Copy of STP 23 | Financial Policies
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Hello and welcome to the Scaling Therapy Practice. This is James Marlon. This week we have a great conversation with Dr. David Hall about adding a testing psychologist to your practice. Thought it was, uh, a pretty interesting discussion about thinking through some of the things you might, you might not always think about when adding a new person to your office.
It's just like adding another master's level therapist, right? Well, Uh, not really. Throughout the, throughout the episode, we talk about the threads of, um, some decisions you're gonna have to make. Like, are you going to take the courses yourself or are you going to hire? And that talks about capacity and your strengths and what you really like doing.
And then another decision that for adding a testing psychologist is what type, you know, what's the niche? Is it, is it gonna be the, the medical ones? Is it gonna be for school children? Is it gonna be for work, is it gonna be for leadership or, uh, employment? Like what are the type of tests that you're going to offer?
There's a wide range, variety, and that probably will determine, uh, it's determined by who's already coming into your office and who are the preferred people that you like to see, because when you offer that specialty, you're going to get more of them for sure. Another decision is, uh, who to hire? Are you gonna hire a fully licensed person or are you gonna start up an internship program and kind of grow them?
And there's challenges with both, of course. And then reimbursements and compensation. Like that's, that's another decision. Can you afford, you know, can your practice afford higher, uh, overhead and higher reimbursement for the psycho psychologist? Of course we talk about the pros. Uh, the pros adding a testing psychologist is, its diversification.
You're adding another service. You're able to serve the community differently and better. Uh, they, they can be very lucrative. Uh, insurance reimbursements, uh, once you get the flow going can be quite, quite well. Um, and, and, uh, there's, there's always a demand like another. Another benefit is, uh, when I was, when I, when I worked with school children, that psychologist was busy.
It, it felt like a hundred percent of the time, overbooked with a wait list, a month long, uh, for, um, individual IEPs. I call them EAPs in the episode, but IEPs, individual education. Plan, I think it's called. She was so busy all the time. And then some of the other, some of the other testing ones, the ones for, uh, the medical appointments, uh, the bariatrics and the, uh, spine spinal fusion.
I think they, they couldn't keep up. Um, in fact, they had the, the interns, the psychologist, interns doing them, and they were supervised. So it was, uh, Quite good. So you can make a lot of money. Of course, the, the, the things to consider would be there's higher overhead. You gotta pay 'em more. You might have, they, they, psychologists send out so much more paperwork, there's more testing, there's more coordination of care.
So who's that gonna fall on you? The owner? Probably not. So we gotta consider, consider that and then the right fit. You know, are you, you, who's the right fit for your office? That can be some, some challenge for you. So let's get into the episode as we talk about adding a testing psychologist to your practice.
Thank you David Hall for, uh, bringing this to us and we'll see at the end of the episode.
James Marland: Hello, this is James Marlon with the Scaling Therapy Practice and I'm with Dr. David Hall. Hello, David. Hey James. Hey James. Hi. Glad to see you today. Uh, this week we're gonna be talking about financial boundaries with clients and some of the policies and procedures to put in place to help with that.
Very excited to talk about that, but, uh, first we're gonna talk about our tool tip or tech of the week. I'm gonna go first. Um, this, this week I went to, uh, the Philadelphia Car Show. My, my sister-in-law gave us some tickets and the, we, I went with my son, his girlfriend, and my wife, and. Uh, I don't, you may or may not know this about me, but I'm, I, I could probably walk through the car show for about an hour and be done.
Like, I'm not super into cars, but I, I went to do it, to be with the family and to be with my son. He's 18 and he, you know, he's gonna be moving out. Soon, eventually. Maybe, maybe. Uh, uh, yeah, as I was talking about that, I'm like, what is he, isn't he, I dunno like, but the, the children years are slowly going away mm-hmm.
In adult years and transformation is coming and he's becoming a young man, and I'm not gonna have too many more of these episodes where I get to go and, you know, hang out. So even an hour and a half car ride and, uh, enduring. You know, $15 sub sandwiches and $5 drinks and $42 parking and enduring all that, it was worth it.
So my tip is take time to do the important things. Mm-hmm. Uh, that spending time with family, building those memories, taking those pictures. Um, it, it's really important and we're gonna remember that car show for a while. So as you're through going through your scaling business and growing your, growing your business and dealing with all the headache of all the business, and Dave and I were just talking about how sometimes I feel so far behind on doing things and like I feel like I always have to go, go back to work and work in the evenings and do stuff like that.
