Psychotherapy Meets the 21st Century
I was surprised today to get a letter from a local insurance company, authorizing payment to me for a session I’d done in September of last year. I wasn’t sure whether to be annoyed or laugh (I decided to laugh) and as I was grumbling about insurance companies I realized that they have taught me what to do and not do with my own billing.
Let’s face it, most therapists don’t like billing and most therapists don’t like insurance. (If you’re not a therapist, read on anyway, you might find it interesting.) Insurance companies are as a rule very difficult to deal with. They make us go through elaborate credentialing processes to join a network that pays us a fraction of our fee. And when we submit claims they often hold on to them for months, delaying our payment. Or they reject the claim because of some technicality, or request a half hour conversation with us to review the treatment so that they can find a reason to stop paying for it. Insurance companies are insulated by layers of administration and bureaucracy, and finding the person to answer the question or authorize treatment can take forever. In fact, the whole premise of insurance has been to have a large enough risk pool of paying clients that they can offset the damages they incur and still make a profit. In short, insurance companies are avoidant, outdated, and hostile to claims.
So why are we just like them?
Therapists groan about insurance companies, and yet we often act just like them when it comes to running our business. We avoid filing claims as long as we can, so that we’ll get reimbursement checks that are bigger and “worth the effort.” We avoid streamlining our billing processes. And we are extremely hostile when it comes to having to file claims to get paid.
Don’t run your practice like an insurance company. Instead, here are some suggestions for you:
1. Don’t delay your billing by unnecessary process. Take a few minutes to look at the way you process bills. Are you writing them down in a ledger, maybe more than one? Do you try to sort things by insurance company rotating different companies at different times of the month? Do you have elaborate formulas for payment plans for your patients’ co-pays? (That’s insurance fraud by the way.) Do you have a calendar that you transfer to your ledger? Or if you have a software program do you enter the same data in several different places? If you are doing any of these things, you’re wasting your time. Come up with one strategy and stick with it, and cut down the number of steps that any strategy you come up with has.
2. Don’t avoid by storing up your accounts receivable. You hate it when an insurance company sits on your claims, don’t do the same thing when it comes to your own accounts receivable. Don’t store up and hoard your accounts receivable to bill “later.” Your patients and you both deserve for you to bill promptly even if it is a $15 co-pay. Don’t drag out your co-pay billing for more than a month at most. Aside from sending a devaluing message to your patients, (“I don’t need that tiny amount of money”) it adds up and can become a source of anxiety to them. Bill out in smaller amounts on a regular basis, and if you don’t, ask yourself what your behavior is expressing about billing. Storing up your accounts receivable may present you with bigger checks later, but irregular ones. For people who know the value of consistent structure, we certainly drop the ball on this one, and then what happens? You see your bank account is low and you say, “I’ve got to do my billing.” And even if you send it out that day, you’ve just set yourself up for a few weeks of anxious trips to the mailbox to see if the money has finally arrived.
3. Don’t treat patient payments like a risk pool. When it comes to billing, don’t rely on a few consistently paying patients to help you avoid billing the rest. If you allow patients to carry a balance set a dollar figure that is consistent across all of them. Mine is $400, because I know that if a patient carries a higher balance than that I may start to get annoyed and that will create static in the treatment. My billing office thinks my limit is too high, but it is what has worked for me and allowed me to be consistent. By all means set your own limit, but don’t have 30 different billing schedules and expectations for 30 different patients! It isn’t fair to the ones who pay regularly, and it also isn’t fair to the ones who don’t. And it also isn’t fair to you. This may work for the insurance companies, but it definitely won’t work for your business.
4. Do your billing every 1-5 days. You heard me, every 1-5 days. None of this once a month or every few weeks or “when I have to” stuff. You’re in business and businesses bill their customers promptly and regularly. And here’s what’s really cool, if you bill every 1-5 days after a while you’ll begin to get paid every 5-7 days. That’s it for this one, 1-5 days, no excuses.
