What's the deal here?

December 21, 2009 5:02 PM

I'm thinking of dismissing my therapist over some billing issues, but would like some perspective from other people.

My therapist is out of network, and agreed at our initial session to permit me to sign checks from my insurance company over to her as they came in.

Stuff started getting weird in August, when a check from a July appointment never showed up. She started getting impatient, and put me on resolving it, which I did. My insurer said they had never received the claim. She said she was sure it had been submitted, and that this was the sort of thing insurance companies did to frustrate out of network therapists.

She wound up convincing me to go to paying up front, which wound up destabilizing my financial situation as the sessions are $185 each, and the checks were coming in erratically. I wound up having to cancel a session, as writing a check would have put me very close to overdrawing my checking account.

I explained this to her, and she agreed to go back onto the original plan, provided that checks come in within a month, to which I agreed.

Recently, a check for a session came in close to a month after the fact. At our last session, I reluctantly wrote her the check, at which point she said the deadline should be two weeks, and suggested that my reluctance was indicative of some sort of underlying issue, and said that she was being generous by offering to allow me any time at all to write the checks.

I responded by saying that the agreement we came up with at the first session was something she had chosen to do to compete with other in-network therapists, and that I was confused about what was happening with the billing and wanted to talk to my insurance company to figure out whether the checks would reliably come within two weeks.

What I found when talking to my insurance company is that the turnaround on their end has been remarkable, rarely going as far even as three days, and that all checks that didn't come within two weeks didn't come within two weeks because my therapist's biller has been taking her time (10-20 days) to submit the claims.

I feel like my therapist has gradually worked me into a billing situation that is very, very dissimilar to the one I envisioned when signing on with her. We didn't hammer out the details, but I expected things to run relatively smoothly, not to hear about a disputed bill until after 30 days, and that this would have a minimal impact on our therapy. This turned out not to be the case, as a lot of session time has been spent on resolving billing issues.

I believe she expected to be paid promptly, but insurance companies have up to 30 days to turn around a claim, and her biller, as I mentioned, takes awhile to submit the claims. I don't think she understood the role the insurance company and the biller played in all of this.

(In no way am I suggesting that she ever personally guaranteed that I would never have to lay money out.)

Basically, this feels like violated boundaries, because the arrangment changed after the fact. It also feels like everything that's happening that would enable us to come to an arrangment agreeable to both of us is occurring on her end. I don't think the way she attributed responsibility to the insurance company for the first disputed bill was a realistic take on the situation.

Part of the reason I'm seeing her is to work on my boundaries and where I should assert myself, and consequently, I'm feeling extremely stressed out about this. I think this situation shows she's not a good person to go to for advice, but I am open to the possibility that there is something I'm not seeing in all of this.

What I'm looking for is a reality check, to test my assumptions here. Is my therapist being unreasonable? Am I? Would this bother you if it happened to you? How much, on a scale of 1-10?

Or is this just the sort of thing where there are two individuals, both of whom are drawing a line in places they're entitled to so, resulting in an absence of middle ground that can only be described as "unfortunate?"

posted by anonymous to Human Relations (31 answers total)

She had a responsibility to adhere to the original agreement. If she's been in the business longer than a week she was aware of the possibility of delays in payments.

Also, it isn't unusual for private practice therapists to use billing services that are less than accurate and prompt.

Sounds to me like she has her own financial issues and is pressing you as a result.

YOU are the customer, if you're not happy with the way she is handling things, find a new therapist.
posted by HuronBob at 5:08 PM on December 21, 2009 [3 favorites]

I would start by informing her of what you found out (that the delays are on her end) and see what her reaction is. It is possible that she actually does not know that the folks doing her billing are the ones causing the delays.

But, yeah, "I'm afraid that a two-week payment schedule doesn't work for me; if you can't accommodate the turnaround times of your billing folks and my insurer, I won't be able to continue" is a polite and appropriate statement to make.

She's allowed to have her policies; you're allowed to have your policies.

(Also, $185? US? Holy crap.)
posted by Sidhedevil at 5:12 PM on December 21, 2009

Can you submit the claims yourself? It seems strange to me that she, or her office, would be submitting the claims but you are getting the checks.

