It’s a fact of every business. There are people who don’t pay their bills. If you allow the number of patients who are late or delinquent add up, you won’t be able to pay your bills either.
Most patients will simply pay your fee each week, often handing you a check for their copayment or payment as they leave the session. But there are always those who make the transaction of payment for services into a challenging dance. Do consider these issues:
Therapeutic Issues
Attention-seeking or entitlement: Some patients use the ritual of paying for their session into a bid for extra time and attention. Others resent that scheduling and paying their bill has to come out of their hour. Week after week, in spite of conversations about it, they wait until the last minute to fish out their wallet or checkbook. It seems to take them forever to write a check. It takes even more time for them to make the next appointment. They act resentful or hurt if asked to hurry up so you can get to your next session.
Avoidance of substantive issues: Other patients somehow make countless mistakes. They pay too much. They pay too little. They “forget” to sign their check. They argue or express concern about whether their insurance company has paid you correctly. If time has to be spent during their session to untangle their account, it may be a tactic for avoiding other, more painful issues.
Transference: Attention-seeking and avoidance may also be manifestations of transference. In addition, a client may accuse you of not being worth your fee, of not being good enough to deserve it or not being engaged with his or her problem. It’s always important to consider whether there may be some truth to what they say. But often enough their complaints and/or interactive style is a replay of other relationships in the person’s life.
Counter-transference: And sometimes we make the mistake of letting an account balance build up because of counter-transference issues. As helpers, we may feel ambivalent about collecting money for what we do. We may feel sorry for the client. We may avoid the conflict that comes with confronting people about their balance, especially if we think it will disrupt the therapy.
Secondary payers: Sometimes it’s not the client’s fault that his/her account starts to be in the red. When the therapy is being paid for by a parent, spouse or other significant person in the person’s life, it can get complicated. The payer may be acting out if you have refused to share the content of the therapy with them without permission from your client. They may believe the client doesn’t need or deserve therapy and resent paying for it. In a divorce situation, nonpayment for a kids’ therapy may be a way that the parent who is responsible continues the fight with the other parent. In these cases, it’s crucial to the therapy that we avoid being triangulated with the client and payer. To avoid an ongoing problem, it’s worth taking an hour of our time to revisit our contract with the payer.
What to Do to Avoid Late and Nonpayment
Deal with any ambivalence you have about collecting fees. You are helping the patients and their families with your work. They are helping you and your family by paying for it. It is a clear and fair transaction. If you don’t believe that, get some supervision to help you work it through.
Contract for services: The best way to avoid financial issues is to establish a financial contract during the first session. Be clear about fees and expectation for payment at the time of service. If you do your own scheduling and billing, make sure your patient understands your routines (last 10 minutes? first few minutes of a session?). If the client has insurance, discuss how billing and co-pays will be handled. Do be clear about whether and to what extent you will let a balance accrue. Also be clear about how delinquent accounts are handled.
Secondary payer: Similarly, when someone other than the client is paying for services, make a financial contract with that individual. Discuss with both the client and the responsible party the limits of confidentiality. Make sure the person paying doesn’t believe that payment means access to confidential information.
Confront immediately: Deal with nonpayment or avoidance of payment as soon as it happens. If you let it ride, issues around entitlement, trust, transference, etc. will only get worse – or will get buried until either you or the client acts up.
Delinquent accounts after termination: Unlike work from the trades or retail, our performance and our products are abstract and often difficult to prove to someone who isn’t interested in proof. There are clients who justify non-payment of their balance on the basis that, in hindsight, they don’t think our work was good or good enough to deserve payment. They are not persuaded by a phone conversation about their progress or by the fact that they made an agreement. There is no opportunity to work the problem through therapeutically because they have no interest in coming in to talk about it. You are then left with sending reminder bills, making repeated calls to ask what the problem is and, eventually, struggling over whether it is worth the time, money and perhaps the negative reviews you will get if you send the account to collections.
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