Kendra Docker, MA, NCC , owner of Soul Garden Counseling in Colorado wrote in with the following question . . . .
I was hoping to get your opinion on something. I recently started taking credit cards on a cell phone device (Intuit).
One of my clients had a missed appointment charge, then a charge for an actual visit.
She called her credit card company and disputed the second charge and I was billed back. Hating to spend client time discussing money, I phoned her and she assured me it would taken care of at our next session. She never came and has returned no phone calls.
Intuit said I can challenge the claim but how does a psychotherapist provide “proof” that a service was provided?
Thank you!”
Kendra, an even better question would be “When should you provide proof of rendering professional services to a client?” I would caution you against pursuing unpaid debt incurred by clients. Consider this . . . . Assuming you’ve done everything right including obtaining a written contract to be paid for your fees, going through the informed consent process, and providing appropriate clinical services to your client . . . . Even then a client may be unsatisfied with your services, your fees, your billing process, or something else. And, if that is the case, one dissatisfied client can cause extensive problems for an unsuspecting therapist. How do I know? It happened to me.
Regardless of doing everything right, a client may still
- file a complaint with your professional association,
- file a complaint with your licensing board,
- file a complaint with your certification boards,
- file a lawsuit against you, or
- take other steps (perfectly legal in the U.S.) to publicly embarrass or discredit you.
Before you choose to pursue your client’s unpaid bill, consider the potential costs (in time, aggravation, publicity and money). Should you decide that it is worth it to pursue, then you can ask the questions of if and how you can provide proof of your professional services.
After many years of carrying (sometimes significant) balances for clients and then later trying (sometimes successfully) to recoup that money, I took the counsel of Attorney Bart Bernstein who advised that I “let them go” for precisely the reasons stated above. It only takes one client with a control issue or vendetta to put a significant dent into a professional’s reputation. For me, it just wasn’t worth the risk.
(And, along the way I also realized that allowing my clients to incur hundreds (or even thousands) of dollars in debt wasn’t at all about “helping them out.” Instead, it was about me and my own hangups related to money. We’ll be talking more about this later this year . . . . Stay tuned!)
It’s tough, but I fully agree! I also had the experience (frustration, shame, helplessness, disappointment, fear, self doubt) of a client making a claim against my license. The result was “unfounded” but I do things differently now! I also write-off those losses, that’s disappointing, but not nearly as much as the complaint. Certainly, I’d wish clients would talk with me if truly unsatisfied, but I choose the clients I serve because of the challenging issues and my interests, and it sometimes goes with the territory. Just like with my five year old, I’m learning to pick my battles.
Yes, Stacey! And, we learn to screen our “fit” better, too. It’s not something you are going to learn in graduate school but you’ll definitely learn it . . . or you’ll struggle for sure in private practice!
Hi there,
I really appreciate your blog and feel your struggles, all of you. I am actually on the other side of this dilemma and desperately searching for an answer.
My child needed therapy over the years. We hired different therapists for many years as issues changed or evolved and paid everyone promptly and out of pocket. Our last therapist we hired completely stopped communicating with us about our child when she became very ill. We were scared and knew we needed her to be in a rehab facility or even hospital. We called, emailed and texted this therapist but got no reply. Our child said though that she felt she needed to see this person ‘til in rehab so we just kept reaching out.
We frantically researched facilities on our own. It was very stressful because this therapist told our child she needed to go out of state to an exorbitant rehab not covered by our insurance. I finally found one nearer and therapist told child that that wasn’t a good one but no explanation why. My husband became so angry that we were paying this person to help child and us with the process, but we weren’t being guided or even communicated with. It was an incredibly stressful time of our lives. My husband and I both have therapists who were absolutely stunned at what was happening and insisted we demand communication. And then they helped us with the rehab process ironically.
I finally went in with my child one day for an appointment and was told by therapist I couldn’t go in. At the end of the session I simply told therapist why it was crucial child go to a somewhat closer rehab and within our insurance. I was told I didn’t know what I was talking about and was admonished and told to be quiet. This was so disconcerting to me, I was alarmed.