That said, I don't think you are being unreasonable. You are paying her for a service, and if she is making you uncomfortable then you shouldn't feel like you have to stick with her.
posted by apricot at 5:13 PM on December 21, 2009

It's entirely reasonable for you to tell her that you cannot afford to pay her, and that you are willing to write a cheque if payment doesn't come within two weeks after her biller has sent out the claim (if you are willing to do this), or that you do not wish to continue with the billing inconvenience and spending most of your therapy time working this out, and so that you will therefore find a new therapist. This is a great place to assert yourself.
posted by jeather at 5:13 PM on December 21, 2009 [1 favorite]

Has she never once called up her billing people and saw to it that the claims were being submitted? Or call the ins company herself? It seems weird to me that she would make you write out checks and destabilize your situation before taking those simple steps. It also seems unprofessional to bill you for time spent hashing out billing issues. Personally this would be unacceptable to me. I would definitely dump this lady and find someone who knows how their own business operates.
posted by amethysts at 5:18 PM on December 21, 2009 [1 favorite]

Oh god yes get another therapist. Preferably one that is in-network and doesn't charge $185 (Wow) a session. There's plenty of fish in the sea when it comes to therapists.
posted by smoke at 5:18 PM on December 21, 2009 [3 favorites]

What I meant to say was that it sounds like she's using up your session time to blame you for the delay in payment when the problem is entirely on her end. Not good.
posted by amethysts at 5:21 PM on December 21, 2009 [2 favorites]

Level of botheredness:

The whole getting a payment schedule down - oopsy, it seems like our assumptions were wrong - awkward!: 3 out of 10.

The assertion that your reluctance to pay her was part of an underlying issue: 10 out of 10.


People get funny around money, particularly when they are feeling cash strapped. And it's one thing for her to verbalize that your behavior is concerning her because it feels to her like you paying her isn't a priority. It's another (okay!) thing for her to decide - you know, the aggravation isn't worth it to me - I'm terminating this relationship.

But to get all therapeutic about it - 'an underlying issue' - that's not fair. Not unless she's got proof. Like you saying, "When I don't pay you, I feel powerful". That's kind of using her power not for good, but for not good. That could be seen as manipulative. Particularly if she didn't revise her statement when she learned that her billing folks were part of the problem.

I'd probably decide if my relationship with her was so good that it was worth figuring all of this out. If not, I'd decide that I probably only have 80 years on the planet, and didn't have time to spend it with someone who's willing to potentially be manipulative just to get paid. Cause if you don't trust your therapist: trust their judgment, their practice, etc., there's really no point. You're getting the worst of both worlds:

Paying out of network AND not working with a therapist you trust. At least go in network and stop paying out of pocket for that.
posted by anitanita at 5:28 PM on December 21, 2009 [2 favorites]

"That" being "therapy with someone whose judgment I don't trust".
posted by anitanita at 5:30 PM on December 21, 2009

you shouldn't be spending any of your session time hashing out her billing arrangements. and her trying to weave it into your therapy would skeeve me right the fuck out. unless paying your bills (as in, the ones that don't concern her) is part of the reason you're in therapy, her spending so much time on billing is an abuse of her power. it would be like a surgeon opening you up and then saying "hey, about those insurance forms..."

find a new therapist.
posted by nadawi at 5:30 PM on December 21, 2009 [1 favorite]

In addition to the payment problems, I am also concerned about her saying that your "reluctance was indicative of some sort of underlying issue." Yeah, the "underlying issue" is that money is tight and she has changed the rules. If she's saying that your reluctance is a therapeutic issue, she's off the beam and manipulative, IMO. Perhaps you and she have done all of the useful work you're going to do together, and it may be time for you to move on.
posted by thebrokedown at 5:35 PM on December 21, 2009 [1 favorite]

Two separate problems here, as anitanita pointed out:

1. Billing. That could have been addressed by her giving you claims at every session, which you would file by the next day. If she wants to ensure her checks come within a certain timeframe, and you are the person who is receiving the checks, you need more control over the process. My therapist doesn't accept insurance (exceptions may apply), but she is very thoughtful about the billing process. If she weren't, I wouldn't be seeing her.

2. Suggestion that you are reluctant to pay her. If she's making a serious suggestion there, that's at least two or three intense sessions of discussing legitimate financial issues you may have. She shouldn't say something like that off the cuff. If you still like, respect and trust your therapist, in spite of all this, you might give her another chance but call her out on the way she has handled this situation.

There are plenty of times when it's perfectly valid to discuss financial issues. In the middle of a billing situation? Not one of them, not unless things have gotten very out of hand on your end, which from your explanation it doesn't sound as if it has. You called the insurer. You spoke with them. In other words, you are holding up your end of the bargain, and it is killing you financially. That is not okay. Her asking you to put yourself in a difficult financial position? Really not okay.

Oh, and don't forget to hit her up for references on your way out the door. Or, if you're in New York, MeFiMail me and I'll give you a few names. :)
posted by brina at 5:43 PM on December 21, 2009

For $185, she should have her shit together in this regard a lot more that she appears to!
posted by rhizome at 5:51 PM on December 21, 2009

If you want to stay with her, you could agree to pay her within [a set amount of time, say two weeks] of the bill being submitted. Have the billing company notify you and her of the date they submit the bill.