5. Do lose the paper. Not as in misplace it, but as in get rid of it! Many of you are probably saying to yourselves, “he’s crazy. I don’t have time to do all that paperwork every few days!” There’s the problem, you’re still using paper! Start billing electronically, most insurance companies have that capability, and there are plenty of software programs out there that can help. When I used software I would send out that days appointments at 5:30, took 15 minutes. The first few times you will need to spend more time on it by typing in things to the program’s database, but after that it goes pretty quickly. And if you can get in the habit of typing in the first part of the intake the day of the intake, that’s even better.
6. Do use a billing service. I saved the best for last. If you don’t want to do billing yourself, fess up to it. It’s a reasonable business expense to have. I haven’t missed the money I pay to my billing service CMS Billing one bit. The amount of money they have captured for me (including the check from last September) has probably offset what I pay them. In addition, they do all my billing intakes, insurance authorizations, credentialing and customer service for billing questions. The time they have freed up has allowed me to develop workshops, write this blog, and engage in other creative and lucrative aspects of my business. Remember that when it comes to owning a business you need to spend money to make money. Don’t be a tightwad, hire a billing service. Then you won’t have to worry as much about the technology part. But bear in mind that they can only bill as quickly as you report accounts receivable to them, so you still need to do that every few days.
As I write this, 97% of my accounts receivable are under 30 days. I get my money with regularity, and my patients know what to expect when they reach the $400 mark. This is possible for you as well! As this fiscal year draws to a close, take some time to take stock of your billing practices. If you’re acting more like a lending company or an HMO it may be time to change.
Last March a friend and former graduate student I supervised was visiting me from out of town. He was telling me about a call he got that went something like this: “Hi Bob, great website! Would you like to do a workshop on creating a online presence for our chapter of NASW? You won’t be paid for this, but you’ll get exposure, what do you think?”
This sort of exchange contains every element you need to have to teach a lesson on how not to do things as a Web 2.0 therapist. Let’s break this down:
1. What you are doing is so valuable we’d rather not pay you for it. Anything that you would go to a workshop to learn is something you should be willing to pay for. Even if it was only $20, a small amount or honorarium is something you should offer when you recruit someone to help you. Offering a rationalization is not the same thing; if my former student needed exposure the last place to look for it would be from this cheapo crowd! I know we have had a longstanding tradition in the psychotherapy disciplines to expect that we will present papers or talks at big yearly conferences for free, and that kind of thing seems a little different in my mind, because they are national conferences or Symposia and have many presenters. But to recruit someone specific for a specific workshop and not pay them any honorarium seems both cheap and arrogant to me.
2. Online Presence=Having a web site. Wrong! A website is just one small (important, but small) part of having an online presence. Having a website is something you should have prior to trying to launch your online presence. Now opinions vary on how to get one. I have some colleagues who know this space who believe that Therapists need to hire someone to build a website for them, and I can see the merit of this. My own opinion is that WordPress and our current technology have made it possible to have a very professional website for a fraction of that price if you are willing to spend some time and a little extra money to get a framework like Genesis. That is the one I use, and this site is one that I was able to design and launch pretty quickly. I have an older site that is still out there, but doesn’t get anywhere near as many hits now. That being said, I do think that whether you build one or have a professional do that, you definitely ought to have a professional critique it. My colleague Juliet Austin has a expertise doing this, and having been in the market for a while, she has a great eye for dos and don’ts.
But having a website is not an online presence in 2011, it is a colorful classified ad. Yes it is necessary now that potential patients want to see and meet you before they see and meet you, but now that there are thousands of Therapists with websites it will not distinguish you much more than a Psychology Today profile. Having an online presence requires you have a vibrant combination of interactive dialogue, recommendations that establish your “brand” as a therapist, multiple forms of media to see, hear and read you, and some amount of change over time.
I’m not trying to discourage any of you from getting started online with a website, I just want to make sure you see it is only one component of having an successful online presence.