Just remember to take time to do the important things of li in life, like, uh, relationships and take time to do that. So that is my tip of the week.
David Hall: Hmm. Um, I have a question that relates to that. You so go for it. Pro. So what do you call a long sandwich? Because people call them different things, different regard to the country.
James Marland: So, uh, probably a hok.
David Hall: Yeah, I think that's, that's a Philly thing, but you're not in Philly. Right. And uh, it just, you know, there's like grinders is one and no grinder not, yeah. And, and so, and it's just interesting. Like I, I'm not from a part of the, of the country that has a sandwich tradition, like in other parts.
And so we just kind of take.
James Marland: I think I, I default to sub though probably cuz of like Subway or,
David Hall: yeah, let's go get a sub. I think, I think that does, that is like more generally recognized now because I think that's become like the, the thing. Yeah.
James Marland: Um, what do, what do you, do you call it, what do you call it?
David Hall: I think we call 'em subs typically, but it, it is funny, like there's, there's certain restaurants that will.
Style them. Like one of my favorites locally is a place that does grinders. Mm-hmm. But like, it's a different, like the, it's more toasted and the bread's a little different and, and, but I would only call something from that store a grinder. Like in general, I would call it a sub or something. Anyone? Yeah.
James Marland: My, my cheese steak had a cheese whizz on it, which is normally up here. I normally get like marinara. So I guess Philly cheese whiz is the thing. I
David Hall: don't, I'm not sure. I, I love, I love Philly cheese takes. Um, it is, uh, I, I, they, they don't always love me back, but I love you.
James Marland: It was good. It was good. So what's your,
David Hall: what's your, um, so for anyone who, who follows things I'm involved with outside of this podcast, Um, one of, I do a lot of collaborations with a psychotherapist named Bill O'Hanlan, who is, I tell people when I'm explaining Bill to people, some people know like, oh, yeah, yeah, bill O'Hanlan, um, because he is been around as an innovator and teacher in the psychotherapy space for a very long time at this point.
Uh, but for other people who, who aren't familiar, he's, I, I usually begin by saying he's the most famous therapist I know. Uh, bill Bill's written and published over 40 books. He was a, uh, a student in the 1970s of a famous psychiatrist and hypnotherapist, Milton Erickson. And, and Bill kind of made his early career as a teacher of Ericsson's material and.
Phil's, you know, he was one of the co-founders of the solution-oriented approach to psychotherapy, to brief psychotherapy. And so he is in textbooks if you study family systems and things like that. And, uh, anyway, I've, I've known Bill now for, uh, uh, about a decade, little over a decade at this point. And, uh, We've worked together pretty closely for a number of years.
I took over, uh, with my CE organization, psych Maven. I took over management of online courses cuz Bill's mostly retired at this point, but he likes to stay in it a little bit and so we kind of have a partnership and anyway, but that's kind of my life with Bill. But as I said, Bill's written, lots of books and he has one on his website for free.
So if you go to billow hanlin.org or billow hanlin.com, you can go to either, it'll take you the same place. Uh, at the, on the, you'll find on the home screen, it's at the top left right-hand corner. There's a optin form where you can get a P d f copy of. It's one of his favorite books of himself, of, of, of books that he's written, but it's called The Lazy Man's Guide to Success, and it's, it's a pretty short read and it's just sort of bill sharing some things he's, uh, gleaned over the years and, and, Um, bill, uh, you know, I think has a, has a history as a, probably a recovered workaholic.
Mm-hmm. Uh, but I, I love watching his work rhythms. Now he's, he's kind of a sprinter when it comes to work. He and I just, um, uh, he put out a new course. Uh, at the time of recording, we, we just finished launching it, but on trauma, which is, it was of course that he had taught before over 300 times, but he never recorded it.
Oh, and I really, it, it was a great training. I attended it live twice over the years and I really pushed, I was like, bill, you should do it. Please do it. And he did, but I knew when he was in his sprint, cuz I get text messages where he's with questions or updates and he would just kind of focus in and get it done.
And now he's down in the Caribbean at the time of recording. Um, not. Recording the course.
James Marland: Good. Good time to be, uh, during winter months here
David Hall: when we're recording. Yeah. So it, it is. Um, and I, I joke that I'm always in certain ways trying to be more like Bill, uh mm-hmm. Not in ways. He, he is, um, uh, uh, for those who are interested in little tidbits of facts, bill is one of the most boring eaters I know.