Can you contact the billing company directly? They may not realize that this bill needs to be handled more promptly than others. That might also help, but doesn't really answer your question here.
posted by amtho at 5:57 PM on December 21, 2009

It seems to me that a major ethical boundary was breached by the therapist when she used therapy time to discuss billing, and when she suggested that billing issues were indicative of your issues.

Bullshit. DTMFA.
posted by dejah420 at 6:31 PM on December 21, 2009 [2 favorites]

nthing gettng a new therapist. you need one that works for you, not the other way around. find a new one immediately. this person is taking advantage of you--i wouldn't even go to any more appointments--i bet she'll charge you 180 when you meet with her to say goodbye.

also, i'm suspicious of her behavior--i wonder if she's submitted for more then what she's actually doing.
posted by lester's sock puppet at 7:08 PM on December 21, 2009

I get a bad vibe from her implication that the billing issue is a therapeutic issue on your part. That alone is a good reason to ditch her and is, IMO, a breach of trust.

Also, I echo the previous poster who said $185, US?! I pay roughly half of that and, yes, out of pocket although my insurance eventually covers a percentage for an out of network provider.
posted by wildeepdotorg at 7:09 PM on December 21, 2009

The nuts and bolts:

What type of therapist is she? If she is a psychologist, she's likely under the APA Ethical Principles of Psychology. Most states regulate psychologists within the APA Principles, which, in pertinent part state:

6.04 Fees and Financial Arrangements
(a) As early as is feasible in a professional or scientific relationship, psychologists and recipients of psychological services reach an agreement specifying compensation and billing arrangements.

(b) Psychologists' fee practices are consistent with law.

(c) Psychologists do not misrepresent their fees.

(d) If limitations to services can be anticipated because of limitations in financing, this is discussed with the recipient of services as early as is feasible. (See also Standards 10.09, Interruption of Therapy, and 10.10, Terminating Therapy.)

(e) If the recipient of services does not pay for services as agreed, and if psychologists intend to use collection agencies or legal measures to collect the fees, psychologists first inform the person that such measures will be taken and provide that person an opportunity to make prompt payment. (See also Standards 4.05, Disclosures; 6.03, Withholding Records for Nonpayment; and 10.01, Informed Consent to Therapy.)

You made an agreement with her. She has to stick to it.

Less binding are the aspirational "general principles" which state, in pertinent part:

Principle A: Beneficence and Nonmaleficence
Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists' obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists' scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work.

Principle B: Fidelity and Responsibility
Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm. Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work. They are concerned about the ethical compliance of their colleagues' scientific and professional conduct. Psychologists strive to contribute a portion of their professional time for little or no compensation or personal advantage.

Principle C: Integrity
Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. In these activities psychologists do not steal, cheat, or engage in fraud, subterfuge, or intentional misrepresentation of fact. Psychologists strive to keep their promises and to avoid unwise or unclear commitments. In situations in which deception may be ethically justifiable to maximize benefits and minimize harm, psychologists have a serious obligation to consider the need for, the possible consequences of, and their responsibility to correct any resulting mistrust or other harmful effects that arise from the use of such techniques.

There are a lot of things that aren't the best in the way she's handled it. I'd cite these issues with her if she asks why.
posted by Ironmouth at 7:17 PM on December 21, 2009 [1 favorite]

I have no particular interest in defending this therapist. It does sound to me as if she has not upheld her responsibilities vis a vis the billing.

I think you could go either way on this. You could make this the moment of your assertion, or you could decide you've been jerked around enough and that you need to find another therapist.

And, while I think the assertion, in this case, that the billing issues are indicative of something that you need to work on, it does frequently happen in therapy that people get very weird about billing. Indeed, this thread shows some of that, with a bunch of people commenting on this therapist's rate, without having any information that might inform their criticism. I'm not sure why $x/hour is an unacceptable rate for a therapist to charge.
posted by OmieWise at 7:39 PM on December 21, 2009

I think the issue is, can you work with this therapist without resentment or ill will if you two can come to another definitive agreement between you two. If not, move on. I think the deal should be some time period (2-3 weeks?) from the point that the insurance company gets the claim. She may not even realize that her billing system sucks.
posted by JohnnyGunn at 7:58 PM on December 21, 2009

As a small sideline, I do the electronic billing for a psychiatrist. I can't help but raise an eyebrow when you say your therapist is expressing impatience with anything that has to do with billing from an insurance company. That's like a baker complaining that "this sugar is really sweet."

Erratic payments from an insurance company are part of the deal with being a therapist. I'm not happy that she twisted your arm into doing this "pay me first, then collect your own damn money" thing.

I also feel it's inappropriate for your therapist to be eating up your session time with billing issues. That is time that you are paying for, to the tune of $185/hour. (Which isn't an unreasonable rate, if you'd been wondering.)

