Tuesday, February 10, 2009

Just A Little More Time

Okay, so I'm going to post a scenario and I want your opinion. There's no 'right' answer, I don't think, or you'll tell me if there is. I'm particularly interested in opinions from other mental health professionals, so please note in your comments if you're one of those, but as always, I'm interested in feedback from all our readers.

A patient and doctor have a long-standing relationship, they always meet for a 50 minute session, and if often goes closer to 60 minutes. Perhaps a few times they've even gone longer. It's been years, and now the sessions are scheduled erratically, so it's not a given that things can be finished up 'same time next week.' On this particular session, the patient brings up something towards the end that unexpectedly takes a long time-- maybe she wants the doc to write a new script (maybe it's even Xanax ! and the doc is uncomfortable). Some disagreement follows, and the session goes until a quarter after the hour. The doctor never formally states there will be a charge for the session that has run over and there has never been a charge for an over-time session before, though this session may be longer than any other. Is the doc justified in sending out a bill for the extra time? And if so, by how much? An extra quarter of a session, or an extra 50% given that the session technically ran 75 minutes and not 50 minutes. Does it matter if it was the last patient of the day and there's not an all-day back up for everyone else because of the extra time? Let's say it was the patient's final session and so please don't answer with "examine it in the next session" or "send a bill and see what the patient says." And don't worry about the Xanax, new script, whatever issue, it doesn't really matter Why the session ran over, the scenario is about the time and the unexpected charge.

I often run my 50 minute sessions closer to an hour, and sometime I run a few minutes over that. There have been a handful of sessions that have run quite a bit over, and it's never occurred to me to charge for something that wasn't agreed upon in advance, but I'm not saying it isn't the right thing to do-- boundaries, income, time-is-money and the doc has bills to pay, too.

Just wanted your thoughts.


April said...

seems like if it happens, the doc should say something to let the patient know that next time there will be a charge---it's hard to quit a session at exactly 50 min. life doesn't always wrap up easily. but you also have to know that abusing the doc's schedule will have consequences.
also, would you charge the patient if instead of asking for xanax at the end of the session, they revealed they were thinking about suicide? i mean, does the reason you go over matter?

Dinah said...

April, good point and I incorporated it into the original post. If a patient, however, were to mention an intent to leave the session and be imminently violent, it would color the issue of responsibility about ending even if the patient announced Hey We're running over and I can't afford it.

"Abuse" of the doc's time, however, struck me as harsh-- many patients will talk forever and the doc is the one responsible for calling time. Though I suppose if the patient repeatedly brings up dangerous or obviously contentious issues at the end of the session, the word might apply.

Let's just say they are in the thick of it for whatever reason, and time goes over, should the doc send out an undiscussed bill for the extra time? We'll give it that most patients walk into a doctor's office or have tests run not knowing beforehand how much it will cost.

Anonymous said...

Sounds like it is a once-in-a-lifetime event for the patient (not the shrink), so "paying the bills" is likely not the issue. For a long term patient, I am sure that once or twice they had to leave prematurely, or something about the shrink's schedule inconvenienced them, etc., so likely it would even out. Good customer relations are necessary even in medicine. On the other hand, a patient who was constantly asking for "more" (phone calls, visits, time, etc.) would likely benefit from boundaries earlier on.


I'm a primary care PA with a special interest in psychiatry and a life long best friend who is a shrink.

Jessa said...

Hi, I read, but I haven't yet commented. Also, I have been a patient.

I would say, in your practice, the first time this ever becomes an issue is an opportunity for you to consider how you will handle this in the future. If you have no policy at the moment, I think it would be inappropriate to charge your patient based on the policy you decide to implement going forward. No ex post facto shenanigans and all. Essentially, this means that you are probably going to act more leniently in that first case.

