Questionable Counseling Practice?
March 5, 2014 5:13 AM   Subscribe

Three months ago Dear Husband jumped through many hoops to get an appointment with the only counselor in town said to accept Medicare. I'd had a good experience with an excellent counselor in our area and was surprised when this new one made promises he did not keep before and during the appointment, including a promise to get back in touch with either a second appointment time or a referral. He made no contact at all after the appointment until yesterday, three full months later, with a bill he'd already submitted to Medicare for $225.00, which they covered, save $29. Does this sound customary to you?

DH says that he did outline his areas of concern at the appointment but that the counselor offered no response to these at all, so it didn't feel like counseling to him. The counselor's qualification is a Ph.D. In contrast, my counselor is a certified, practicing family physician who sees counseling patients in the afternoons and is a diplomate of our area's Jungian Institute. He has a great reputation with five-star reviews online and treated me with impeccable ethics. His rate was around $90 per hour.

DH is thinking about writing a letter in response to this bill basically to say we're surprised that DH was ever considered a patient as he didn't feel treated like one and now that he is we will take advantage of online reviews to caution others while alerting Medicare. We just want to be sure this is reasonable here.
posted by R2WeTwo to Society & Culture (33 answers total)
You are responsible for paying 20% of the Medicare-approved amount for treatment. If Medicare allowed $145 for the visit (which doesn't seem like an unreasonable amount), then you owe $29.

Are you saying you don't think you should have to pay for a one-time-only counseling session? You don't have a good justification for that. Counselors routinely spend initial appointments doing a lot more listening than talking. The counselor not scheduling you for a second appointment does not mean you don't have to pay what you owe.
posted by grouse at 5:26 AM on March 5, 2014 [2 favorites]

Yes, it's reasonable to write a letter saying you didn't get the care you think you needed, and post it as a review online or whatever, but it doesn't absolve you of paying the $29 fee in my opinion.

I'm surprised it took 3 months for them to bill you, though. They sound more disorganised than anything.
posted by Xany at 5:34 AM on March 5, 2014 [1 favorite]

His flaking out on scheduling a followup appointment is a good reason to not want to continue working with the guy, but it's not a good reason to skip paying for the appointment you did have with him.
posted by ook at 5:36 AM on March 5, 2014 [6 favorites]

DH is thinking about writing a letter in response to this bill basically to say we're surprised that DH was ever considered a patient as he didn't feel treated like one and now that he is we will take advantage of online reviews to caution others while alerting Medicare. We just want to be sure this is reasonable here.

As others have said, feel free to write the letter and post the online reviews, but you still have to pay the $29. It would be utterly unreasonable to expect to not have to pay.
posted by schroedingersgirl at 5:44 AM on March 5, 2014

We are not asking for justification for not paying $29. We would not spend a MeFi question to try and save $29. I hope I conveyed that our concern is about far more than that.
posted by R2WeTwo at 5:49 AM on March 5, 2014

It's possible that the first appointment was actually an assessment session, wherein the client's details are taken and they outline the presenting issues, background etc but no "real" counselling work happens. This should have been made clear, and they certainly should have followed up with either a referral or second appointment. So yes, feel free to write a review saying that you are unhappy with the lack of clarity and further contact. But, as others are saying, if the appointment went ahead it will have to be paid for.
On preview I see that you have no issue with the payment, and yes it sounds like an unprofessional service but not inexplicable.
posted by billiebee at 5:50 AM on March 5, 2014 [1 favorite]

What is your concern?
posted by grouse at 5:50 AM on March 5, 2014 [2 favorites]

Grouse, as clearly as I can put it: "This 'professional' behaved like a jerk in our view. We are aware that we're experts in this area and would appreciate MeFite's perspective before we respond."

Is it still unclear?
posted by R2WeTwo at 5:56 AM on March 5, 2014

You're right, this is not the way therapy is supposed to work. Sometimes you get a dud, just like with everything else.
posted by bleep at 5:58 AM on March 5, 2014

You are a consumer of services. You didn't like the way those services were rendered. You should feel free to write a bad review.
posted by Admiral Haddock at 5:59 AM on March 5, 2014

We're also hoping to hear whether the rate charged sounds typical.
posted by R2WeTwo at 6:00 AM on March 5, 2014

Yeah, nthing disorganized practice, but there's nothing unethical going on here.

In counseling, you need to assess the situation before you can figure out in what direction to steer. You wouldn't want any stranger giving you life advice after knowing you for 45 minutes, right? Same here. It's irresponsible.