We've talked, when we talk about food, he, he has such, he likes. We've talked about food because, you know, he, uh, he'll travel and I'll say like, oh, have you tried this or you tried this? And he's like,
James Marland: oh, well, you're a big, you're a big, you plan trips
David Hall: around food, food. I'm, I'm, I'm a, I'm a bit of a foodie. I, I enjoy, I enjoy food and I understand that not everyone's the same degree, but man, like he treats Italian food as a little exotic.
And, uh, he's very much a meat and potatoes, very simplistic. Sort of. I can respect that. I can, I, I don't knock him for that. Uh, I don't, I don't, I don't feel it's a, it's a poor reflection on his character. But for someone who's traveled, he's, he's taught on five of the seven continents and I don't think there's a lot of teaching in Antarctica.
Uh, and so he's traveled the world. And for me, when I think of traveling in the world, I think of like, oh, all this interesting food to eat. And, uh, I don't know what other people think when they think about travel.
James Marland: So he has that free book on, what was the webpage again? Billow handlin
David Hall: billow handlin.org or dotcom org.
Okay. Okay, great. Or billow handlin do com. It it's, it's the go, but like that's, uh, lazy Man's Guide to Success Free download on his website. That's
James Marland: a great tip. Um, Cool. All right. So, uh, well, let's get into our topic for the week. We're, we're talking about financial boundaries with clients and policies and procedures to put into place.
Um, uh, I, I have, I, I can start with my first one, but David, you probably have more in, in place, but, well, first, let's, why, let's, let's start with this though. Why have. Why have set up boundaries with clients around financial things? What are, what are some good reasons to do this?
David Hall: It helps scale, to help scale.
That's kind of what we're about in this company. Yeah. Uh, it's the, there is, we've talked about this in Ative episodes, I think, but just there's a general discomfort that a lot of therapists have in conversations about money. Yes. And having good. Set P policies, procedures, boundaries around these things makes what is a hard conversation for a lot of people.
A little bit easier and it helps. Mm-hmm. Free up hard drive space in your brain to not have to think about this because ultimately you're, this is a side thing for what the relationship is supposed to be about. Now, depending on where you're working and how you're working, you may not have to have a lot of conversations about this.
You may be in places where billing is. You know, I, I mean, whether it's, it's handled by non therapist in a practice, which is just happens to some degree. I've worked in places like that to, I've had friends that have worked in places that their funding structure is. The clients don't, you know, they, they're a Medicaid or grant funded organization, so there's no direct, there are money, uh uh, things, but it comes from third party entities exclusively.
And so there are no direct conversations with clients necessarily about that beyond, you know, what's your Medicaid information or things like that. So, um, but yeah, it frees up space. Uh,
James Marland: yeah. And I, I would also think having these policies makes, makes the policies the bad guy, I guess not the therapist, like mm-hmm.
This is, this is how we handle money. We handle it for everybody. Mm-hmm. The same way. And so you don't have to rethink how to handle this sort of issue with your, like reinvent the wheel or redo the process every time you have a process that, as you said, frees up your space so you can focus on therapy and the, the main reason people are coming in.
Mm-hmm. Uh, are there people that might take advantage of you? Is that another reason for having, uh, financial boundaries?
David Hall: Sure, sure. Or you will. Be disserving yourself as far as the idea of of, of, uh, yeah. As far as the first part of taking people, taking advantage of you. Sure. But in any situation, you're gonna have that and there are other people that won't and Right.
I, I don't want to, to talk about this and that, the idea that the clients you're going to have or going to be Sure, yeah, yeah, yeah. More problematic. But it, it's, it, it will, but I, I think the bigger thing is something I. And it is an expression I gleaned from one of my long-term clients about being kind to your future self.
So, you know what I, if it was me talking about it, is I've gotta think about what is going to make life easier or harder for future David. Mm-hmm. And. Kind of embracing that because part of not having these conversations is you don't want to have it cuz it's uncomfortable. But then what happens when you're dealing with, uh, late cancellations or no shows or a balance being run up, then you've just created more work for future David or future James
James Marland: because you didn't wanna have that
David Hall: uncomfortable cause you didn't wanna have that.
And yeah. So it is to a certain extent, it's, you know, the, like the proverb eating the frog. If you've gotta eat a frog, go on and get it done. Um, have you heard that one, James?
James Marland: I, I've, I think I've just heard about the boiling pot. You know, the frog? No, that,
David Hall: that's a, that's a different frog metaphor. That's, that's where I'll slowly do that.