As for the policy you might make. You might allow for a 10 minute "grace period" because maybe that won't infringe on your next patients if you schedule them hourly. To keep patients more on time with their requests, you could let them see the clock (maybe you already do, no mental health care professional I have been with has ever had a clock readable for the patient, I think this is silly), maybe you could ask at the beginning that they list everything they think they need to talk about and assign those things priorities (that way you might be less likely to have a surprise xanax request at the last minute, you will know to ask earlier, "you said you want to ask for some xanax, let's hash that out"). If someone always wants to go way over, maybe suggest scheduling a longer session so that you can accommodate that without imposing on your other patients.

Just suggestions.

Alison Cummins said...

My rule of thumb in business has always been that customers can have whatever they want, they just have to pay for it. To have a reasonable conversation with the customer about what they want to pay for, they need to understand what they are paying for and getting.

This goes back to time management. Neither my GP, my psychiatrist nor my talk therapist has a clock I can see. Only my talk therapist tells me how long an appointment is. For all these appointments I have to guess when the appointment is over by watching the professional’s body language.

If the clue I get that the session is about to wind up is that the professional stands up and asks when I want to book my next appointment, then they are going to get stuck with a list of last-minute stuff. I would be very annoyed at having to pay for an overrun if I were dependent on someone else to manage the time. It also damages the relationship when the professional doesn’t charge me but makes me feel guilty for using too much time and implies I’m trying to get freebies or depriving other people — all the while keeping the crucial information from me that would allow me to end a session on time.

1) Don’t start a session with “How was your week?” Or if you do, follow up immediately with “Is that what you want to talk about today?” Your patient would be forgiven for thinking this formula is a conventional exchange of pleasantries. You could both waste a lot of time struggling with the subsequent discussion when your patient wants to talk about her plans for starting school next month and you are trying to get her to explore the deep meaning of the remote car starter she just got installed.

2) Ask at the beginning of the session if there is more than one thing the patient wants to talk about.

3) Set parameters. Say how long the session is. Explain that you will need time to review medication and set up the next appointment, so you will wind up conversation at __ time. Then do. Make sure the patient has a clock to look at so they aren’t caught by surprise.

4) If, after all this, the patient springs something at you that you can’t address in the time available, say so right away and explain pleasantly that they will need to make another appointment to cover it.

None of this is something that can be done after the fact; it has to be part of every appointment with everyone. By choosing to share information rather than maintaining a monopoly and issuing guilt cookies when people guess wrong, you actually get more control and ease of management. If there is something urgent and you really do have to extend the appointment fifteen minutes, then you tell them you are unfortunately going to have to bill them for the extra time. But they knew that all along, so it’s not something that you have to work out while you’re in the middle of handling something urgent.

This still gives you leeway to extend a session — say with someone who left an abusive partner last night and doesn’t know what to do, or someone who needs hospitalisation, or whatever — and not bill for it. Turn the clock around and tell them not to worry about the extra time, that extraordinary events are built into your fee schedule or something.

Does this help? You might know how long your sessions are; you might be sure whether the 10 minutes between one appointment and another is private time for peeing and writing notes or whether it’s the time you take to book your next appointment; you might know how long 50 minutes is by feel. But that doesn’t mean your patient is or does.

Even if your patient uses a watch to manage the appointment, you might be running on slightly different time. A friend was in psychoanalysis with an analyst who liked to spend their sessions discussing why he was late and reviewing the fact that he wasn’t going to get special treatment and an extended appointment. It took him months to get the psychoanalyst to admit that her clock was five minutes fast.

Anyway. Worry less about being a nice person. If you work on the assumption that you both have the same agenda — a session that addresses everything that needs to be addressed in order of priority — then effective time management and patient empowerment should go together.

Anonymous said...

From a patients perspective, I would expect the courtesy of a "heads-up" to an additional charge. So, if it wasn't my last session ever, I would appreciate it if my shrink would say, "We often go over session by a few minutes, but you should know that when we go over by more than ten minutes, there is an additional charge of fifty bucks." (Or whatever.)

If it was the last appointment with this person ever, I'd just let it go.

But in an ongoing therapeutic relationship, I think it's absolutely fair to bring up the matter of time and money with clients, even in the moment.