3. Professional Organizations need to become more professional when it comes to business and social media. Asking your constituents to take the lead without compensating them is just lame. But even more concerning are the attitudes I see many organization taking towards social media. One example recently was a workshop NASW was promoting on HIPAA and Social Media. The flyer began with the bold red words “Protect Yourself!” The workshop like many others I have seen approaches the Internet and Web 2.0 from the point of view of fear-mongering, if the advertisement is accurate. Be scared of social media. Don’t learn how to use it for marketing your business, let alone your clinical work. This is not the message we need from our leadership. Include a component on social media in a general ethics course, sure. But please stop fostering the association of technology with ethical risk, social media with liability.
Our professional organizations also need to put the same thought and care in finding expertise when it comes to Web 2.0 as they would other workshop topics. Would we ever email a colleague and say, “Hey, want to do a workshop for NASW on EMDR?” based on information as limited as a website? I doubt it. As leaders of our profession, our professional organizations need to treat the topic of social media and health care with the same care as other topics. Their endorsement gives an imprimatur. If they say, the only thing you need to know about social media is to avoid it or you’ll be sued, we learn nothing but fear. If they say, social media requires no expertise or experience, we underestimate the skills we all need to learn to use it.
Bob is a great guy and an excellent clinician, but his having a website doesn’t make one an expert. Being on Facebook or Twitter doesn’t make one an expert. Having 5-15 years of experience working in the space of Web 2.0 like Juliet, Susan Giurleo, or myself does. These are peer-vetted experts, experts vetted by peers in both the clinical and Internet fields. I used to be hesitant to say this, because even though I teach people how to self-promote as part of their business I still feel uncomfortable with it myself. But I feel it is important to make a distinction between people who have spent years and thousands of dollars learning how to integrate clinical practice and Web 2.0, and your colleague who has a nice website.
Look, we need to start taking social media seriously, 97% of our patients and other human beings use it. I applaud our professional organizations for trying to offer something. But the above approach reminds me of having your grandson hook up your DVD player when he comes home from college. It is shortsighted and underestimates the complexity of the matters at hand. At some point Therapists need to strike a balance between a healthy respect for the growing importance of social media and avoidant fear. And at some point we’re going to need to invest time, money, and serious thought into how, not if, we use it in our practice.
Please do this for me; even if you never contact me and ask for a consultation or supervision, just do the following.
Huh?
This week in MA, we had further seismic tremors in the land of health care. Two tremors in fact. First, the news broke that our three biggest insurers Blue Cross, Harvard Pilgrim, and Tufts had reported financial gains this past year and strong investment income. In addition, the story reported that the CEOs of these companies made salaries ranging from 780K to 1.2 million dollars. News also revealed that BCBSMA’s board members collected an average of $68,000 last year to attend board meetings. That’s roughly $1,100 an hour.
The other big insurance news was that Tufts and Harvard Pilgrim decided to call off their merger. The reasons cited were that there wouldn’t be enough savings to offset the cost. Translation: They just wouldn’t make enough money to make it worthwhile.
What does this have to do with anything? Lots.
First, the salaries and board stipends underscore that Blue Cross Blue Shield is a non-profit business. That is why if you look at this list of BCBSMA’s Board of Directors, you will see top-ranking business-people and government officials. Put simply this means that it can dispense its surplus to reward board members and top management. They are a franchise, and in many cases, publicly-traded companies.
Second, and this is a reiteration of the first in a lot of ways, health-insurance companies are designed to make money, not just break even. They are a Non-Profit not because they don’t make money, but because of the way they disburse the money made, to their managers and board members (who incidentally are some of the people who have legislative power when it comes to healthcare reform.)
Back to your picture and my post title.
You are not a non-profit. You don’t even have to play the shell game with board members and management, because you are the management. It is understandable and easy to get distracted by the rage and yes, envy, that one feels at these “fat cats” making so much money. But let’s get real honest now. Here, I’ll go first:
1. I’d love to make 1.2 million dollars a year.
2. I live in a capitalist system, not a caste system, which means that just because I was born in a capitalist system I don’t have to live here, or, I can try to alter the system to be more in keeping with my socialist goals. But as long as I live in a capitalist system, money is an inevitable fact of my existence.
