Records, fees and ending therapy well

Transcript

RyanIt's eleven at night. An emergency room physician in another state needs records for a patient who has just arrived, confused and frightened. He used to see a psychologist, and he still owes her three months of fees.

SoheeAnd her billing assistant has put a sticky note on the file. Do not release anything until the balance is paid.

RyanWelcome to EPPP Prep, the podcast. I'm Ryan.

SoheeI'm Sohee. Today is the business side of ethics: records, fees, money owed, and how therapy ends. These standards can sound administrative, but they protect clients at the moments they're most exposed.

RyanLet's settle the sticky note first. Standard 6.03, Withholding Records for Nonpayment. Psychologists may not withhold records under their control that are requested and needed for a client's emergency treatment solely because payment has not been received.

SoheeSo the records go to the emergency team. The unpaid bill is a separate matter, and it doesn't get to block emergency care.

RyanNotice how precise the wording is. Requested. Needed. Emergency treatment. Solely because of nonpayment. Exam stems tend to build in every one of those pieces.

SoheeLet's back up to why psychologists keep records at all. Standard 6.01 gives five purposes.

RyanTo facilitate services later, by the psychologist or by other professionals. To allow replication of research design and analyses. To meet institutional requirements. To ensure accuracy of billing and payments. And to ensure compliance with law.

SoheeI like that the first purpose is about the next clinician. In a way, a record is a letter to whoever helps this person after you.

RyanThen Standard 6.02 covers confidentiality across the record's whole life. Psychologists maintain confidentiality in creating, storing, accessing, transferring and disposing of records under their control, whether written, automated, or in any other medium.

SoheeCreating all the way through disposing. Shredding old files, wiping an old laptop, all of it.

RyanThere's a detail about databases, too. If confidential information goes into a database or records system that people can reach without the client's consent, psychologists use coding or other techniques to avoid including personal identifiers.

SoheeAnd 6.02c looks ahead to the psychologist leaving. Psychologists make plans in advance to facilitate the appropriate transfer of records, and to protect their confidentiality, if they withdraw from positions or from practice.

RyanWhich ties into Standard 3.12, Interruption of Psychological Services. Unless a contract covers it, psychologists make reasonable efforts to plan for facilitating services if they're interrupted by the psychologist's illness, death, unavailability, relocation or retirement.

SoheeOr by the client's relocation or financial limitations. Interruptions can start on either side.

RyanAnd Standard 10.09 handles a job ending. When psychologists enter employment or contractual relationships, they make reasonable efforts to provide for orderly and appropriate resolution of responsibility for client care if that relationship ends, with paramount consideration given to the client's welfare.

SoheeParamount consideration. Not the agency's convenience, not the psychologist's next job. The client.

RyanNow money. Standard 6.04, Fees and Financial Arrangements. Part a: as early as is feasible, psychologists and the people they serve reach an agreement specifying compensation and billing arrangements.

SoheePart b: fee practices are consistent with law. Part c: psychologists do not misrepresent their fees.

RyanPart d is the one I find most humane. If limitations to services can be anticipated because of limitations in financing, that's discussed with the client as early as is feasible.

SoheeSo if you can see the insurance benefit running out after a set number of sessions, you say so early, not in the last session.

RyanAnd part e is the collections rule. If a client doesn't pay as agreed, and the psychologist intends to use a collection agency or legal measures, the psychologist first informs the person that those measures will be taken, and gives them an opportunity to make prompt payment.

SoheePause and think. A client owes several months of fees. The psychologist sends the account straight to a collection agency without a word to her. What went wrong?

RyanThe warning step was skipped. Under 6.04e, she must first be told that collection measures will be taken, and be given a chance to pay promptly. And as we said in the confidentiality episode, anything disclosed to get paid is limited to the minimum that's necessary.

