Billing problems

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psychma

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I have been in private practice for five years and have not encountered any issues with billing until the last 2 months or so. Usually, when a client presents to my office for an assessment or therapy, they provide their credit card information upfront. We have the session and then I create a bill, enter the credit card information, and make the payment. Now, so many people’s credit cards are denied when I try to charge them. When I reach out, the clients tell me they have no money and can’t pay. I do not allow therapy clients to get more than 2 sessions behind as a rule, but for assessments there is more time and cost involved. The billed amount is higher and a non-payment is significant. What is really discouraging is that my therapist/social worker clients are the worst offenders lately!

Has anyone else seen this as a trend? How can I handle this going forward to prevent losing my shirt?
 
The answer is to collect upfront. That said, I know people have mentioned business being slower generally the past few months. However, Scott Bessent assures us that we are not in a recession and will not be in 2026.
 
I REALLY want to emphasize sending people to collections.

There is a difference between “I can’t afford an evaluation, can you help me?”, and “Now that I have your evaluation in my hand, I'm revealing that I never had any intention on paying you for your services, AND I hid that from you from the start.".
 
Interesting about collections. I was taught that sending people to collections is likely to trigger a lawsuit, but I don't have any personal experience. I can imagine a patient feeling angry about collections and lashing out through litigation.
 
Peacemaker36 said:
Interesting about collections. I was taught that sending people to collections is likely to trigger a lawsuit, but I don't have any personal experience. I can imagine a patient feeling angry about collections and lashing out through litigation.
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Never heard of that. Hospitals do it all the time. No one is spending thousands to sue you for a few hundred dollars.
 
Peacemaker36 said:
Interesting about collections. I was taught that sending people to collections is likely to trigger a lawsuit, but I don't have any personal experience. I can imagine a patient feeling angry about collections and lashing out through litigation.
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I've heard of this in the sense of board complaints, but I think it's more of a fear than a common occurrence. I'm no attorney, but I'm not sure what grounds there would be for a lawsuit if the informed consent is reasonably clear. Same goes for a board complaint.

Although I've also heard many colleagues say that they don't bother pursuing via collections because it's not worth it to them. I've also heard folks say that they don't complete their work product, such as an evaluation report, before payment is received. You can't withhold a record for non-payment, but nothing says you have to work for free.
 
Peacemaker36 said:
Interesting about collections. I was taught that sending people to collections is likely to trigger a lawsuit, but I don't have any personal experience. I can imagine a patient feeling angry about collections and lashing out through litigation.
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Never heard or seen this happen. And, I have never seen a board action in my state related to this.
 
Peacemaker36 said:
Interesting about collections. I was taught that sending people to collections is likely to trigger a lawsuit, but I don't have any personal experience. I can imagine a patient feeling angry about collections and lashing out through litigation.
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LOL. Let's think about this.

1) You're saying that someone, who can't pay for clinical services, is going to come up with money to hire a lawyer?
a. Or a lawyer is going to accept an IOU from someone who can't pay a much cheaper bill? That's like fearing that a homeless guy has the money to afford a gun.

2) For a lawsuit, you have to have damages.
a. Your premise is that someone is permanently upset because they being held accountable to their contractual debts. Can you imagine the legal effects if some court said, "You can't try to enforce contracts for sensitive people, because it might permanently hurt their feelings?". Every credit card company, mortgage company, etc would collapse immediately.

3) I'd pay money to watch a board complain.
a. Patient "Yeah, I signed an informed consent that said I would pay for services. And I had no intention to do so. But that's definitely not fraud...for .... reasons...".
b. Psychologist, "I am the victim of fraud. This is the perpetrator of the crime. Are you colluding with the perpetrator in this crime, potentially becoming accomplices?" (this is not far off from my response to my only board "inquiry", and I'm still here).

Protip: If someone says they're going to call their lawyer, they don't have a lawyer. (This also applies to people who claim to be rich, have ginormous gentials, or about to punch you).
 
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Thank you. I agree about finding a way to collect upfront. I have let these people know they will not receive a report from me, but the financial damage is done. I also want to thank you for mentioning collections. In the past, I never thought it was something I would pursue, but I feel right now like even if I don’t get a penny, people should be responsible for honoring their agreements. I can’t imagine being seen for 5 hours of testing with the intent of not paying.
 
psychma said:
Thank you. I agree about finding a way to collect upfront. I have let these people know they will not receive a report from me, but the financial damage is done. I also want to thank you for mentioning collections. In the past, I never thought it was something I would pursue, but I feel right now like even if I don’t get a penny, people should be responsible for honoring their agreements. I can’t imagine being seen for 5 hours of testing with the intent of not paying.
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Yoooooooo!