Now the hardest one, at least for me:
3. The minute I accept insurance reimbursement I become part of the medical establishment, and that means that the sickness and suffering of others is what creates a need for the commodity of psychotherapy. In other words, I need a steady stream of unwell or hurt people in order to make my living. If I do my job well enough, people won’t need me any more, and I’ll need to attract other hurt or unwell people. And even if I try to gussy it up in the form of “self-help,” I’ll still need people who need help.
Now I am not going to try to justify this to you, gentle reader, by saying I only make as much money as I need. I don’t believe greed is good, but I do want an iPad, and I don’t need an iPad. So I have to come clean and admit that I am not an non-profit.
I consult so often with therapists who take great pride in the amount of “slide” they have in their sliding scale. They are willing to give up that money without a lot of regret. Until they take out that picture of their family that I ask them (and now you) to put on the office desk. Look at it, at them. Those are the people you love, they are also being affected when you don’t charge full fee to someone who just got a new job, or when you don’t enforce your cancellation policy. They are the ones who are depending on you to help keep your family afloat. They are the ones who embody the best care you can give, and they will be with you and counting on you the rest of their lives in one way or another, often financially.
You are not a non-profit. You need to make a profit, and you need to stop pretending you don’t, and minimizing the profit so that you can pretend. I hate insurance companies and a lot of our healthcare system, and I am fighting for social justice when I am not working in my practice. But these companies get it, they get that they are in business.
We need to get that too.
This time of year the reply I often get from colleagues when I ask how their business is going is “Busy!” This is often said with shortness of breath, decreased blinking, and other physiological signs of anxiety. At the college I teach at, I often see my fellow faculty members commiserating with each other about how busy they are there. I think lots of us are busy, but I think it is time to re-evaluate if we are really busy, or hectic.
The way I differentiate between busy and hectic is simple: ROI and organization. When I am busy, I have most of my clinical hours filled, am up to date on my billing, know which week I am teaching on the syllabus, and returning phone calls or emails within 24 hours. I am also eating and sleeping well. That’s “busy.” When I am “hectic” I am thinking “oh my god I have too many patients to see;” forget to do my billing (or avoid it;) unfocussed when I get ready to teach; and start “saving” (read sitting on/avoiding) voicemails and emails. I also feel more of a pull to commiserate, to tell people how “busy” I am. For me, talking about how busy I am when I could be doing something more productive is usually a sign that I am hectic, not busy.
Once you have started to feel more stress in your practice, pause immediately and ask yourself if this is a prod from your psyche to take care of yourself. Have you done that? Good, if the answer is you haven’t, and that you don’t have time to because you are too busy, you’re being hectic.
Now knock it off.
Really, I am suggesting it is that simple. Other than an opportunity to review for self-care there is NO ROI on being hectic. You won’t get more patients, you’ll get less. You won’t have more time by worrying or commiserating, you’ll have less. You may derive a sense of self-importance from how crazy things are, but you aren’t really impressing anyone, including if you are honest, yourself. So put down the cross, we need the wood.
Here’s a suggested checklist if you are still unsure whether you are being “busy” or “hectic:”
You may notice that some of these can also be signs of burnout: This is not a coincidence. I firmly believe that if you don’t learn to distinguish between being hectic and busy, your business will fail. It will fail because you burn out, and or because you sabotage your income streams to the point where you have to close up shop and go work for someone else. And if you do that, you can guarantee they’ll help you learn the difference between busy and hectic the hard way.
So this weekend, take 15 minutes to sit and reflect, is my practice busy or just hectic? And if you don’t think you have 15 minutes to do that this weekend, you already have your answer. 🙂
It may be a coincidence, but when I turned 40 I began to hear the term ROI a lot. For those of you who may not have heard of ROI, it stands for “return on investment.” There is a technical definition of it on Investopedia, but I think I figured out why it kept leaping to my attention last week when I was speaking to someone about dragging my feet on a piece of work I had committed to do.