SoheeTwo quick standards about money and other people. Standard 6.06, Accuracy in Reports to Payors and Funding Sources. Psychologists take reasonable steps to report accurately the nature of the service, the fees and charges, and where applicable, the identity of the provider, the findings, and the diagnosis.

RyanSo the person who actually provided the session is the one reported, and the diagnosis reported is the real one, not one picked to fit what a plan covers.

SoheeAnd Standard 6.07, Referrals and Fees. When psychologists pay, receive payment from, or divide fees with another professional, outside an employer and employee relationship, the payment is based on the services provided, and not on the referral itself.

RyanIn other words, no paying or being paid for referrals as such. And barter, accepting goods or services instead of money, has its own standard, 6.05, which we cover in the episode on multiple relationships.

SoheeNow let's talk about endings. Standard 10.10, Terminating Therapy. Part a: psychologists terminate therapy when it becomes reasonably clear that the client no longer needs the service, is not likely to benefit, or is being harmed by continued service.

RyanThree triggers. Goals met. No benefit likely. Harm from continuing. And notice the verb. Psychologists terminate. It isn't, they may consider it.

SoheePart b is a permission rather than a duty. Psychologists may terminate therapy when they're threatened or otherwise endangered by the client, or by another person with whom the client has a relationship.

RyanSo a threat from a client's partner counts too.

SoheePart c is the process. Except where precluded by the actions of clients or third-party payers, before termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.

RyanPretermination counseling means talking the ending through together before it happens. And the exception makes sense. If the client stops coming, or a payer cuts off coverage abruptly, the psychologist may never get that chance.

SoheeHere's where the exam gets sneaky. The stem: a client has made no progress for months and isn't likely to benefit, but he enjoys the sessions, pays out of pocket, and wants to keep coming weekly.

RyanAnd the tempting answers are: continue for as long as he wishes and pays. Or: continue, but cut back to every other week until he asks to stop.

SoheeBoth miss the rule. Not likely to benefit is one of the triggers in 10.10a. The client's wish to keep coming and his ability to pay aren't on the list. And meeting less often is still continuing.

RyanThe other trap runs the opposite way. End therapy at once with a letter, no more sessions, no referrals. That skips the pretermination counseling 10.10c requires when nothing has precluded it.

SoheeSo the keyed answer usually has two halves. End therapy, and do it with pretermination counseling and suggested alternatives.

RyanOne more version from our practice questions. A practice is short on income and wants to keep a client who no longer needs therapy. Same answer. The practice's need for income doesn't justify unneeded services.

SoheePause and think, number two. A psychologist is leaving a group practice for a hospital job, and she has a full caseload. Which standards are in play?

Ryan10.09, orderly resolution of responsibility for client care, with the client's welfare paramount. 6.02c, planning the appropriate transfer of records while protecting confidentiality. And for each client whose therapy ends, 10.10c: pretermination counseling and suggested alternatives as appropriate.

SoheeLet's recap. Standard 6.01: records serve future services, research replication, institutional requirements, billing accuracy, and legal compliance.

Ryan6.02: confidentiality from creation to disposal, code out identifiers in shared databases, and plan ahead for transferring records if you leave.

Sohee6.03: never withhold records needed for emergency treatment solely because of nonpayment.

Ryan6.04: agree on fees early, don't misrepresent them, flag financial limits early, and warn the client before sending an account to collections.

Sohee6.06: report accurately to payors. 6.07: fees follow services, never the referral itself. And 3.12 and 10.09: plan for interruptions, with the client's welfare paramount.

RyanAnd 10.10: end therapy when it's no longer needed, not likely to help, or harmful, with pretermination counseling and referrals, unless the client or the payer makes that impossible.

SoheeEndings are hard, for clients and for exam takers too. If you're coming back to this exam after a result that hurt, you're doing what 10.10 asks of every psychologist: noticing what isn't working and choosing a better next step.

RyanThat isn't failure. That's good clinical judgment, turned toward your own path. Keep going. Thanks for listening to EPPP Prep.

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