But the expression is, if you've gotta eat a frog, if you know every day you're gonna have to eat a frog, it makes sense to do it first thing. And so I see that in business and structure sort of things you talk about, go on and get the frog eaten. Like go on and eat the frog. Uh, because there's this idea of like, this is not an appealing thing to do, but if you gotta do it, go on and get it done.
Um, and putting it off, not having good structures or boundaries just usually means you're putting off problems. Sometimes there's wishful thinking. Sometimes there's the thought of, if I ignore this, it will go away or it will resolve itself. And every once in a while, maybe it does, but more often than not, no.
James Marland: Great. Well, here there's some things that, uh, we gotta talk about, uh, some policies that make it easier and help you set up some boundaries, financial boundaries with the clients. The first one I was gonna talk about is, you know, how do you get, uh, people to pay their copays and the, um, the, the fees ahead of time, even the no-show fees.
And I learned this, um, just by doing the virtual assistant company is collect the credit card at registration, you know? Mm-hmm. Have the policy of collecting the credit card for the client on registration where n now if, uh, for their, for their, um, copays, it's on record. Because one of the things the virtual assistants would had to do in, uh, an office that didn't do this is.
Inevitably copays would get missed or they didn't have it, or, you know, bill my card and then they would bill a card after the appointment, after the client is gone and, mm-hmm. And, uh, the card would get declined. And so then you'd have to track them down or spend a lot of time, a lot of time tracking that down and then reentering it and, and people could have, you know, thousands of dollars in co co-payments.
Uncollected if they didn't get the credit card ahead of time. So I, I always love that tip. Get the credit card at registration. That also prevents, uh, uh, you can correct me if I'm wrong, but that can prevent some people from no showing the first appointment if they know that they're,
David Hall: yeah. There, there's a certain amount of that I, I think.
With a lot of modern electronic healthcare record systems, like, um, therapy notes and, and other ones, oftentimes the credit card information is saved within it. That's a lot better. The, the issue of, of, you gotta think about how you're storing people's credit card information because you wanna, cuz what happens in, in the system, I use that people save their credit card when they sign up, they do all their paperwork through their online client portal.
The, they save a credit card. Um, but Ida can't access their full credit card information. It'll show me their last four digits and expiration. So I can't lift any infor because you gotta be careful about that as it relates to Yeah, that makes sense. Um, and so, you know, writing down their credit card number in their file, you, you need to have a more secure system than that.
So there's that. So if you're using a, an ehr, Um, that's a much easier thing to collect and save. And for me, like people can't even request an appointment unless they file a credit card. And so we've, uh, we've kind of automated that process now, uh, going to the, you know, does it how fees, um, stack up, like, yeah, that's a big thing.
Like if, if it's copays, that's one aspect of it. If you're doing a fee for service practice where it's. They're paying for the entire session. That's even more. Yeah. Um, and make sure that whatever your system you have though works. It's cuz I'll give it an example. So my primary care physician, I've been trying to pay them for a few days and they're making, making it too hard.
So, I've gone into doctor's appointments and most of my doctor's appointments with, like, I, I see a lot of doctors in the same medical system, so it's all one billing thing. My primary care and some specialists, I, I see you all in the same, and I've, I've got a balance at this point that I'm trying to pay, and they're making it difficult unintentionally.
So I've got, I've gone into the office once and said like, Hey, I think I have an outstanding balance. They're like, oh, oh, you just, just follow the link and pay online. And they do text me. They'd be like, Hey, your bill is ready. Follow the sl. Well, here's the thing. I go in to pay it, and then I get this error message and I've tried it multiple times and on multiple devices, I keep on getting an error message.
So at some point today, I'm gonna go back to my primary care office and I'm like, Hey, I have a bill to pay. And they might say like, oh, oh, you should pay online. Well, I can't pay online. Can I just pay you? And my fear is, is I'm gonna go to collections at some point. But this is not, I'm, I'm, I'm a good patient.
I'm trying to pay my bill. But yeah, I, I, all that to say is if you say, if you have a system to save people's credit card information, make sure they have a way to update it, that's pretty easy if they need to, because, you know, I, I have long-term people that I've worked with that they've just get new credit cards issued where it's a new expiration date and, and make, make it easy and, you know, If you can't get mad at your, your clients, if part of the reason that payment's not happening well is because you don't have a smooth system.
If you don't have, uh, if you have people that are doing the check-in process, are they well trained, whether it's a virtual assistant or in-person, receptionist or whatever. Are they trained to collect the payments or do the, cuz I'll go to my doctor's office, I'm like, Hey, do I have a copay? They're like, um, and you know, They're, they're not, uh, very focused on on that.