We did everything rehab on our own. Both our therapists advised us to stop letting child see this person as it was dangerous to some extent. And not right that they weren’t communicating basic logistics with us, the client.
Husband refused to pay last few sessions and this therapist is now demanding payment even texting our child who was a minor ‘til recently. We just asked for receipts to compare what we had already paid but therapist only has receipts for last few sessions. We asked again but still received nothing. Are receipts of service mandatory? We have already paid this person thousands of dollars and then incurred thousands and thousands more of rehab expenses.
We don’t mind if she calls an attorney. We would pay if we had to but it doesn’t seem right since we the client stopped being communicated with and were not helped in very difficult rehab process. We never contacted the licensing board nor wrote any reviews but since this person is now threatening us with attorney, we are happy to explain what transpired and that there are no receipts or information on services.
This seems like bullying behavior especially with constantly texting our child who in fact was not the client. We were. I’m worried. But again, we have psychiatrists and psychologists both for ourselves and have never not paid a bill. Not one. For over a decade. This just seems unethical?
Oh, my gosh, CJ! I am so very sorry that you and your family are going through all of this!
I’m not sure I fully understand all of the circumstances but I do her your frustration and concern – both for your child’s well-being and also for your own financial well-being.
I would suggest that you start by contacting the therapist’s licensing board.
They will be able to investigate this for you and determine if rules have been violated.
You may also wish to contact an attorney that is knowledgeable about malpractice issues.
I do not know if malpractice has occurred – the laws under which mental health professionals varies from one jurisdiction to another.
What I do know though is that it is a common standard of practice and customary for professionals in health care to provide receipts for all professional services rendered.
Wishing you a quick resolution and a healthy child ahead!
What about having clients pay up front to the therapist and then THEY get reimbursed from their service provider?
Yep! That’s exactly what I do, Nanette, and my clients don’t bat an eye. After all, many of us are used to paying for our services and then seeking reimbursement from insurance companies later. Heck – some of us remember when physicians never billed insurance for us!
I’d like to hear more about this! Maybe a follow-up post? I do some of this with insurance clients, but maybe I could restructure things and make it more uniform across the board. How do you make this work in your practice?
Sound advice! Sometimes it is worth $150 to let someone go! Better now than more problems down the road with more complaints, lawsuits, or even unflattering word-of-mouth untruths. There are more good clients out there waiting to be served.
You’ve got that right, Lynn! It’s wrong. It’s not fair. It shouldn’t be that way but I can tell you . . . . It feels really good to just let it go!
You got it right Tamra- advised that I “let them go” for precisely the reasons stated above. It only takes one client with a control issue or vendetta to put a significant dent into a professional’s reputation. For me, it just wasn’t worth the risk. ”
here is California we are told in the risk management classes that money is the most common reason clients pursue suits of any kind, and it’s often just an excuse and not the real issue. So the lawyers say don’t carry a balance that’s higher than $250 at any time. Better not to carry any balance.
Also, and the woman who asked the question may know this, but have the client fill out a from with their credit card info at the start and on that form it states when and how it will be used, the credit card, in the clients absence. Restate this on your office policies and payment form. The client signs each from with a signature and receives a copy to take home. This way if you ever had to defend your using the card for a missed appt., at least their agreeing to it would be in writing.
This is a very sticky subject IMHO, and it’s great that you have written a post about it. Thank you!
And, Kimberly . . . if the attorney’s aren’t willing to carry higher balances, why would we ever think that we should?! That and the fact that many would perceive that as a dual relationship as therapist and creditor!)
I so appreciate your suggestions to get that credit card on file, too! That can always be a safe backup!
That’s interesting… what about safety/security issues related to having all of that client credit/debit card information on file? Seems like a huge liability for us to have that. I like the idea, but I’m just not sure it’s worth the additional risk.
Kimberly, here’s how you can set up a little picture of you so that others can see your smiling face and feel more connected to you – http://www.allthingsprivatepractice.com/how-a-tiny-picture-of-you-can-help-drive-traffic-to-your-website-or-blog/
It’s so disheartening when clients don’t pay for your services. I am very clear up front about my fees and payment policies and rarely have an issue with an unpaid service. On the few occasions when it has occurred I’ve opted to just let it go.