Like, "Wow, it's interesting you would bring up such a loaded question when we only have five minutes left. Should we leave this for next week, or do you want to pay for an additional half an hour?"

If my shrink sprung an extra bill on me without talking about it, I would probably be hurt. I always pay in full at each appointment, and since he takes the money, I don't feel like it would be "weird" to talk about payment stuff, even in the middle of a session. Once he saw me in an emergency situation, on what is a normal day off for him, and I jokingly asked if I'd have to pay double for the session...like plumbers on a Sunday. (It was just the normal fee.)

Anyway, all of that to say, hopefully the client values the therapeutic relationship as much as you do and would be open to talking about the money stuff.

Anonymous said...

I'd not get upset about it. But you have to keep reminding yourself that medicine is a calling. I mean, think of the days on call and stuff when you were younger. I just can't let myself get upset about staying over...ever. I'd flip out if I did.

And my shrink runs closer to 60 minutes and has often run over for me at the end of the day and I always feel bad about that. I've always seemed to be the one trying to make sure I'm out on time. I think he's just relaxed about schedules and stuff. But it's tremendously helpful to know it's not like he's just waiting to get out of there.

And at the end of my career, the things I'll most remember are the home visits (for which I'm not compensated really), the staying during a long labor to be there for a delivery, etc. It's a question of priorities I guess. I do resent my job, but I also know that it gives me opportunities to be with others in a rare way.

Alison Cummins said...

... Or I could have just posted “What Jessa said.”

Anonymous said...

I have a couple of thoughts (which echo some of the comments already posted, but I'll repeat anyway.) :^)

~ I believe that the therapist is responsible for managing the time.
~ If we--the therapists--choose to let the time go over, we are accepting responsibility for that.
~ If it happens repeatedly, we need to check our own time-management skills/issues/whatever
~ Some clients do need more than 50 minutes, but that can be discussed & scheduled (and paid for) consciously.
~ Sending a bill for extra time when that hasn't been done before seems unwise to me. That seems like a 'rule change' without having properly informed the client ahead of time. I can certainly imagine the client feeling hurt or angry, and/or resisting the bill.

Viewpoint: I'm an LCSW in private practice.

PS--love the blog! (first time commenter)

Novalis said...

It sounds like you may be an agreeable and flexible person by nature, and you feel it may have been taken advantage of this time. "Fool me once, shame on you..." (shame, yes, but not the bill, which would only be due if the patient passively or actively refused to end the session despite a explicit time observation).

Midwife with a Knife said...

Um.. what jessa said?

Unknown said...

Can't change the rules in the middle of the game.

It seems all about boundaries on both sides.

adult psychiatrist in private practice

Alison Cummins said...

Thinking about responsibility: most people here, including you, seem clear that the responsibility for time management lies with the professional.

“[T]he doc is the one responsible for calling time. ... Let's just say ... time goes over, should the doc send out an undiscussed bill for the extra time?” (Emphasis mine.)

Ok, so you’re positing a situation where only the doctor knows what time it is, only the doctor has responsibility for time management, and the doctor and patient have an agreement that a session is 50 minutes long and costs $X.

You are asking whether it is proper for the doctor to decide to change the length of a session without consulting the patient and to charge a correspondingly different amount. Phrased this way, the answer has to be No. Time hasn’t “gone over” all by itself; the doctor has extended the session.

To get a “Yes,” you would have to assume that the patient was self-serving time, knew how much they were taking, was responsible for taking that much, and that the agreement was that sessions were somewhere between 20 and 110 minutes at the patient’s discretion and billed at $Y per 10-minute increment. They would take the time they needed or wanted and you would send them a corresponding bill after the fact.

Basically, you can’t both say “the doc is the one responsible for calling time” and “the patient is responsible for the length of the visit.”

The analogy with tests is not appropriate, because in principle patients are supposed to shop around, to ask which tests are actually necessary and to get the best deal. That is, nobody is supposed to get a test without their consent; if they are billed for it, it’s because they agreed to be tested and had the opportunity to discuss the cost.