So, so,
James Marland: um, so that's about collecting credit cards. Uh, I at least, I think at least having it on file saves a lot of problems. And you can, you can use it as sort of a, you know, a jumping off spot for some other policies that keep you, keep you from traveling to track down. Mm-hmm. Uh, the money, it is uncomfortable, you know, let's, you know, you might not.
They, they might resist. Why, why do you need a credit card on file? But you know, it's, if you have it as a policy, we, it helps you, uh, collect those fees, uh, in the future. So, so future David doesn't have to do.
David Hall: Yeah, I, I wanna make life as easy as possible for future, David.
James Marland: All right, so another, another thing is, uh, charging for filling out paperwork.
And I've worked with some therapists who don't charge. For paperwork, and then some who, who are like, I gotta start charging for paperwork. So I, I, um, what's the advantage of having a policy on some sort of fee for filling out paperwork,
David Hall: David, simply for that it accounts for your time. Um, I, I think the biggest thing is you have to have a policy.
It has to be a policy, it has to be written. Um, you're, you're. It's hard to, to say you're gonna charge for something when it's not something, cuz it's, it's part of, in some ways an informed consent process and something that's big now and, uh, new in the therapy space. Good faith estimates. Yeah. What, what are things gonna cost?
So it needs to be part of, you have a policy so you have something to follow, but it takes time. Um, we have a, a $30 fee. I think is what it is currently, and it's for, it's based on units of time, but like it's a minimum of $30. But if it takes longer to fill out, then it's, um, and that's related to things of just anything that's outside of normal therapy.
We have policies in place if, uh, fortunately we're not in settings where we have to do this a lot, but, um, if there's like something court related, You know, we have to be like, how's that time paid for? How's that? And you need a policy in place of how that's gonna be accounted for. Um, because otherwise you could find yourself, you know, you respond to a subpoena and you're waiting around to be deposed in a child custody case or something like that.
And how, how you paid for that time, that's time that you can't see clients or taking out of, uh, your normal day. And how's that going to be in place? But it just, do you, there needs to be a way to account for your time that what you do, because one of the things I think you said in a, in a previously recorded James, is that you, it it comes from somewhere.
Yeah. You're stealing from somewhere and there's no free time. Right. Uh, in, in that sense, it's coming from, it's either coming from yourself or it's coming from your family, or it's coming from friendships, or it's coming from other relationships or places where you invest, you know, your time either volunteering or being a part of, or other clients, but it comes from somewhere.
From your sleep, from your, yeah. And, um, sometimes we, we, uh, we steal from different, Funds to kind of balance the sheets, you know, robbing Peter to pay Paul as the expression goes. But you, it can get really unbalanced if you do it too much. And, and if you assume that like, well, this is, this is just a way to account for that, and it doesn't have to be an exorbitant fee.
You don't have to think about it as like, I'm going to charge huge amounts of money. Mm-hmm. But, and also, um, when you have that fee, it encourages clients to think through their boundaries of what they ask you to do or not. Because there may be, I've gotten paperwork before where like it could have been mostly filled out by the client.
Right. And, and oftentimes I have to go digging for information. I have to get into their file to figure out what's their date of birth, what's their mm-hmm. Where other clients will, you know, give me a mostly completed form, um, that I just have to, um, follow up with. So I had a, I had
James Marland: a friend, um, This was mostly boundaries with insurance companies.
But I had a friend, Ralph, who ran a department and he, he was always saying the insurance company was giving us unfunded mandates. Mm-hmm. Where we had to keep filling out more and more paperwork. But they wouldn't pay, pay you more for that. And I think if, you know, the, the clients, um, expect, uh, If they expect you to fill out the paperwork without a fee and there's nothing written down, it can be sort of like, well, why are you charging?
You know, there can be that push pull. Why are you charging me for this? Mm-hmm. There's no, you know, I, I only pay for therapy. Mm-hmm. So your time is valuable. I guess that's a main point to think about that like, your time is valuable and you should be compensated for it.
David Hall: Mm-hmm. Absolutely. Uh,
James Marland: another big policy that people talk about is a no-show policy.
Do you wanna talk about how you came up with your no-show policy and how you enforce it?