You can’t withhold the report. That’s a BIG legal no no.
 
Our policy is to pay upfront. The initial consultation is $250. At that meeting, we decide what kind of testing to do and the amount it will cost, they pay it when they come in for the testing. A significant number of people don’t really need testing and then we can just come up with a treatment plan like I would with people who present as therapy cases to start with.
 
PsynofTimes said:
How though? Some of my assessments will be in the thousands.
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Cash, check, or Zelle. Plenty of rich folks paying cash for these things if they need it. For example, What is $2.5k for an assessment that gets you school or testing accommodations when you are paying $30k in private school tuition annually?

If you don't know why they want to pay for assessment, then why offer it?
 
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Checks you can cancel, but I am old and forgot about Zelle and other cash apps. Those are pretty much set, correct?
 
PsynofTimes said:
True, but there's a little gap there where it could be. I suppose that's a touch on the paranoid side though.
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E-deposit the day you get it, usually clears in 1 to 2 business days, then you start the report. Never had an issue.
 
PsynofTimes said:
How though? Some of my assessments will be in the thousands.
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Think about this. It's expensive before you do it, and it's the same price after you do it.
AcronymAllergy said:
This. If it's not finished, that's one thing. But if the report's done, you most definitely cannot withhold it for non-payment.
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I think this might be state dependent. AFAIK, most states require you to document your clinical services, and most have some form of timeline for you to finish notes, and federal law require you to release medical records to requesting patients regardless of payment. Maybe you could say that you didn't score the tests, and argue they can't compel you to work for free. IDK.
 
PsynofTimes said:
Checks you can cancel, but I am old and forgot about Zelle and other cash apps. Those are pretty much set, correct?
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I've never tried reversing a Zelle transfer, but I know that every time I send one, I get what seems like a half-dozen warning screens telling me that the transfer can't be undone, to watch out for fraud, be sure I actually know the person I'm sending money to, etc. Seems to be the same with Venmo.
 
PsyDr said:
Think about this. It's expensive before you do it, and it's the same price after you do it.

I think this might be state dependent. AFAIK, most states require you to document your clinical services, and most have some form of timeline for you to finish notes, and federal law require you to release medical records to requesting patients regardless of payment. Maybe you could say that you didn't score the tests, and argue they can't compel you to work for free. IDK.
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Very true, likely state dependent. Also, at least for testing, I'm not sure it's even applicable unless the person is being charged up front or at least immediately after the assessment session is finished. If you test someone for 4-5 hours, they leave, you go to bill their card, and then it's declined, you could then potentially hold off on doing any other work until you're paid (other than possibly a brief "placeholder" note).

But all in all, it's just easier to bill before doing the testing. I've seen multiple psychologists who list flat rate amounts for different types of evaluations on their website.
 
This conversation is making me feel really old. I only take checks, EFTs, wire transfers, and begrudgingly cash (very rare, provide a receipt). My practice setup is still mostly assessment, so it's large check/retainer and then usually 1-2 more payments. I should probably setup a biz Venmo/CashApp option, but haven't. I have a handful of long-term TBI patients, but their conservators/guardians just send checks.
 
PsynofTimes said:
Thanks, but I meant literally how. I'm middle aged, so I envisioned people coming in with stacks of 100s.
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I've had one cash transaction in 15ish years. I literally pocketed the money, pulled my wallets out, gave change, printed a receipt, and handed it to the guy.

Otherwise it’s a card. I prefer using Costco processing. I know some people that like square.
 
PsyDr said:
Yoooooooo!

You can’t withhold the report. That’s a BIG legal no no.
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Wow. Thank you for that information. I’m glad I mentioned this. I’m curious though about how I can be required to provide a report for services that were never paid for. It’s just not logical. Why should I put in the time and effort to do this without payment when I know no payment is coming?
 
AcronymAllergy said:
This. If it's not finished, that's one thing. But if the report's done, you most definitely cannot withhold it for non-payment.
Click to expand...
The way I have handled it the last two months is to withhold the feedback session until payment is made. Because they don’t make the payment, we can’t have the feedback session to give the report. Is that wrong? I don’t ever provide people with reports that I have not thoroughly discussed with them in advance. This is dangerous. I had a client end their life 2 months after a feedback session. (This was unrelated to the assessment process and the client denied any suicidal ideation at the time of the assessment. This is well documented. I did refer this client to psychiatry and a PhD psychologist at the time of feedback. There was never any blame cast in my direction, but it affected me.) I don’t ever want a client to be distraught over results so I spend a great deal of time at the feedback session going over everything, checking for suicidality, etc. My first report recommendation is always about what numbers to call/text and to go to the ER if they have any thoughts of self-harm.
If I need to change this practice, I will do so immediately. I feel like I even want to call my Board and double check. I do have all of the documentation in the chart and if asked would produce the raw data.
 