I think of these incidences, Pam, as my “little lessons learned.” I talk with clients from the beginning about our “relationship” – and I am intentionally using that word with them – and really lean into the need for mutual trust in a therapeutic relationship. Like you, I don’t get taken very often these days, but when I do, I chalk it up to me misreading the relationship – or the client’s ability to engage in a relationship with me. It’s a good reminder for me that I can still learn and do better at assessing where we are in our relationship.
What I know is that misreading those cues can sometimes be much more costly than just my hourly fee.
I agree – lessons learned. Sometimes it reminds me of the challenges I face with discussing finances and reinforces my need for honesty and clarity, and other times just that I need to be consistent and look ahead to foreseeable situations to address them early. I really like what you said about “misreading the relationship,” Tamara. It’s a good reminder that I need to always be on alert – paying attention to every detail of the relationship, even those initial stages when we’re not talking about anything clinical yet.
Oh, that’s true, Aaron! I remember back in the early days of private practice (and even before) when I wanted to and really did believe that “good things happen to good people” . . . and then they didn’t. It was so disorienting for me in the beginning because, of course, that is how the fairy tales always ended. Eventually, I hit another developmental milestone (thank goodness!) and realized that . . . no . . . that’s not always the case and it’s best to practice with my eyes wide open . . . always.
A dilemma we can all relate to, for sure. I agree that for the price of a lost session, it’s better to let the situation go.
And yes, I also believe when we’re not “moving” the client, we may take on some of the blame and unwittingly let the financial issues remain unclear or unpaid.
One thing that has helped me over the years is to have a conversation around money initially, and periodically throughout our work together about the difference between paying me and paying their contractor/dentist/doctor, etc. Talking honestly and authentically about the fact that paying doesn’t mean you’ll see or feel the results instantly usually brings clarity and allows for a deeper connection.
Money–it’s so psychologically laden. But if we’re uncomfortable talking finances, what are we modeling for our clients?
Linda, would you mind sharing briefly how you talk with clients about the difference between paying you and paying their contractor/dentist/doctor? Your perspective sounds really helpful and I’d love to hear more. 🙂
Oh, this is a great point, Linda! Talking about money with clients is not a one time event . . . at least it shouldn’t be. And, if therapists will do the work to get comfortable talking about money, then clients will, too.
(If money is a challenging topic for you guys, stay tuned. I’m working on something to help you out with this. Details coming in the fall!)
Tamara and other therapists…I just realized that I am owed over $8000 in unpaid balances (I use a billing service and prefer not to know “most of the time.” Some of this is the waiting game for insurance companies but I have two clients right now who owe me close to $1000 each. After reading this post, I have a question. Is it ever alright to speak to a client about their bill and to ask if they believe they can afford to continue therapy? The clients that owe me the most need therapy the least!
I am just seeing this, and I do understand what has been said. Honestly I think it is so sad that we have eat the costs for work we provide out of fear of retaliation. In any other profession, clients with unpaid balances will be sent to collections or taken to smalls claim court. I am in a solo private practice and need every dime I can get to stay in business.
Hi, Kia! Welcome to Private Practice from the Inside Out! Thanks for dropping in. What I have learned, Kia, is that it is less expensive for me to let these go, get better at recognizing my own issues around money, and to charge enough that “letting a few go” doesn’t negatively impact my livelihood or state of mind. I keep meaning to offer a group for therapists on money issues but haven’t quite finished putting it all together yet.
Thanks for your response. The challenge I have is that 99% of my clients are through insurance. When they come in I don’t always know if deductibles have been met or what someone’s copay is until after I’ve seen them and bill. Some companies take forever to process claims so I have seen someone 3 or so times already before knowing if they have any out of pocket costs. Some stopped coming before finding out they had a bill and some stopped coming because they have a bill. One lady even wrote me a check that later bounced so I was out of the money for the work I did plus the fee my bank charged me for the bad check. I always stress to clients to find out their coverage and out of pocket costs before coming in so there won’t be surprises. Some do and some don’t.