(The analogy you are looking for is perhaps lawyers’ billable hours, where the client requests a service (for instance, a letter) and is billed after the fact for the amount of time it cost to write that letter. The cost of the letter is not known ahead of time, though the product is known and the cost of the time is known.)

Anyway, while the answer to the question as asked is “No,” you can still get paid for extensions without becoming a self-serve buffet if you share responsibility for the length of the session by allowing the patient to know the time and by discussing extensions. It shouldn’t be a big deal.

Anonymous said...

And let me just add, since the subject of time keeps coming up, that my therapist has several clocks in his office...two of them right in my view.

I can't imagine *not* knowing how much time was left in a session, honestly. And I do take responsibility for bringing up the most important / urgent stuff early on in a session, or at least give him a heads up early on.

Dinah said...

So Alison assumes the patient doesn't know the time or the rules, and Novalis comments about passive or active transgression.

What if the doc says, "we need to wrap up" and the patient keeps talking and the doc gets engaged. The patient does know it's time, and let's say there's a huge clock, so it's not a misunderstanding about time, but a longer-than-planned for session.
Does this change anyone's thinking?

This isn't my patient, it's a hypothetical, but Alison, in your honor, I'm going to get another clock for my office. I, too, believe the doc is responsible for ending the session, and I would not bill for a run-over. If it happened repeatedly with the same patient, I would be more aggressive about tying up. I generally don't leave the next patient to wait, never more than five minutes.

The after-the-fact bill does have the same feel as a lawyer's fee (or even another MD's fee--who quizzes the dermatologist about the cost before the appointment and the assessment of the problem??). I was quite miffed to discover a lawyer had billed me for the phone time discussing the issue and the fees before he was officially hired.

Roy said...

I agree with most of the above sentiments. It is up to the doc to call time. If doc calls time and pt keeps talking (and doc allows this to happen), then no charge. Unless there was previous agreement to pay for overtime after it was called.

If I were to get back into private practice, I think I'd just set a flat hourly rate (yes, like a ::I'm gonna say it:: a lawyer) and have people schedule their time online, reserving it with a credit card, just like you would do for a hotel. People could schedule in 15 min increments. This would take care of the no-show and late problems, too. If I did that, though, I'd have to pay them if *I* was late. Seriously, it would be the mutually respectful thing to do. (yes, Dinah, I'd lose a lot of money that way... lol)

Alison Cummins said...


I don’t assume the patient understands the rules any less than the psychiatrist!

If the rules aren’t clear to the psychiatrist, the patient can’t be expected to divine them and transmit them to the psychiarist.


Yup, that happens. And you have just illustrated a miss of a perfect opportunity to finish the thought. “We need to wrap up now or this session is going to cost you extra.” “This is a really good discussion, but I’m afraid we absolutely must wrap up. I’m looking forward to continuing next week.” “This is a really good discussion. Do you mind extending the session? It’ll be another $X, but otherwise we’ll need to wrap up.”

If the psychiatrist isn’t sure whether not wrapping up immediately should warrant billing for extra time, and this is why she doesn’t say anything, then the patient can’t be assumed to be sure.

If the psychiatrist is mentally completing one of the thoughts above but not saying it out loud, it’s not realistic to expect that the patient is correctly completing it. Perhaps the psychiatrist knows exactly what she thinks the rules are, but is in a quandary because she is too polite to talk about money out loud, but not confident enough in the patient’s telepathy skills to actually go ahead and bill.

Dinah, I believe you to be a sensitive and tactful person. I’m guessing you don’t like to be too direct; you like to rely on a shared understanding of the rules to make directness [confrontation] unnecessary. But for folks like me, you really have to spell it out. We don’t think that explaining things clearly is rude at all. For folks like me, what is rude is being unhappy when we don’t read your mind. You and I might not be a great match for that reason.