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PsyDr said:
I've had one cash transaction in 15ish years. I literally pocketed the money, pulled my wallets out, gave change, printed a receipt, and handed it to the guy.

Otherwise it’s a card. I prefer using Costco processing. I know some people that like square.
Click to expand...
Costco processing?! Tell me more. I am using Global Payments which is integrated with Therapy Appointment and they are royally screwing me over. Last month there was a random $450 charge due to “system updates.” Plus this month their annual fee will hit. I feel like they are a really poor choice, but I have used them during to convenience. I’m starting to research switching.
 
psychma said:
The way I have handled it the last two months is to withhold the feedback session until payment is made. Because they don’t make the payment, we can’t have the feedback session to give the report. Is that wrong? I don’t ever provide people with reports that I have not thoroughly discussed with them in advance. This is dangerous. I had a client end their life 2 months after a feedback session. (This was unrelated to the assessment process and the client denied any suicidal ideation at the time of the assessment. This is well documented. I did refer this client to psychiatry and a PhD psychologist at the time of feedback. There was never any blame cast in my direction, but it affected me.) I don’t ever want a client to be distraught over results so I spend a great deal of time at the feedback session going over everything, checking for suicidality, etc. My first report recommendation is always about what numbers to call/text and to go to the ER if they have any thoughts of self-harm.
If I need to change this practice, I will do so immediately. I feel like I even want to call my Board and double check. I do have all of the documentation in the chart and if asked would produce the raw data.
Click to expand...
I'm not sure of the legality of withholding a discussion of the results of an assessment with a patient due to non-payment, although I suspect you can't be forced to meet with someone who's made it known they aren't paying. But if that ends up being essentially a "backdoor" way of withholding the report (i.e., I won't give them the report because I haven't gone over it with them in feedback, and I won't schedule feedback because they haven't paid), my guess would be that it's probably illegal and grounds for a board complaint.

I also think it could be difficult to make the blanket argument that nearly all patients are at risk of significant harm by reading their report without having gone over it with the psychologist first. My personal practice is to offer the feedback to everyone, which the vast majority of patients accept. But if the patient doesn't want feedback, that's their choice and right, and I still send them (and the referral source) the report.
 
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Doctor Eliza said:
Costco processing?! Tell me more. I am using Global Payments which is integrated with Therapy Appointment and they are royally screwing me over. Last month there was a random $450 charge due to “system updates.” Plus this month their annual fee will hit. I feel like they are a really poor choice, but I have used them during to convenience. I’m starting to research switching.
Click to expand...
I don't use it myself, but I've heard multiple small practice owners in my state also recommend Costco.
 
AcronymAllergy said:
I'm not sure of the legality of withholding a discussion of the results of an assessment with a patient due to non-payment, although I suspect you can't be forced to meet with someone who's made it known they aren't paying. But if that ends up being essentially a "backdoor" way of withholding the report (i.e., I won't give them the report because I haven't gone over it with them in feedback, and I won't schedule feedback because they haven't paid), my guess would be that it's probably illegal and grounds for a board complaint.

I also think it could be difficult to make the blanket argument that nearly all patients are at risk of significant harm by reading their report without having gone over it with the psychologist first. My personal practice is to offer the feedback to everyone, which the vast majority of patients accept. But if the patient doesn't want feedback, that's their choice and right, and I still send them (and the referral source) the report.
Click to expand...

psychma said:
The way I have handled it the last two months is to withhold the feedback session until payment is made. Because they don’t make the payment, we can’t have the feedback session to give the report. Is that wrong? I don’t ever provide people with reports that I have not thoroughly discussed with them in advance. This is dangerous. I had a client end their life 2 months after a feedback session. (This was unrelated to the assessment process and the client denied any suicidal ideation at the time of the assessment. This is well documented. I did refer this client to psychiatry and a PhD psychologist at the time of feedback. There was never any blame cast in my direction, but it affected me.) I don’t ever want a client to be distraught over results so I spend a great deal of time at the feedback session going over everything, checking for suicidality, etc. My first report recommendation is always about what numbers to call/text and to go to the ER if they have any thoughts of self-harm.
If I need to change this practice, I will do so immediately. I feel like I even want to call my Board and double check. I do have all of the documentation in the chart and if asked would produce the raw data.
Click to expand...