Hi Kia,
I know what you’re going through, and I was there before as well.
Tamara’s right – I had to work through my own fears with money, and once I did this issue pretty much went away. What I do now is tell people that they are responsible for paying 100% of my fee until I start getting EOB’s from the insurance company.
I make sure that I submit claims right away (I use a clearinghouse that does this electronically, which is fast and secure), which is also a bonus for clients because they don’t have to deal with the claims themselves.
When an insurance does pay, I offer a credit or reimbursement if the client ended up overpaying.
Typically, when clients aren’t willing to do this, they’re either not really committed to the process in the first place or are trying to get something (a few sessions) for nothing which is not the best fit for my practice anyway.
What ends up happening is that I may lose the opportunity to work with some of these people, but my practice actually then fills up with people who are willing to put forth the time, effort, and money to benefit from my services.
I’m happy with this and they’re happy with this, so it’s actually a win-win!
I hope this helps!
Aaron! I’ve missed you here. Welcome back! You are definitely doing several things the right way.
– You are putting the financial health of your practice first by expecting clients to pay your full fee until EOBs from the insurance companies start coming in.
– You are filing claims right away. (That was something I failed to do when I first went into practice and it cost me dearly!)
– You are taking your clients’ needs into consideration by allowing them to choose whether they get a credit or reimbursement when they have overpayed.
– You are paying attention to reality by taking note of patterns in your own practice rather than making assumptions about your clients i.e. “. . . when clients aren’t willing to do this, they’re either not really committed to the process in the first place or are trying to get something (a few sessions) for nothing which is not the best fit for my practice anyway.”
– And, you are managing your own expectations by observing that if / when you allow spaces to open up in your practice, those spaces then fill up with “people who are willing to put forth the time, effort, and money to benefit from my services.”
Nice job, Aaron! I always appreciate your thoughtful contributions to our community here at Private Practice from the Inside Out.
Kia, I know that there are many therapists who are also struggling with this scenario, too. I know I did. The best step I know of in preventing this situation is for you to verify new clients’ insurance coverage prior to seeing them. Doctors’ office staff do this every day so your new clients won’t be surprised at all.
Here’s a blog post to show you How to Verify Insurance Benefits for Your Professional Services. Some therapists have office staff that can do this for them; other will need to pick up the phone and do it for themselves. Some therapists rely on clients to provide all of this information but I don’t recommend it. Clients make mistakes in gathering information, they often don’t understand what it is they are asking for from their insurance companies, sometimes “forget” to get all the information, and sometimes hear only what they want to hear when it comes to insurance coverage. If it’s important to the health of your business, then it’s important enough to gather the information correctly.
Was there ever a follow up post to this? Very curious to read more!
Hi, Leah . . . . Maybe . . . . Are you looking for something in particular?
One of my therapists led me on to believe she was an in-network provider, by telling me she accepted my insurance, but failing to mention that she was not in my providers network. She proceeded to bill my credit card full price for each session, even though I had only agreed to pay a small out of pocket fee, that being my co-pay. Something I have done with every other therapist I have been with, without problem. Finding out she had been billing me 150 dollars instead of the co-pay of 35 per session, I messaged her and asked her what the deal was. In which she said I would be reimbursed by my insurance and not to worry about it. When I asked my insurance, they said she was an out of network provider and none of it would be covered. She even was late in sending in the claims which were sent in all at once, over 2 months after I had first started seeing her. Leaving me stuck with the bill.
Hi, Conrad. I’m so sorry this happened to you!
If your counselor was licensed, you may have some recourse for recouping some of your financial loss by addressing this with an attorney or the licensing board in your state.
All mental health professionals are supposed to fully disclose all terms and conditions related to fees.
If you misunderstood them, then recouping your loss may be more difficult for you; however, if she did not fully disclose this to you in writing, then I believe the onus falls upon her.
I am not an attorney and not offering legal advice on this matter.
Just saying that as a mental health professional we are ethically and legally obligated to be transparent about how we conduct the financial aspects of our business and those transactions must be fair and equitable.
I am wishing you the best of luck, Conrad in getting this issue resolved.