But let's spread out the blame. Did your husband follow up with them? Even in the most organized practice, miscues happen. So did he call them and follow up on his desire for another appointment or referral? You have to be your own advocate in your own health care. Go forward. Move ahead. Find another doctor.
posted by inturnaround at 6:01 AM on March 5, 2014 [3 favorites]

This definitely sounds like the wrong counselor for your husband. And, yes, others would probably want to know that the counselor promised to follow-up and didn't. Also that he wasn't very clear about his timetable for treatment. So posting online reviews would be a public service. I'd avoid mention of the bill or your Jungian MD. Those seem like red herrings.

I don't think Medicare will care, so writing them will waste your time and theirs.

The going rate for medical services depends on your location, but $145 does not seem like an unreasonable rate for a visit with a PhD psychologist. Medicare knows a lot better than any of us what the market rate is, so if they paid based on that rate I would assume it is reasonable.
posted by grouse at 6:08 AM on March 5, 2014

Grouse where did you get $145? He billed $225. This is why we are writing here.
posted by R2WeTwo at 6:09 AM on March 5, 2014

in turnaround, DH "followed up" FIVE TIMES to GET the "consultation." Each time DH left a message the counselor called back and promised to call with an appointment time within one week. This went on for five weeks before a time was given. Some would say DH was TOO persistent. He certainly was not going to "follow up" after the consultation when the counselor failed to. Sadly, DH told me he felt the counselor did not like him enough to call back. I mention my counselor's credentials, in part, because mine would be appalled by this. Mine was chagrinned when he had to answer a phone for an emergency during an appointment.

I'd appreciate responses only be people with some experience and knowledge in this area. Sometimes I feel that people respond just to respond and these are not helpful.
posted by R2WeTwo at 6:14 AM on March 5, 2014

This 'professional' behaved like a jerk in our view.

I see a scheduling error, not a "behaved like a jerk". You allude vaguely to "promises he did not keep", were there others beyond failing to schedule a followup?

The rate charged to medicare sounds high but inflated amounts billed to insurance are sort of the nature of the American health care industry; and presumably medicare found the amount reasonable since they paid it. Your out of pocket rate sounds perfectly reasonable. You're comparing $225 to $90, you should be comparing $29 to $90.

TBH I feel writing to medicare or to the doctor would be a mild overreaction (especially the "surprised DH was considered a patient" bit -- of course he was considered a patient, he scheduled and attended an appointment with a doctor. What else would he be?) Writing a bad review in reference to the scheduling botch would be reasonable.
posted by ook at 6:15 AM on March 5, 2014 [2 favorites]

225 per (hour?) session for a PHD psych (ologist or psychiatrist?) Is not out of the realm of reason, to me, no. A little high maybe, yes. But if hes a psychiatrist, no, it does not sound at all above average to me. A lot of psych types have sliding scales, depending.

Now, the quality of scheduling was terrible, and I would be pretty embarrassed if that was my office/dr/me.
posted by Jacen at 6:19 AM on March 5, 2014 [3 favorites]

We are not asking for justification for not paying $29. We would not spend a MeFi question to try and save $29. I hope I conveyed that our concern is about far more than that.

As almost all of the previous posters to this thread have said, you are well within your rights to write a complaint directly to his office and/or to post negative reviews online.

We're also hoping to hear whether the rate charged sounds typical.

Yes, this rate sounds perfectly normal. Counseling/mental health services are very expensive unfortunately.

Also if you're going to threadsit could you please at least be kind and polite to the other posters? Everyone here is trying to help you as best they can given the information you have provided.
posted by schroedingersgirl at 6:21 AM on March 5, 2014 [37 favorites]

Yes, speaking from a medical billing perspective, $225 is a reasonable charge for an office appointment. What a provider charges is not generally what they expect insurances to pay; there's a negotiated rate if the provider is in-network the way your provider was with Medicare. So why would he "charge" $225? A provider generally has one charge for each procedure, even though each insurance they are in network with pays differently for each procedure. Medicare may only pay $145, but maybe BC/BS pays $215. Being in-network, you're not responsible for the difference between $225 and whatever Medicare paid; you're just responsible for the $29 Medicare said is your responsibility.
posted by ThePinkSuperhero at 6:24 AM on March 5, 2014 [3 favorites]

[OP, anyone can answer any question here, and this is not the place to get into debates with other members.]
posted by goodnewsfortheinsane at 6:29 AM on March 5, 2014 [6 favorites]

The rate sounds within the realm of normal, and billing you for the appointment and considering you a 'patient' for the length of that one appointment sounds normal. The only thing I see here that is a legitimate issue - and it definitely is one! - is the repeatedly failing to make the promised followup call or return your husband's calls.