In my jurisdiction, this would be illegal. If you have a product/report, it cannot be witheld for non-payment. They cannot force you to have a feedback session, or write a report you have not yet completed, but you do have to provide completed records.

OP, if you withhold the record without feedback, and the patient requests it anyway, you better have a legally defensible reason for not providing the report. And that bar is high. This would be grounds for a board complaint and legal action in many jurisdictions.
 
psychma said:
Wow. Thank you for that information. I’m glad I mentioned this. I’m curious though about how I can be required to provide a report for services that were never paid for. It’s just not logical. Why should I put in the time and effort to do this without payment when I know no payment is coming?
Click to expand...
You have to write a note, legally. If you legitimately did not score the tests, you MIGHT be able to write a note that says what you did. IDK.

It's like if I had a knee replacement, and my insurance didn't pay for it. I would still have the right to get the operative report, and take it to my next treatment provider.

Doctor Eliza said:
Costco processing?! Tell me more. I am using Global Payments which is integrated with Therapy Appointment and they are royally screwing me over. Last month there was a random $450 charge due to “system updates.” Plus this month their annual fee will hit. I feel like they are a really poor choice, but I have used them during to convenience. I’m starting to research switching.
Click to expand...
www.costcopaymentprocessing.com

Credit Card Processing for Costco Members

Costco and Elavon provide merchant services to help you process payments securely.
www.costcopaymentprocessing.com www.costcopaymentprocessing.com
 
WisNeuro said:
In my jurisdiction, this would be illegal. If you have a product/report, it cannot be witheld for non-payment. They cannot force you to have a feedback session, or write a report you have not yet completed, but you do have to provide completed records.

OP, if you withhold the record without feedback, and the patient requests it anyway, you better have a legally defensible reason for not providing the report. And that bar is high. This would be grounds for a board complaint and legal action in many jurisdictions.
Click to expand...
I do not have a product/report at this stage. I have my intake note, assessment notes, and unscored assessments. I can provide those records completely. I find it outrageous that I should put in hours to write a 15-20 page report for someone not paying me for services. That’s bullcrap.
 
psychma said:
I do not have a product/report at this stage. I have my intake note, assessment notes, and unscored assessments. I can provide those records completely. I find it outrageous that I should put in hours to write a 15-20 page report for someone not paying me for services. That’s bullcrap.
Click to expand...

If you haven't written a report, you cannot be compelled to write one without payment. However, if they wanted the raw data sent to someone else, you'd have to send those to that qualified provider most likely.

But, as to your comment about withholding the report for not having a feedback session, that's illegal.
 
WisNeuro said:
If you haven't written a report, you cannot be compelled to write one without payment. However, if they wanted the raw data sent to someone else, you'd have to send those to that qualified provider most likely.

But, as to your comment about withholding the report for not having a feedback session, that's illegal.
Click to expand...
Thanks for the clarification. I just got off the phone with my Board and was told that as long as I am willing to provide the raw data as well as all session notes, I am working ethically. As far as withholding the report for not having the feedback session, I was trying to say that personally I prefer to have a feedback session with a client to discuss the report when written. My policy these last two months has been to tell clients we can schedule the feedback session when their payments are up to date.
 
Doctor Eliza said:
Costco processing?! Tell me more. I am using Global Payments which is integrated with Therapy Appointment and they are royally screwing me over. Last month there was a random $450 charge due to “system updates.” Plus this month their annual fee will hit. I feel like they are a really poor choice, but I have used them during to convenience. I’m starting to research switching.
Click to expand...
I’ve used Elavon through Costco for years. They always have the best rates and I check all the options every couple years or so. I’ve never found a better deal for credit card processing than through Costco.

The vast majority of my business is via credit card transactions and credit card processing fees are in the thousands for me. Any reduction in the rate translates to significant savings.
 
psychma said:
Thanks for the clarification. I just got off the phone with my Board and was told that as long as I am willing to provide the raw data as well as all session notes, I am working ethically. As far as withholding the report for not having the feedback session, I was trying to say that personally I prefer to have a feedback session with a client to discuss the report when written. My policy these last two months has been to tell clients we can schedule the feedback session when their payments are up to date.
Click to expand...

Good clarification, your earlier comment of "I don't ever provide people with reports that I have not thoroughly discussed with them in advance" sounded a bit too definitive and definitely illegal if someone wanted the report without a feedback of any sort. I strongly recommend feedback, but occasionally some people simply want the report. I just document that it was offered and the patient declined.
 
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