My discussion of the patient’s (lack of) knowledge of the time was to establish context for the need of the psychiatrist to take ownership of time management, including making sure that there is enough time to deal with the “important stuff.” If the psychiatrist intends to share responsibility for time management, then the psychiatrist also needs to share information about time — and most psychiatrists, for whatever reason, do not. I assume that ‘most psychiatrists’ have a good reason for not having a clock, but the price to pay for that choice is not being able to bill for an extended session without an explicit discussion.

A trick from back in the days when I worked for a diaper service. Panicked customers would call to say that the driver had forgotten to pick up the dirties, and would present a whole string of reasons why it wasn’t their fault. I’d explain that if they needed the driver to go back and get them, then what they were asking for was an ‘Extra Pick-up.’ “Normally an ‘Extra Pick-up’ is $6.35, but...” [customer’s vehement protestations of innocence] “... but we know that using a diaper service can take some getting used to at first, so everyone gets one free Extra Pick-up.” [Customer’s surprised and pleased expressions of gratitude.]

A psychiatrist can do something like that too. The first time a session runs over (clock in full view), the psychiatrist explains that normally this would be considered an extended session and charged $X. But this is the first time, so it’s free. Just watch out, because if it ever happens again, it won’t be.

This lets the psychiatrist discuss money after the fact, not interrupting an engaging discussion; it avoids a guilt trip; it shares information clearly so that both the psychiatrist and the patient can share responsibility for managing time; and next time it happens, the bill can reflect the extended session without needing to interrupt the flow of conversation to get informed consent.

Oh — and on behalf of tactless dunderheads everywhere, Baltimore in particular — thanks for the clock!

Anonymous said...

Patient viewpoint:

My psychiatrist generally schedules 50 minute sessions and ends at 10 minutes before the hour. If I bring up a new topic in the last 10 minutes he says something like: "You will have to make it fast or postpone this issue until next week because we are almost out of time." When the time for the end of session arrives the session is OVER. I have never seen him go more than 1 minute past the ending time. He has clear signals which indicate the approaching end of the session and he indicates the very end clearly. The only clock faces him on the table next to my chair, set slightly back so I would need to turn to look at it. If he is doing a "first" session he schedules 2 session "hours" and announces before the session that actual amount of time used will be billed, but that the time will not go past 10 minutes before the end of the second hour.

I have a few gripes about time with my psychiatrist:

1. "His" clock is fast and is NOT set to match the rest of the world which currently seems to run on cellphone time (though I am early for every session so I never miss the beginning of the session.)

2. Once or twice a month and sometimes 2-3 weeks in a row, he extends "his" time (the ten minutes) before the session (in which he makes phone calls) into "my" time, starting my session up to 10 minutes late, but he does not add the equivalent extra time at the end of the session. I pay $180 for 50 minutes ($3.60 per minute), so I may then pay $180 for 40 or 42 or 45 minutes (as much as $4.50 per minute) which seems unfair to me.

3. He loves to talk about politics (and I am knowledgeable about the topic though disinterested) and he frequently brings up a current event topic he's interested in and he will ask for my commentary. (It's not being brought up because he's checking to see if I am oriented as to time, place etc.) It seems unfair to me to discuss topics that are his pet interests during time I am paying $180 an hour for, and still not extend the session for me to get "my" time.

Should I send him partial payment without announcing it with him ahead of time for sessions which he starts late and should I deduct partial payment for the number of minutes we talk about politics and his vacation? If he starts 10 minutes late, perhaps I could deduct $36, the amount I am paying him for that time.

Why I do NOT quibble about time with him:
1. When I have gone through rough patches some of those minutes between sessions were spent talking to ME. (no charge)
2. When I have been at the end of my rope and have called him at home he has always talked to me (no charge)

The phone contacts are another area that he manages with very tight time management. He generally has been able to get right to the heart of what's bothering me, say something to reorient my thinking and calm me and be off the phone in 2-3 minutes, 5 minutes maximum.