I think you would be well within your rights to send a letter to the office about that issue specifically, and to post a review online to warn others of the same thing. I would leave out the part about not feeling like a patient, and I would not mention the bill, since it is reasonable and you intend to pay it. The more you make the letter about your feelings instead of the objective facts of their screw-up, the less chance you will be taken seriously by them or by others reading the review.
posted by Stacey at 6:35 AM on March 5, 2014 [5 favorites]

I'd say write the review, but think about it in terms of what other potential patients might find useful: do your best to just document what issues you had, clearly and in neutral terms, without subjective words like "jerk." Some people might not be put off by a therapist who doesn't start addressing the patient's issues during the first session - as has already been pointed out, this could have been just an intake/assessment session - but poor follow-up on the office's part seems more egregious.

Personally I wouldn't bother with the letter you seem to be planning on sending the office - at the very least, if they didn't respond to your husband's request for a referral I doubt they'll respond to an irate letter - and I don't think Medicare is likely to see this as an overbilling issue. But go ahead and write the review, and then let this go.
posted by DingoMutt at 6:50 AM on March 5, 2014

Grouse where did you get $145?

The amount you owe, $29, is 20 percent of $145. If Medicare had allowed $225, you would owe $45. This may not have been clear on the provider's bill, but it should be clear on the Medicare Summary Notice.

As has been explained by others, in the U.S., health care providers often initially charge more than what an insurer eventually allows. You can trust that the Medicare allowed amount is a reasonable amount for the service described on the Medicare Summary Notice.
posted by grouse at 6:51 AM on March 5, 2014 [5 favorites]

Yes, the fee sounds well within the normal range.

the only counselor in town said to accept Medicare

Not to be a pedant, but is that actually the only counselor who accepts Medicare? I know it can be difficult to find any kind of doctor in private practice accepting new Medicare patients. If you have access to any city, county or state mental health services I'd suggest looking there; this one was clearly a bad match, and that's really the bottom line.
posted by Room 641-A at 6:51 AM on March 5, 2014

DH is thinking about writing a letter in response to this bill basically to say we're surprised that DH was ever considered a patient as he didn't feel treated like one

The rate sounds average, especially for a standard initial assessment. Husband doesn't need to be a patient in order for the therapist to bill for his time. At the end of the day the bill is between therapist and Medicare. I don't see a smoking gun here for any untoward billing, just bad practice.

If you need reassurance that therapist behaved unprofessionally, then you have it. He behaved unprofessionally and earned losing your husband as a client. Write a review, but keep it to the facts - lack of follow through, non-responsiveness despite numerous contact attempts. If writing a letter will make husband feel better, then by all means write away, but don't expect anything to come of it. Unless you've left out some critical detail, I don't think his behavior rises to the level of an ethics violation or anything actionable.

The Jungian can't bill insurance, he can charge whatever he likes and whatever his clients are willing to pay. If he's been helpful to you, by all means refer husband to him, but understand that it's not actual mental health treatment. I personally don't cotton to non-licensed therapists practicing in a therapy-like capacity, but that's me. As long as he is explicitly clear and transparent about what he is and is not trained, licensed and qualified to do, he's within legal bounds.
posted by space_cookie at 7:01 AM on March 5, 2014 [2 favorites]

It sounds like you and your husband had a really bad experience with this person whose professional role is to give you a safe place to be vulnerable and examine some potentially painful or uncomfortable things about yourself. Instead of creating a safe place, he created a stressful and awkward place--the phone tag around scheduling, the unclear purpose/format of the initial appointment, and the lack of follow-through.

So: yeah. This was a bad and frustrating experience. A frustrating and bad experience with a therapist is probably going to feel like a bigger deal than a frustrating and bad experience with a mechanic. I'm not surprised that you're feeling pretty raw about this. I do think it would make sense to examine that feeling a bit. I'm guessing your husband feels like he was kind of put through the ringer with this experience--and I'm wondering how that's coming out for the two of you. Is he taking his frustration out on you? Or, are you both feeling angry with this therapist and not sure what to do with that anger?