“I’m just worried that this will be a waste of time.” I was talking about return on investment.
I have always been a worrier about time, and like Marvell always hear Time’s Winged Chariot. But it has usually been from a fear-based perspective, and somehow, ROI has gotten me thinking more about finitude from a more positive perspective. Yes, there is a limited amount of time in my life, so what am I going to do with it? Am I going to spend it angsting about the ever-decreasing amount of it, or am I going to embrace my agency and be mindful of how I am investing myself in life? My colleague, psychologist Susan Giurleo is an excellent power of example for this. We both have psychotherapy and consultation practices, and have watched as health insurers have begun to put the squeeze on providers while continuing to enjoy their own salaries stability. I have become a founding member of AMHP, a group of mental health providers who are becoming activists about this issue. When I asked Susan if she would post an entry on our group discussion she was ambivalent about it, and in her explanation of why she was ambivalent she wrote:
1. I think major efforts will generate a low ROI. We can fight a cut, but
the nation is heading toward insuring more people for less money. Writing is
on the wall for all health care, not just mental health.
2. I’ve found putting my energies into diversifying my income stream has
huge ROI. I’m working toward a business model where I don’t take insurance
because I want to be paid for everything I do at the time of service.
Accepting managed care is just a bad business plan for so many reasons. I’d
rather slide my fee and get the money in hand than have to bill and haggle
with a third party.
There was that phrase again, ROI! Susan’s point makes good business sense, but it also makes good life sense. And the beauty of it is that each of us get to evaluate ROI for ourselves! I can wholeheartedly understand her point of view, and at the same time find that investing my time and effort into AMHP brings returns for me that I find very valuable. I have already begun to meet more of my local colleagues throughout my work on this. I actually enjoy reading about antitrust laws, and discussing this and the business side of my practice. I find political activism very rewarding, and get more energized to research and advocate for AMHP. It has me talking more with colleagues about another interest of mine, working with therapists to make better use of technology like social media. We live in an historic moment in that never before has it been so easy to share so much information with so many mental health providers across the world so quickly! This has been utilized by the health insurance industry to our detriment, but it is accessible to us. And not just in fighting the good fight against managed care. Technology can bring great ROI on our practice. I have used Skype to conduct psychotherapy in Asia, and have supervisees who “beam in” regularly for their appointments. And if you don’t have a website, if you don’t “invest” yourself in the internet, I am convinced that you will see diminishing returns in your practice.
As therapists we invest in our work, and more importantly we ask that our patients invest in it as well. But therapy should never be an act of completely blind faith for a patient, they can and should consider what the ROI will be on the hours and dollars spent. We have an obligation to be able to explain why the work is worth investing in. And we need to get more comfortable with the idea of ROI, because if we don’t define our ROI the insurance companies will. They already have: the briefer the treatment needed to get symptoms reduced to a least common denominator, the better the ROI. As one clinical reviewer at UBH told me last week when I said that a patient’s GAF of 70 was their highest the past year: “Well we need to look at the fact that this is probably their baseline and end treatment.” Oh, really? I guess I should just say to them, “sorry, you can’t become any more insightful, have greater well-being according to UBH. You’ve plateaued at ‘meh,’ so don’t let the door hit you on the way out. My solution to this problem is to say to UBH, sorry, not enough ROI for me, I’m out of your network. Will I need to work harder in other areas to generate revenue? Yes. But will I ultimately have a better quality of life without having to play such profane games, you betcha. Thinking in terms of ROI has made me more confident, more thoughtful about what I take on for work, and what I pass by.
So let me know, what brings you your highest ROI in your work, your life? What brings the lowest? When that car cuts you off, what is the ROI on teaching them a lesson with your horn or finger? When you feel a sense of presence and accomplishment with a therapy’s deep work, remind yourself that you are experiencing a moment of mindfulness. Mindfulness of ROI. Don’t miss it, and when you notice opportunities for ROI act on them, because as Jack’s mother in “Into the Woods” says, “opportunity is not a lengthy visitor.”