Your sessions could end at the 50 minute mark if you were to pay attention to the time, indicate to the patient when 15 minutes were left, then give a final 5 minute warning on time. The ball is in your court. Why do you choose to go over? At 50 minutes you could say, "I am sorry but our time is up, let's finish this next week", or "would you like to make another appointment to finish this topic?" If the issue is generally meds, perhaps that's the first topic to discuss so that the time left can be devoted to talk therapy or leave a time slot at the end for that purpose. An unannounced bill for overtime that's generally provided free is not a good idea. Good time management is a good idea.

As a patient, I would feel annoyed if I felt the rules of the game were abruptly changed retractively as it would be in your case if you regularly go over, but in this instance you send out a bill for the time. Also, to do so on a final session I would find especially insulting. I would not be insulted as a patient to have you spend 30 seconds discussing your new payment policy at the beginning of a session or perhaps you could save time in the session and write a letter to give to all your clients in person that they could read later.

Catherine said...

If it's the patient's last session, it's over and done. Unless that person comes back, of course.

For other patients, write it into your office policies page for new patients and hand out a notice for existing patients with a short explanation (on a note attached to the paper) of why a blanket policy was needed. Give one freebie, but don't tell that in advance -- everyone screws up / has a bad day. I would suggest doing a 25% payment for anything up to ten minutes and 50% payment for anything over 10 min extra (read the section in Freakonomics about what happens when a daycare charges only a nominal fee for late pick-ups).

Also, it doesn't make a difference if it is the last appointment of the day because then that person is cutting into *your* time which is just as valuable as anyone's.

Anonymous said...

Just a patient not a pro

Another perspective: once I was kept waiting for 20 mins by my therapist (she's usually fairly punctual).
She saw her previous patient out and came to get me - the woman was a sobbing heap, in immense distress, bawling her way out of the waiting room - and my therapist looked quite distressed, for her. Whatever it was hadn't been resolved and I doubt it could have been no matter how much time they'd spent. She didn't mention it and neither did I but it affected the tone of our meeting obviously.

I would've preferred to wait even longer while she composed herself for 10 minutes in the bathroom instead of launching into the next session with me.

So I guess - therapy isn't jabbing people in the arm, there are all sorts of factors that mean it's not always 50 minutes and there is room for give & take.
(& clocks visible to both parties, and clearly written policies about fees)

Aqua said...

I think it is like any other business arrangement. If you feel the pdoc feels s/he was unclear about the client paying for any extra time, then there should be no charge this time, but a reminder if the patient is seen again, and clear boundaries/times and expected payments discussed if the patient is seen again. It doesn't seem fair to charge the patient without clearly having told them there will be a charge for this kind of service at the time it was provided.

Aqua said...

oh yeah I forgot,...the reason I, as a patient, might wait until the end to ask for medication, especially one I know my pdoc isn't keen on, would be because I am scared to ask and it took me the whole session to get brave enough to make a request. This may be an opportunity for helping the patient be more assertive.

Anonymous said...

Good point acqua. I think for some people endings are the hardest part of therapy. Sometimes you can only get to the crucial point in the last five mins, whether it's about medication or something else.

Do therapists find the ending as hard as the patients do?

This post links well to all the ones about hugs, handshakes etc if you think about it dinah...

Patient patient, or patient client.

Anonymous said...

I agree with Tigermom. How did I get seduced to extend the session? The client knows the time. It's grist for the therapeutic mill.

But if we can't process it next session and I'm just commenting on billing - I have no answer, just another question ... Do I charge less if the patient and I wind up the session ten minutes early?

Anonymous said...

what tigermom said.
and what Roy said
I don't understand the question what if the doc called time but the pt kept talking and the doc became engaged. that doc has an issue then, not the pt. it wouldn't be unusual for a pt to keep talking but it is not therapeutic for a doc to be that engaged once the session is over. that is more like enmeshed, no sense of boundaries. the pt should not have to pay for that. if the doc called time and the pt refused to budge well that would be different. the doc would be late for his next pt or would late getting on with life and it was not the docs choice to become "engaged". in that case the doc is held hostage until he or she can call security or convince the to leave. i would be afraid to see a doc so engaged by me and my stories that he or she could not disentangle themselves at the end of a session. (yes, on occasion there is a little extra time but not because the doc is engaged.) that is one hell of a slipperly slope and it is the doc's job to make sure the road is salted or sanded or whatever.