Write a letter, or don't. Write a bad review, or don't. But be aware that your feelings about this experience won't disappear once you send the letter or write a review.
posted by Meg_Murry at 7:14 AM on March 5, 2014 [7 favorites]

I've read and re-read your question, and nowhere do you say that you are trying to get out of your co-pay; it is clear to me that you are just trying to assess whether it would be reasonable for you to post a bad review given the circumstances. That's very considerate.

I am of the opinion that reviews are a form of public service so I am with you that you need to warn others about what happened with your husband. You really can't go wrong if you just describe the situation as plainly as you can, and let the reader decide.

I also want to make another point that I don't know how to make concisely so please bear with me.

There are certain kinds of services that are by their nature made of two parts, where the first part is just a hurdle to get to the part that has actual value. This can be anything from a house painter prepping your walls to a mental health counselor assessing your issues. In these situations, I feel that it's unethical for the provider to charge for their time after they bailed mid-way. Scheduling is Business 101 and this guy essentially bailed when he failed to schedule, not to mention those other "promises" that you say he failed to keep.

I say post your review. The doctor's time is valuable but so is your husband's and he failed to respect that. Also, I disagree that writing a letter or a review will do nothing for your feelings. Personally, I derive satisfaction from helping others and being active in the community and I also feel gratitude to people who invest their time to write thoughtful and honest reviews.

(FWIW I used to do consulting where I charged strictly for my time and even though it cost me, I'd always avoided charging my clients if I could not complete the job, provided the bail was on my end and not theirs, of course).
posted by rada at 8:06 AM on March 5, 2014 [2 favorites]

When I had therapy, I would get explanation of benefits for my appointments that would go something like this:

Date of Service
Charged amount: $180
Amount disallowed: $115
Amount paid: $50
Co-pay: $15

The "charged" amount is what therapist charged for his session. That's what I would have paid if I didnt' have insurance. The "Amount disallowed" was the amount in excess of what the agreed amount he would be paid by insurance was. The "amount paid" is what insurance paid to him: around $50. The co-pay is what I owed: $15. Ergo, he was paid around $65 for an hour long session between me and insurance.

It is entirely possible that the psychologist you encountered billed at his regular rate, but that's not what he was paid by medicare and the difference was "disallowed" based on his agreement with Medicare. The rate is not unreasonable for a PhD.

That all aside, the first appointment sounds like it was more of an assessment, discussing what would be discussed, etc, and that then he completely dropped the ball in responding appropriately about another appointment. Therapists are people, too, and sometimes they make critical errors in how they practice. This sounds like it was a critical error. Pay the $29 you owe and find another therapist that's a better fit.

Also, if he's the only therapist in the Medicare network in a given area, he could very well be swamped with cases, and if a number of them had emergency situations arise it is possible he didn't have an appointment time for your husband. This doesn't excuse not responding to your husband in a professional manner, but it's possible he intended to and as things happen, this slipped by him. The real issue here could be a lack of therapists who take Medicare in your area, and what your husband experienced is a symptom of that.
posted by zizzle at 8:20 AM on March 5, 2014 [3 favorites]

If the counselor "accepted Medicare" your husband is responsible for the Medicare co-payment, which is $29.00. You stated above that the payment was accepted, "save $29.00". You are not responsible for anything else, and it is unethical (and illegal) to bill for the remainder. They "accept Medicare" and that is what this means. If I had surgery that was billed at $10,000, and the surgeon "accepted" my insurance plan - let's say my insurer pays $3,000 for this procedure - the surgeon is contractually required to bill me only for my insurance copay. His take is my copay plus the contracted insurance payment. That's it. He is not permitted to seek additional payment no matter what the insurer reimburses the surgeon. This is part of their contract with the insurer, not a contract with the patient.

Call Medicare and complain that the practitioner is seeking additional fees. You owe nothing else, and the therapist (or his billing office) is in error. Medicare looks very dimly at this double-dipping practice and will be very interested to hear about it.

The quality of the interraction he had with the therapist is a separate issue, but charges after his one session are proper. What is not proper is that a therpist that "accepts Medicare" is attempting to receive payment beyond what Medicare allows.
posted by citygirl at 8:27 AM on March 5, 2014

Call Medicare and complain that the practitioner is seeking additional fees.

