the therapee is in denial if she questions that. It's the power imbalance in who gets to define reality that I am so poorly equipped to negotiate.

* Not always, but often enough to make me frightened and miserable at the thought of discussing it.

Alison Cummins said...

Oh, and I don't like talking about medications with talk therapists because that tends to come back to the therapeutic relationship again. If I would just work hard in talk therapy I wouldn't need medication. Isn't my talk therapist good enough for me? Or I am relying on a crutch instead of facing life. If I deny significant side effects, that's it, I'm in denial: I must be paying a much greater price for my reliance on my pharmaceutical boost than I'm admitting, and it becomes the talk therapist's goal to get me to break down and confess.

I'm able to jump through this hoop too. I've gotten better at it. I state that the therapist's assumption that I don't need meds is made in ignorance, and that it upsets me that she will assert this without knowing enough about me to know whether it's true. I then go through my personal and family history (alcoholism and suicide on both sides of the family, back at least three generations), my medication history (very stable), my personal history with prescribers (very stable), my dosages (low). A talk therapist will usually back off at this and say something like "Oh, I didn't know." (Of course she didn't know. So why did she feel qualified to tell me that I wanted to be off meds, or should want to if I knew what was best for me?) Then of course she charges me $75 for the session and we meet again next time.

Yes, I'm sure it's necessary. But I wish it weren't, and my resentment isn't about meds but about the assumption that someone who doesn't know me, knows what's best for me. If a therapist simply asked about my medications and what I got out of them that would be fine. But that doesn't usually happen and I end up having to set boundaries that a talk therapist should be able to respect all by herself. So it's back to the therapeutic relationship, and having to fight for my sense of self with someone who I'm hiring to help me deal effectively with the world.

To the extent that I am put in the position of having to set boundaries for the therapist, I feel like I am acting in a therapeutic role towards her. I resent that. And I don't want to have to talk about my resentment either. I want to talk about needing to develop a new career path or whatever.

Anonymous said...

Most people just pay their bills and it's not an issue. I also work in a clinic where I get paid by the hour and I don't deal at all with the patient's finances/insurance, and I like having a little of my life be in an "employee, just here help you" role. Of course, I give up some autonomy for this.

While NHS hasn't been sounding like all roses, I agree with The Shrink that it would be nice not to deal at all since I Hate Talking About Money (did I mention that).

Anons: pick as many of the above as you'd like.

Many people walk in the door and say "I can't afford to come every week, can I come every other week or once a month?" I ask them to come weekly for a few time (to "frontload" treatment just so I really get a chance to know them), but this is generally fine with me. I've seem people get remarkable benefits out of monthly therapy used well.

If you read my why I don't take insurance post, you'll know that it didn't help to have a middle man deal with the money. If anything, once you're in a group, the patients seem to think they're stiffing the group, that the secretaries are responsible for eeking the money out of the insurance company, and ownership of the process gets harder, not easier.

Alison: you have a lot of unhappy shrinks stories.

FooFoo, I agree with you that people resent us rich docs. I won't tell you how I feel about lawyers who charge $300-$500/hour.

There was something else I wished I'd put on the survey but I forgot what.

Just saw The Kite Runner.....

Anonymous said...

I can talk easily with my therapist about all of the listed options. In fact I would prefer to talk about any of them instead of those things which I do find almost impossible to discuss-- namely, my actual problems.

How long does one attempt therapy before giving up?

Alison Cummins said...


Almost all my unhappy shrink stories are about talk therapists, not psychiatrists. I think often the issue is that I work hard to manage as well and responsibly as I can... and succeed too well.

For instance: If I tell someone that my income is $400 per month and they say Ok, That'll Be $30 Per Week, I assume they have all the information they need and I make the decision to make things happen, square my shoulders and soldier on. I don't bring money up again because I'm an adult and I take responsibility for my decisions. It's not up to my therapist to pay for my therapy and I don't want to appear to be asking her to.

But then... I show up on time. I don't have stories about not being able to get there for lack of transportation.

My clothes are clean.

I don't moan about having my utilities cut off.

I'm not passing out from lack of food in the middle of a therapy session.

I talk about issues that people with money talk about, like school and work and relationships and plans for the future and self-doubt.

How is my therapist supposed to really know what living on $400 - $120 = $280 per month means? I must not have meant it that way. Perhaps she misunderstood or I was being dramatic about my finances to garner sympathy. Or she forgets my words in the face of what appear to be the facts. Whatever, it doesn't seem to be a big deal.

When in fact it is a very big deal, preoccupying me, constraining my life, and requiring a great deal of effort to manage.

But how is she supposed to know that, when my words and actions contradict one another? And what am I supposed to do - bring my actions more in line with my words? Cancel appointments at the last minute because I don't have bus fare, instead of packing a lunch and walking six miles there and six miles back? Tear my remaining clothes to look pathetic? Stop doing what I need to do to get food?

Or perhaps I should talk to her about my financial situation? But if I needed someone for that I would go to one of the consumer groups that counsels poor people on how to manage their money, not a talk therapist. I'm paying her for cognitive-behavioural therapy for major depression, and that's what I want to get out of our sessions.

(On a related note, my father is right now in hospital for typhoid fever contracted in Bangladesh. He went to the ER three times in three days before they admitted him, because he looked too well to be really sick. They wanted to send him home the third time too, to follow up with his PCP, except that his PCP was out of the country at the time. And no, he was not well enough to go home, and yes I mean that typhoid fever, the one that kills people. So I'm not the only one, and it's not just shrinks.)