David Hall: Um, yeah. Uh, we have, so they kind of run together. So we have a late cancellation slash no-show policy. Okay. Um, we. I worked at a, the counseling center I worked at before, it was if you had a late cancellation no-show and late was anything under 24 hours from the appointment, and you think of the 24 hour, and that's a common, one of, of what qualifies as a late cancellation or not.
And you think about, so you know, James, you're a therapist and you have your day planned out and you, let's say you've got, you know, six sessions booked that day. Seven sessions booked that day. We'll, we'll say six. And somebody calls that morning and you have somebody you're supposed to see, see at three, but they call it 10 that morning.
Mm-hmm. And so they've called, it's not a no-show. They've called and said like, Hey, I'm so sorry, I can't make my appointment today. Well, the difference is if, if they, if this is Tuesday and they called versus they called on Monday. On Monday, if they called at 10, you, you may have had time to then think about like, oh, how do I, how am I gonna account for this time differently?
Right? What am I need? I may have somebody, another client that I can fit in this time, or, hey, I can plan to run to the bank and get some errands done. But if it's in too tight of a time, you have less ability to have agency. To use the time differently. You can't account, someone calls me, let's say it's really tight.
Someone calls me, you know, five minutes before their appointment. That's still a cancellation, but I've, I don't, I don't have a lot of flexibility of what to do with that hour. Now, right now, if this is my last session of the day, then it's, oh, I go home early, or something like that. But the worst, the absolute worst, you start your day.
It's your first appointment of the day. You show up to work. And you get in and you find you have a message. So they may be called the night before, but after you went home. Hmm. And they're canceling. Like you, I could have slept in a little bit or I could have, yeah. You know, I could have not, uh, given myself indigestion by inhaling my Chick-fil-A chicken minis on the way in, or whatever it was that I, I, my morning looked like.
And so it goes back to the whole thing. Your time is accounted for. It's not just that your time is valuable, that that's something to, to get on a slight soapbox. I get, I do get miffed cuz therapists will get, um, a little high horsey, uh, about like, my time is valuable. Yes, your time is valuable. Everyone's time is valuable to a certain degree and, uh, uh, and so it's not that your time is not valuable, but so is everybody's.
And I think there, I think there's, there's kind of an elitism that can slip into some therapist speech, but I don't know that would be, that would be a different episode of like therapist elitism. But the, uh, but your time needs to be accounted for because it is your work time. The same that everybody's work time should be accounted for.
And that's the issue with light cancellation. So anyway, going back to the policy, the policy was before. 100%. I didn't like that when I started my own practice. I didn't wanna do that because I didn't feel, even though I couldn't use my time, it, I didn't feel I earned it quite that much. So, so,
James Marland: so there, there, the policy, the previous policy was I.
Uh, late, late, cancel. Or cancel what? Either one was. A hun They paid a hundred percent
David Hall: for the, not late, not normal. Cancel. If you canceled in less than 24 hours, then there was no fee then. I do the same now because life happens. People, if people are responsible. Okay. More than 24 hours. Yeah. Yeah. If it's more than 24 hours, then there's no penalty.
Okay. And I, I will say like, you don't wanna do something, like someone cancels three days for their appointment. You penalize. Yeah, yeah, yeah, yeah, yeah. Yeah. That's, that's 24 hours is generally a good Okay. Rhythm. If you, if the only caveat I would say, if you're doing like, um, a program, like it's not just an individual session, but like you've got a three day intensive, you're doing.
And, you know, the, that makes sense to maybe set like, Hey, the boundary is you, you've got up to two weeks before the event. Mm-hmm. Or something like that. But that's a, that's a whole different can of worm. So we're just talking about normal
James Marland: therapy. Right. So what's your, what's your policy
David Hall: now then? Uh, uh, if it's late cancellation or a no show, it's 50% of the session fee.
So whatever their session fee was, it's, it's half with the understanding now that is the policy as it's written. The therapist I do give discretion to, um, to waive that fee. It's still the policy, but you, you, we have informal procedures of how and when it's waived. For example, if an unexpected snowstorm happens, and, and I'll say like, where I live in the world, um, it snows infrequently enough that no one knows how to handle it.
Like, like we don't have like a lot of committed snow plows because it, you know, a, a wintery winter for me is there's, you know, 14 days of snow on the ground. Mm-hmm. Uh, and not in a row, like, just kind of throughout. And that's a pretty snowy winter for, for me. And so we don't have the infrastructure to handle that.
People don't know how to, so if, if, It's just not gonna happen. And people get sick. Like I'll oftentimes where someone, you know, particularly in this, in the pandemic years, I'll get a call from somebody an hour before their appointment and be like, Hey, I just tested positive for Covid. I'm not going to charge that person right now.