The doctor does not appear to be seeking anything from the OP other than the copay amount.
posted by ook at 8:49 AM on March 5, 2014 [2 favorites]

I may not be "credible" enough to answer your question, but in my experience, there are different type of therapy -- I've had people who outline a whole plan for me, therapists who simply listen and then ask me what I want/need, therapists who do little more than sit and listen, etc. It's a range, and just because you enjoy a good fit with your therapist, it doesn't mean it's always that easy -- your husband found a Medicare specialist, which is great, but that doesn't make it a good fit. The lack of follow up

You want to know if you should post online reviews and respond to the office? Sure. Go right ahead. But I think that you are conflating the hoops you had to jump through to get the appointment with your DH's lack of follow up when the counselor didn't get back to him within the week (or weeks, however long it was). I work with individuals all damn day and I offer to email or follow up on things all damn day. Every once in a while, that falls short because I get busy or forget to write it down or whatever. I think that your DH has a bit of responsibility to call and schedule another appointment if that's what he was wanting. I've also been on the other end of this and after a reasonable amount of time (2 weeks), I'll follow up. So, be careful that when you present this online that you are clear that the counselor offered to follow up and then you chose not to call on your own when that didn't happen immediately (or at all).

Frankly, based on your attitude in this thread and on this question, I wouldn't take your online review very seriously -- it comes off as entitled and outraged about something that could have been addressed by a simple follow up and/or a short conversation with this therapist to determine the way forward (more response, less listening, etc.) or a realization that this therapist wasn't a good fit.
posted by mrfuga0 at 8:54 AM on March 5, 2014 [1 favorite]

The rate he charged sounds perfectly reasonable to me. Billing your husband sounds perfectly reasonable.

It sounded like your husband's session was a pretty normal initial assessment/intake appointment and not what he was expecting therapy to be. Again, that sounds normal to me.

Does this therapist handle all the scheduling and billing himself, or does he have any staff who does this? I'm asking because it might be the staff who dropped the ball here--which isn't okay either, but is absolutely something the therapist should be aware of. I have had issues with a good doctor with terrible staff--I once went a week without a cast on a broken wrist because my doctor's staff cancelled an appointment and was terrible with rescheduling, which I didn't think was that big a deal. My doctor was furious when he found out, and said he was going to have a serious talk with his staff immediately. I never had a scheduling problem with that office again.

He certainly was not going to "follow up" after the consultation when the counselor failed to. Sadly, DH told me he felt the counselor did not like him enough to call back.

This is....weird. I'm sorry, I don't know how else to put it. Your husband doesn't sound like he is interested in seeing this counselor at all, since he told you he thinks the counselor doesn't like him, and wasn't willing to give him a call at all to follow up. Yes, the counselor or his staff should have called, but if no follow-up was done on your husband's end, I don't think the blame is all on the counselor.

It's entirely possible that the counselor doesn't have the right number for your husband in his records, had some kind of emergency, or left a voicemail on your husband's cell phone that got ignored. Heck, unless you are checking your husband's email/voicemail/missed calls and were present for his appointment, you don't know for sure that this therapist hasn't made any follow up attempts, or that your husband wasn't asked to call to schedule something.

You have had a positive experience with therapy. So far, your husband has not. It's probably a lot easier for him to blame the doctor and his lack of follow-up and for being a "jerk" than to admit he doesn't want to go back. I think there's a possibility that something like this is happening here.

I understand that you and your husband are hurt and frustrated. Go ahead and write a review if you want, but I think you might be better served focusing that energy into finding someone who will be a better fit for you.
posted by inertia at 8:58 AM on March 5, 2014 [9 favorites]

The rate charged is fair, and he may accept the payment from Medicare as 'reasonable and customary.' It's the same as a hotel 'Rack Rate'. Sure the state price of the room is $450 a night, but no one is actually paying that. Same exact thing.

I wouldn't bother with Medicare, there is no fraud here, just a provider who you didn't gel with.

I'd write a letter to the practice, outlining your concerns. Often the doctor is unaware of the terrible job his/her office staff are doing.

I'm sensing that you have serious anger problems. You're taking everyday disappointments and setbacks very personally.

Not all doctors are organized and professional acting, same as hair dressers or shop keepers or any other profession. We vote with our feet and stop patronizing those folks. We don't have to destroy with extreme prejudice and salt the earth behind them.

If you feel that the doctor was aggregiously terrible, bordering on malpractice, you can file a complaint with his/her certification board or the AMA.

But honestly, just pay the $29 and find another provider. Life is too short.
posted by Ruthless Bunny at 10:12 AM on March 5, 2014 [2 favorites]

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