So yes, I have a lot of unhappy shrink stories. Most are about not having my words taken at face value. I can't fault a talk therapist for being confused or misled, but it still makes me unhappy. I don't have a good answer, but I do currently have a talk therapist who listens well and backs off quickly when I repeat my verbal statement about whatever. I resent having to plow through what I had to plow through to get where I am and to find this therapist, but apparently it was necessary. I can accept that, but I don't have to like it.

As a topic of conversation, the therapeutic relationship remains a source of distress.

Anonymous said...

For me, the hardest thing to talk about is the therapeutic relationship. My last therapist seemed to stick himself on a pedestal and see his relationship with me as something that should be very important to me. To me, he was just someone paid to listen to me once a month and I resented his trying to be something more. He wasn't a friend, he was someone paid to do a job.

Anonymous said...

Lol, yes, I did talk about sex in front of 7 million people, but in a complete anonymous fashion. I have no anonymity in therapy. I know I have to go back there next week and face them again...(blush).

I was thinking again about the therapeutic relationship. I really like my therapist, and I think we're a good match. We talked about trust the other day when the issue of suicidal thoughts came up. I didn't realize how lucky I am to be able to do that.

I've fired about 4 therapists and 3 shrinks because I was unhappy with the therapeutic relationship. I'm doing much better with my current treatment team because of it. My question to the shrinks is: what's the "proper" or "best" way to fire a shrink or therapist? Do you like to know that something's not working, and you're getting cut loose? How much should a patient explain about their reasons for firing you? What's the proper etiquette?

I usually end up silently firing them by calling and cancelling my next appointment. If I'm asked if I want to reschedule, I say I will do it at a later time (but then never actually do). I've never had anybody follow up on my sudden disappearances, so I assume it's okay.

HP said...

Thinking about things from the practitioner side, I think money would be the hardest thing for me to handle. Lucky for me, it's not something I have to deal with currently.

Michelle, I usually review with patients how things are going for them. If things aren't working on some level, I'd rather know. I believe it's important to have a good therapist-client fit and, if it's not something we can work out and they'd rather move on, I might at least be able to help them find someone suitable.

The standard practice at my workplace was to follow up people who suddenly drop out of therapy with a single phone call/letter to see if there was any specific problem and just to let them know they could reschedule at any time. Not to 'bully' people into continuiing when they didn't want to but more to make sure they were okay.

Gerbil said...

Michelle: I don't think there is a "best" way to terminate a relationship with a therapist or a psychiatrist... kind of like there's no "best" way to break up with someone you've been dating! Still, there are some ways that are better than others.

There's a pretty clear message in cancelling (or no-showing) for an appointment and then saying that one will schedule another "later." When a client of mine does that, it makes me wonder whether there was something that I missed, or something I could have done differently, or if it was just a poor personality match. Was it a case of "it's not you, it's me" or vice versa? IMHO, therapy is as much a learning experience for the therapist as it is for the client.

And I think this applies to medical providers as well as to mental health providers. I made very clear to two physical therapists the reason why I was not returning to them. One of them refused to believe that my insurance covered as many sessions as were medically necessary. And I lost confidence in the other when I asked her to tell me what goals she'd set in my treatment plan, and she had absolutely no idea what a treatment goal was--then told me that I didn't need to know my treatment plan anyway! (The nerve--no pun intended.)

I guess what it all boils down to is that nobody's perfect. But few of us know exactly where our shortcomings are, regardless of what side of the proverbial couch we're on, unless someone tells us.

Anonymous said...

I don't find any of those topics particularly distressing to talk about, but sex would be the closest. I can talk about it, but it's slightly squirmy. Money, who cares. I pay my bill, and if there's an insurance screwup and they don't pay the part they're supposed to, we discuss it and one of us calls and clears it up. The therapeutic relationship? Never discussed that with any shrink, but I don't see having a problem. I think you should have included "suicidal thoughts" as a choice. Maybe it's just me, but it really makes me squirm to have to talk about my suicidal thoughts, especially specific plans. It's like talking about your sexual fantasies -- something you never expected to have to say out loud.

Anonymous said...

I saw a very nice woman for therapy several years ago. I got better and discontinued - it was totally amiably on both sides.

A year or so later I was dx with cancer. One book I read suggested that if you'd been in therapy for depression that checking in with your therapist after a diagnosis like this was prudent. So I made an appointment. I saw her once before the surgery and again after.

When I'd seen her before she'd always sent a bill, and I'd paid it. I never got a bill for those two sessions - to my discredit I didn't send her payment either.

I ended up wishing that I had because a year or so later I was in the dumps again and would have consulted with her -- except that I had that bill issue hanging unresolved.

The bill is a like a fence as in "good fences make good neighbors."

Anonymous said...

I responded to your poll without needing even a moment to think! I have been seeing my psychiatrist for several years (psychoanalysis takes a while). Talking about sex is not difficult for me. I have never taken medication so that is a non-issue. I pay at each session and agree his fee is fair so there is nothing to talk about. Working through The Transference, on the other hand, is very, very difficult.

Anonymous said...

Hi there,
I came accross this blog just when I decided to start looking for 3 shrinks for a CA hospital; no, I am not a professional recruiter, believe it or not, I work in that hospital and can not stand having to explain to patients why "the doctor is not available". Being a gov. hospital, there is no insurance headache and the job is unbelievely easy; Let me know if you know anyone who would be interested, or if you give me a lead, I would also be very grateful. More power to you!