Our policy still says, you, you have this, but I'm not gonna charge this person. And there's this idea of being able to extend grace to people. Mm-hmm. It's better though to have a harder policy in place and then extend grace than to have too loose of a policy. Um, one of the things I treat it for people is everybody gets a freebie that the first time it happens, you know, to have flexibility, to have, uh, um, I also have a, a policy that if it's under 24 hours but they can rebook the same week, we do not charge them.
Ok. And the reason for that is, is cuz most therapists like their schedules are on a weekly basis. We see clients generally weekly. Or even if we don't see them weekly, the week is still the unit. And so if you late cancel on Monday, but I had a spot open on Thursday that you can take my income for the week is not negatively affected.
Mm-hmm. So there are all these different caveats, but you, you wanna find ways that kind of set that boundary. But that's, if they call now, if it's no show, I'm less likely to give grace for that. Usually the policy is if they no show call. You know, my way of calling is, Hey James. This is David Hall with Haven.
It's about, uh, three 20. I had you down for a three o'clock appointment. Wanna just check in to see if. We need to reschedule or anything like that? Uh, I, I like putting it like that because I have no accusation. I'm just sharing information. Why
James Marland: did you miss, why, why
David Hall: did you miss I why are you disrespecting me?
Yeah. It, it's, it's, I I don't wanna be passive aggressive about it. I don't wanna be overly confrontational. That's the script I use. Whereas I acknowledge like, Hey, like I had you down for three o'clock. It's three 20. Just want to check in, see what the deal like, um, let me know. Please call me back. Uh, if you need to reschedule or.
Whatever. Mm-hmm. If I don't hear from you, I will charge. If you call me and be like, I'm so sorry. I've been in the er, I've had, you know mm-hmm. Kidney stones, it's been, I'm like, oh, I'm so sorry. You know, I'll usually give that a pass, but there's a point where, you know, if, if when somebody's had their, you know, eighth grandmother pass away, It
James Marland: becomes like, yeah, I, so that's where I guess keeping records helps you if you record what the reason why Yeah.
David Hall: I, I encourage a chart note if most EHRs will let you do that, cuz it'll show as like a cancel or like cancel like an
James Marland: admin note or something. Yeah.
David Hall: Right. To say like, you know, talk to client, they had this and, you know, you could notice patterns, but better to have a, a pretty firm policy in place. And to something you said earlier, James, it allows the policy to be the bad guy or the center to be a bad guy.
Yeah, and I, I'm, I'm the, I'm the clinic director, but I'll, I'll reference the policies where people are like, why was I charged for this? I'm like, wow, I'm sorry. It's the center policy for this. And I'll kind of act like, uh, you know, I'm just this victim of it too. Mm-hmm.
James Marland: Sometimes I have a, the policies are for everyone, you know, they're
David Hall: for the boss too.
They'll ask me and be like, well, didn't you. Aren't you the boss? I'm like, I am, but I still gotta follow the policy. Yeah. I'm not above the law,
James Marland: not, yep. Yeah, I do. Yeah. I follow the same rules as the therapist. Yeah. Yeah. That's great. Um, anything else on nohow? I feel like that could be a whole thing.
David Hall: It's a, you, you figure out, you know, you've gotta think through some of it's your clientele, some of it's your, uh, uh, of.
I do think we have to have realistic expectations on what it looks like and what our policies are. Um, for example, most of my clients don't use public transportation to get to me. Mm-hmm. If they did, I would realize that there, there are factors that are more outside of their control. Mm-hmm. And that becomes safe.
You guys also have to think about it, of what's a lot like I can set the policy the way I do it because I have a cash-based practice. Right. How does it, you can't bill insurance for a no-show. Insurance will not pay for that. And, uh, and you can't bill, uh, if you're doing Medicaid or something, you can't bill for that.
And for most Medicaid systems, I think this works universally. The client isn't responsible for a copay. Um, at least that's how it works in Tennessee. So there's no recourse for that. And so when I've worked with places that do very heavy Medicaid work, It's typical that double, triple booking is the, is the norm because they're counting for a certain amount of nohow.
Hmm. And the problem is what happens when everyone shows up.
James Marland: Yeah. I, I was gonna mention that I had a, I worked for a hospital system that did not, uh, charge for nohow. There was very little mm-hmm. Anyone could do, um, money wise anyways for, for people who missed their treatment sessions. And I had a friend who moved to a, a cash pay office and he said, the, the, their no-show policy, instead of having a third of his patients not show up, he had like one a.