Anonymous said...

A follow-up question based on what Roy said: Is it even *possible* to schedule in an extra session back-to-back or does it always have to wait "until another time"? Why *not* do it in half-hour increments? What about people who need more time to process things? And what about the people who really have nothing to talk about at that session?

Anonymous said...

This is a little off-topic, but I just went to see my pdoc, whom I've seen exclusively for med checks for the last several years. The past time I saw her, it was a long appt., and I thought later -- how nice of her to take more time to talk. I then got the bill and instead of billing me for a "med check" it was "psychotherapy" and cost several times as much... :(

HP said...

I often run closer to the 60 minutes and occasionally over that - dependent on the circumstances. However, if something important is raised at the last minute AND the person is a repeat offender, I will reinforce boundaries and say that such important things should be brought up earlier in future sessions.

HP said...

Oh, should also add that I start each session by setting an 'agenda' with the patient, finding out what they want to talk about, maybe suggesting some things my self and then working with them to assign priorities so we get the important stuff done first.

However, even doing that, people can sometimes forget something until last minute or simply only get the courage to mention something as the session is ended and they feel they can escape!

tracy said...

Hummm.....i just started with a new Psychiatrist who actually does therapy (yay!) a few months ago and i contstantly find myself glancing at either my watch or the clock towards the end, to see how much time i have "left". Then having to assure the doctor i am n o t hoping the time is almost over...it's atually the opposite...!

Bix said...

I think I agree with many commenters...

Don't charge this time because of precedent. Do communicate that time over 50 minutes in the future will be charged - new office guidelines.

William said...

My perspective is as a Navy Psychiatrist - so I'm not getting paid by the hour, but I'm usually still a stickler for time. I agree with many of the points made above ... not everything can be wrapped up according to schedule, etc. I also agree that it's important to have a clock my patients can see, and to make sure they understand the boundaries going in. Since it's not a question of money, I'm able to focus on exploring why it is that time boundaries are being pushed ... is my patient genuinely in distress and why? Is it something that really has to be resolved prior to leaving today (or is it my anxiety that's driving it?) Why a last minute "oh by the way," or a med request (as noted above, is my patient scared to ask me, or are they being manipulative? People are more likely to say "yes" perhaps to end an uncomfortable discussion quickly ...)

But the long and the short of it is that I think the blunter the better when it comes to time and money boundaries with patients. I would also add that by being very up front about such things, eventually the discomfort can fade for both parties and proper business can take place.

Anonymous said...

i think all billing information should be discussed at the outset of the treatment relationship, and made available in a tri-fold brochure for both parties' future reference.

my opinion's based on an experience several years ago with a therapist who did not discuss anything but her hourly rate at the outset, and i didn't know enough to ask any followup questions. my irritation point came when she billed me for a session i canceled with less than 24 hours notice, and then later refused to compensate me for a session she canceled with less than 24 hours notice.

at the next session, i presented her with an invoice for my billable hour. after some discussion, she agreed to waive her cancellation bill "in light of the circumstances."

Anonymous said...

The doctor is in charge of the session. No, I don't think the doctor should charge extra for the session. If it is a continuing problem with a specific patient, you can negotiate a new fee schedule at the next session. And then schedule a longer session.

If the patient wants paperwork done, the patient can be charged an administration fee.

I am a month away from my MSW...so I am both a professional, and a patient.

If you find this is a widespread problem, you can restructure your fee schedule to reflect whatever billing codes are appopriate.

These also depends on if the patient has insurance that pays for therapy, and if you are a participating provider.

Whatever model you use, you need to ensure that every patient is subject to the same rules. (even if the insurance companies pay different rates). Technically, if you don't take medicaid or medicare, it doesn't really matter. But it is still a good practice.

