Mental Health Law & Ethics

Do You Think This Orange Jump Suit Makes Me Look Fat?

by Dr. John Riolo

I wish I had a dollar for every time I heard one of my colleagues say something like, I really can’t understand why I can’t bill for telephone calls.

Well therapists can bill for telephone calls. In theory they can bill for just about anything that suits their fancy. The problem is who is going to pay that bill.   As a general rule unlike lawyers, psychotherapists do not charge for telephone calls. There may be exceptions of course but as a general rule telephone calls are considered part of the job or part of pre- and post-service work and they may not be billed to insurances such as or Medicare. Also many other third party insurance companies have similar rules or restrictions. 

So before we get to the heart of the matter let’s get some of the exceptions out of the way.

 First, if you are seeing a patient privately, that is cash only and no insurance is involved, if the patient agrees, you can charge them for phone calls if that is what they want and are willing or pay. In theory I suppose you can conduct all your therapy over the phone or the internet if they agree to pay. Whether that is a good idea or not is the subject for another series. For the record, I don’t recommend it. 

Some insurance plans will cover “telephonic services” for a few select benefit plans. “   However the purchaser need to request this service to be included and such plans will in all likelihood cost more in premiums. It is possible at times to contact the insurer and get special permission to conduct therapy over the phone under special circumstances for a particular patient.

Some billing experts will advise that therapists who want to charge for phone calls should require their patient to sign a waiver where they understand and agree to pay out of pocket for phone calls. However before doing this they may want to consider this as nickel and diming patients and in the long run may be more costly in good will than it’s worth. Also they would need to be sure that their contract with the insurer does not prohibit such actions.

OK, so why the jumpsuit reference?

 Well some psychotherapists find the above limitations too restrictive. So their solution is to take it upon themselves to simply do therapy via telephone and bill it to insurance as if it were in person face to face session. They think no one will be harmed or anyone the wiser.

The experts strongly advise against this. People who do billing for therapists for a living have seen it all from up-coding to out right lies. Some therapists think it OK to lie to an insurance company because they are big and rich. Well telling a lie to an insurance company is not any different than telling an outright lie to your patient.  It’s a breech of trust in both cases.

Susan Frager, LCSW  who operates a billing service for mental health professionals out of St. Louis, MO has this to say.  "It may not be what most therapists want to hear, but the definitions of CPT codes 90801/90806/90847 clearly state that psychotherapy is conducted face to face. When you bill a claim to insurance this is a legal document with your signature attesting to the procedures you have conducted. If you substitute a phone session for a face-to-face visit, this is a blatant lie and is considered insurance fraud. If caught, penalties could range from losing your license, inability to bill government or commercial carriers again, fines, or perhaps even jail time. Is it really worth the potential consequences?"

Jean Thoensen, another operator of a billing service for psychotherapists in Centreville, VA, says, ”As  a professional mental health biller for over nine years, I have heard all kinds of excuses on this subject. ‘I know plenty of well respected therapists who do it.’ ‘I just want to help the patient.’    IT DOESN'T MATTER. This is a legal issue, not an ethical one. Orange jumpsuits aren't flattering to most complexions."

Unfortunately not all psychotherapists want to hear from experts.  Some would rather go to an internet discussion groups and listservs and  have people often with no experience and sometimes no ethics for that matter tell them what they want to hear. And there is no shortage of people therapists telling others what they want to hear on some discussion groups.  

Well over the years I have heard a few astounding excuses by mental health professions to rationalize committing fraud.  Some actually sound almost reasonable a long as you don’t examine them too closely and some are simply ridiculous.

So let’s look at a few.   Below is my “empty type chair” debate with a colleague who advocated fraud as a way of conducting business.  Anyone who thinks I am exaggerating or not being fair to the fraud advocates is free to debate me in reality on this website in writing or in a podcast. However, if you think fraud is acceptable be forewarned.  You may not like what comes next.

The patient is too sick or too distressed to come to the office.

Well that is certainly a concern.  If in fact the patient is too sick or so distressed that coming to the office is both necessary and not possible that could mean that the patient requires  a level of care that is more than what a private non-physician practitioner can accommodate and a referral may be in order.  Hospitalization might be a possibility. However in almost any modest size city there  are agencies that specialize in providing services to the home bound and have contracts with insurers to provide such services to meet both physical and mental health needs. If the client meets this level of care,  most insurers have contracts with agencies that specialize in this. They utilize nurses, social workers but mostly case managers who can go into the home. From what I have observed they do a fair job too. It may mean of course for the therapist that they have to give up seeing the patient and they will not be able to bill them for anything.  But that should be no problem since they are only thinking of the patient, or so they say. 

It’s too far!

Well if it’s too far perhaps they should be seeing some a little closer.

No one is closer.  

Well that argument might work for people in rural or remote areas such as in the desert of Nevada  or perhaps the Australian Outback.  However in most populated areas of the US and in just about any western industrialized nation there is no shortage of psychotherapists. If anything there may be too many of us.   Try calling the insurance company and I am sure they can find someone on their panel closer in most cases.

You don’t understand. It’s me that they want to see.

I understand completely. Out of all the hundreds if not thousands of therapists  in your area (assuming it’s not the Australian Outback), you are the only one with the skills, empathy, warmth, compassion and sensitivity to help them.   However if you are the next Sigmund Freud and Mother Teresa rolled into one we should expect that the client would take every effort to get to see you even if it means taking a taxi at their expense.

Riolo, How can you be so obtuse? They are poor don’t you understand?  They could not afford a taxi or pay out of pocket. That is why it’s so important that the insurance pay.  They really need this therapy. It’s a necessity.   It’s a real ethical dilemma.  You see  I have to tell a little “white lie” sometimes or the alternative would abandoning the client. Don’t you get it?

Oh I get it alight.  You need to tell white lies sometimes so that money will go from the insurance company’s bank account into your pocket. If that does not happen you will have no choice but to abandon your client that you just said was poor and in desperate need of services. So in addition to fraud we are dealing with abandonment a serious ethical breach. 

However since we established among your attributes are empathy warmth, compassion and sensitivity etc. what about offering a service pro bono?  FREE! GRATIS!  Will it kill you once in a while to actually do something out of kindness?   

But, you miss the big picture. I could do that but that would just let the managed care companies off the hook.   Their refusing to pay for phone call therapy by managed care companies is nothing but a risk shifting strategy. 

Well this discussion is now to the point of true silliness,  if it was not silly earlier. Managed care companies like any other insurance will try to spread or shift risk where possible.  It’s  part of the business of insurance. Capitation and case rates are attempts by MCOs to shift risk. However their not paying for phone calls falls short of fitting that description.  It would be like having GEICO   auto insurance for comprehensive and collision coverage on your car and then accusing them of risk shifting because they refused to pay for a new transmission. So you claim your car was totaled in an accident or stolen. No matter how you slice it; no matter what altruistic sounding platitudes you want to describe it as,   it’s FRAUD!

So we are back to the orange jumpsuits. Some of my colleagues seem determined to try one on. Oh well! Martha Stuart wore one for a while.. It didn’t make her look too fat.

We would like reader’s comments on this article. We would especially like comments from: a) attorneys  and b) anyone who believes that there is a justification for giving false information to insurance companies in order to obtain payment.

Comments can be in writing in the form of an email to johnr@psychjourney.com or  one can call in and leave a recorded voice message at  (214) 615-6044- ext. 8460. Long distance rates may apply. Or, we can arrange an interview on the Insider Internet Radio Show.

Footnotes

- Or bill for one patient by using another family member’s insurance or routinely waiving co-payments . there is a long list of similar activities, but the basic idea remains the same.