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.