Ladyk73 said...

Oh...I guess I need a "little more time."

I am a grad student for an MSW. I paid for crappy student health insurance, and with that I can go to the student health places for free. Student Health is near the dorms (or the med school). Anyways. I had a 15 min check with the PDoc...and then the fire alarm went off. It was not a drill (although not serious). My Doc wrote me scripts in the parking lot. It was funny as hell. It was a weird day.

I want a "guilt cookie" now...

Wait...90 days until my MSW? BLAHHHHH

Anonymous said...

As a patient, it takes about an hour 15 to keep me composed. And as a medicare patient, i know money is not being made on me. But I do wish, if a session goes beyond a regular session, which for me is a long time - that I ask if I can have another session that day or the next.

Anonymous said...

Clients pay for 50 minutes - minute 51 and beyond are your time. If you'd like to give them your time, so be it, but don't charge. If, after dozens of sessions you haven't clarified the boundaries or established a consistent routine for starting and stopping, the responsibility falls on you. You'll need to eat that fee and let the sting teach you a lesson about setting boundaries.

Anonymous said...

I am a shrink with 25 yars experience. I think it would be dirty pool to charge extra for the session without warning the patient first.

Same on phone calls. The first 5 minutes is free, after that, I say "Telephone advice is worth $XX/hr. Do you wish to continue this call at that rate or do you wish to book an appointment?"
Patients often phone for telelphone prescriptions and its the same deal "It will cost $XX for me to phone this in. Do you wish me to continue or come in and see me?"

In our system, appointments are free to the patient, but if we could charge the patient, I would say "This sounds really important but our time is up for today. Do you wish to rebook another time, or continue right now at an additional charge?"

What's the harm in doing the logical thing with money?

Anonymous said...

OMG! I'm salaried & I stayed until 5:20PM today. That's 20 minutes! 20 whole minutes of MY time for which I was not paid! I'm outraged! How dare that person come in & ask me a question at 4:59PM. They know my hours are 8:00-5:00, with an hour lunch that runs exactly 60 minutes. They must be taking advantage of me! This has happened before. OMG!

purplesque said...

Have been on both sides of the situation, and never charged/was charged. If it was a recurrent occurrence, though,I would inform the patient and start charging.

Rachel Cooper said...

I was reading through some old journals today and stumbled upon an entry that stated that my psychiatrist informed me that he instituted a policy that if I was late by ## of minutes, he would charge me $$. So I turned around and said to him straight up, "so, if you're late by ## minutes, can I charge you $$?

Based on what I wrote, it's not exactly clear what his response was, but I'm sure he was not amused one bit.

BTC said...

Hi, What an amazing blog.. I can't believe it's taken so long for me to discover it!

I have to say I am something of a fan of boundaries. They should always be communicated by the practitioner to the client consistently and regularly especially if there is any chance of deviation from existing rules occurring "accidentally" - and I believe this is important no matter how long the relationship has been continuing because as long as it is a professional relationship then professional boundaries apply; one is the client and one is the service-provider.

However, I do agree that in this case the boundary should not be enforced on this occasion because clearly there has been a lapse and it is always the practitioner's responsibility to enforce and maintain boundaries. However, once the rules have been re-communicated (is that a word?) then henceforth the client should be charged.

I guess its more about *how* it is done rather than *if* it is done.

The relationship must be protected and this can be achieved with the right level of professional tact and diplomacy.

Not a shrink - just a client who likes professional behaviour.


Thanks for a great post!


Anonymous said...

Yesterday near the end of my appointment my therapist and I started talking about an issue that was happening around town, something that we couldn't believe had happened. When I next looked up at the clock it was 5:15!

Thinking about your post, I told her that she needed to promise that she would kick me out so that she could actually leave on time. Her response?

"I think I've been doing this long enough that I can manage my own time. I know how to say 'Our time is over' but I am choosing not to."

Interesting response, I thought.