When she does this, she is basically charging you to talk about why you haven't paid her yet. It's not only a violation of the trust and rapport you have (theoretically) built together, it's also really tacky.

(FWIW, the therapist I work for discusses billing issues outside the boundaries of the session. Typically by sending letters, or over the phone.)

Legal issues aside, I'm not happy with her approach. Are you unbelievably happy with her performance otherwise? I would have to like a therapist A LOT to go through all that.

I think it would be worth your while to shop around a little. Explain up front that you liked your last therapist, but that the billing issues got weird and made you uncomfortable. Hopefully you can find an in-network therapist, or an out-of-network therapist who's willing to wait for the insurance payments.
posted by ErikaB at 8:15 PM on December 21, 2009 [3 favorites]

There are plenty of other therapists. There are certainly a few who won't jerk you around and break their payment agreement.

Why I would fire her: You agreed to payment arrangements and you were meeting your end of the bargain. Once she knowingly pushed you to a payment plan you couldn't afford, she became a problem. That she used therapy time to resolve a minor payment issue (you were behind less than $500) is enough reason to fire her. That she manipulated you by telling you that the billing issue was about your mental health, is indefensible.

Why you should fire her: I think this situation shows she's not a good person to go to for advice. Part of the reason I'm seeing her is to work on my boundaries and where I should assert myself; this feels like violated boundaries. I pulled those words out of your last paragraphs. You already know the answer. You're not going to learn effective boundary setting from someone who violates your boundaries.

Fire her ass.
posted by 26.2 at 8:21 PM on December 21, 2009 [2 favorites]

Many therapist require payment first, particularly for new clients. It's weird to me that she didn't state that up front. Is she new? Sounds like a therapist who doesn't communicate her needs very well, not so good.

The only other question I might have is did you cancel your appointment without the stated (required) notice and then didn't want to pay for a late-cancelled appointment (which insurance does not cover). That's the only plausible reason I can think of a change in her attitude.
posted by ClaudiaCenter at 10:46 PM on December 21, 2009

It's time to move on if she is messing up your billing or she needs to tell you up front that it's your responsibility to submit for reimbursement. Most therapists who do cash only are out of network or refuse to do the headache of billing. The ones who will do insurance are far and few between. Out of researching 20 therapists, I found only 3 in network that accept insurance.

Sidhedevil --- $185 is pretty norm for 15-30 min. The one I'm thinking of going wants $300 cash (no credit cards) for a 2 hour assessment then it's $175+ depending on 15 min or more. It's nuts. Talk about a division of healthcare that needs reform!
posted by stormpooper at 7:00 AM on December 22, 2009

Have been in therapy, know lots of therapists. At $185 a session, part of what you're paying for is avoiding this shit. Nobody's making her accept insurance at all, but this kind of dickery on your dime is unacceptable.

(Seriously, y'all, different kinds of therapists in different parts of the country are going to have really different rates. $185 for a 50-minute session, if that's what this is, is not out of line for a major city, especially if the person in question has a doctorate.)
posted by chesty_a_arthur at 8:33 AM on December 22, 2009

Uh, the therapist. I don't think patients are charged based on their educational attainment levels. I hope.
posted by chesty_a_arthur at 8:33 AM on December 22, 2009

Sidhedevil --- $185 is pretty norm for 15-30 min. The one I'm thinking of going wants $300 cash (no credit cards) for a 2 hour assessment then it's $175+ depending on 15 min or more. It's nuts. Talk about a division of healthcare that needs reform!

Wow, that's nuts. I live in Boston, where living expenses are crazy out the wazoo, and $150/hour is high for psychotherapy.

Where does someone charge $175 for 15 minutes of therapy?!?!?
posted by Sidhedevil at 8:34 AM on December 22, 2009

For a therapist to pressure you about money, saying it's a therapy issue is flat out unethical. There are way to many crappy therapists. Find a better one.
posted by theora55 at 8:38 AM on December 22, 2009

Just chiming in to say that your therapist's behavior is inappropriate, and is negatively impacting whatever value the actual therapy might have. Finding a good therapist is a difficult and time-consuming proposition, and your journey is not yet complete. Move on.
posted by booknerd at 10:02 AM on December 22, 2009 [1 favorite]

It is not unethical for the therapist to talk about money. Money is a therapy issue.
posted by y6t5r4e3w2q1 at 6:58 PM on January 16, 2010

When she agreed to allow you to sign the insurance checks over to her, she was agreeing to the method of payment, not to the time of payment. From what you said, it doesn't sound like she has changed the deadline, has she? I don't see how you can reasonably expect anyone to accept late payment unless the lateness of the payment was what was agree on in the first place, which isn't clear from your post.
posted by y6t5r4e3w2q1 at 3:21 PM on January 17, 2010