Year or something like it was, if you, if you have
David Hall: a good no-show policy, it will help. I I, I do also wanna be cautious as people are thinking about it, that you have to think of generally what sort of resources your clients have emotionally. Yeah. Financially, things like that. And people that are more resourced in their life, you know, will, will have more stability to show up.
And, and, and there's a, I I think of one person I saw years ago, this was at the old counseling center I worked at. They would late cancel notoriously and had to pay the full session fee, but they were wealthy. They even said that I, I wasn't the one calling. It was, I had a receptionist that would call, uh, and cuz this person would call like an hour before their appointment, they'd be like, oh yeah, I got, I got distracted, my massage ran long.
And, and uh, the receptionist would say like, well, you do know that there's a, and they say, well, I've got plenty of money. And that was when I wished I could. Ramp up my fees to make it, to create more of a pain point for this person. Yeah. But for most of my clients, most of my clients, I'm expensive enough.
There's a, there's a pain point, and, and so you wanna give yourself the ability to extend grace. You want to be mindful of circumstances, but have the policy. You can't just make it up on the fly. And you've gotta think about how it's really nuanced.
James Marland: Like, uh, it is, you know, oh, let's just have a no-show policy.
But as you're talking, uh, through it, there's a lot of things to think through to have a really good. No,
David Hall: sure. You've gotta start with the policy. Yeah. And you've gotta thought, and you've gotta think about, you know, I have a system there is Nuance James, but I do have a system of when and how we enforce it.
And because you don't want it to be like, I like this client, therefore I'm going to not enforce it, or I don't like this client regard. Yeah. You, you do need to have, I guess the difference is, is that we have internal systems that we say amongst the staff and be like, Hey, if, if they're ill. We're not gonna charge for that cuz we don't want them to come in if they're ill.
No. Yeah, yeah, yeah, yeah. And, uh, but we don't want to have that as a written policy because then it becomes the excuse of like, well I'm sick. And then it becomes like, do we need a doctor's note? Like I, part of my policies for future David is I don't like any extra paperwork. Mm. This is a side notebook.
Good policy. Yeah. We don't do a true sliding scale in our practice. Because if we did legally, we would need people to bring in proof of need of, of either pay stubs or bills or things like that. So we don't do a slight, cause I don't wanna deal with that one. I think, I think there could be a shame aspect for clients that could make them avoid it.
So we do something different where we run a scholarship system, which functions similar to a sliding scale, but because we have it set up as a different mechanism. We don't have to do the paperwork of like, prove that this is mm-hmm. That you need this, prove that you're in need. Yeah. Yeah. And if we had a policy in place that said we didn't charge for nohow, uh, if you were, if you're ill, everybody would say they're ill.
Yeah. All the time. And, and do I wanna follow that up? So, great. Um.
James Marland: Okay. Uh, so maybe one of the one, one other policy that we could talk about, and it's kind of related to these fees, is outstanding balances. Mm-hmm. What are some best practices for having a policy on collecting outstanding balances? This is really tricky because as we talked in the beginning, you wanna be the therapist, you wanna have the therapeutic relationship.
You don't necessarily want it to be all, you know. You just want my money type of conversation. But you know, you pay for your, you pay for your staff, you pay for your lights, you pay for your building, you're paying for your education. Mm-hmm. So how do you, how do you have this policy or this conversation on collecting outstanding balances?
David Hall: You have a policy in place and, uh, it, well, it, it's the, or another way to, to borrow a term that's common from the VA world. Of standard operating procedure. Yeah. And, and, and, uh, S P S O P. Like what's the S sop? Yep. Yeah. What's the standard operating procedure for this? So, It depends on who's responsible.
Like if you have administration staff for people that you know, what's the, and they're the ones that are handling balances and billing, then there's that. And how do they handle that with clients and how do they communicate that to therapists in the ways that are necessary based on what's going on?
Because there needs to be, if you have different people that are providing the services, Versus billing. Okay. Yeah, you need to make sure that there's kind of understanding in that. Um, or if it's the same person, then again, what's the standard operating procedure for us? Um, therapists are generally managing their own schedule in my practice, and the rule we have is if once a client is more than.
Has two sessions that are not, have not been paid for, they cannot book again. And that could be dicey because we have, I, my practice is in a university town, we have a lot of college students, we say. Mm-hmm. And for them it is oftentimes it's a parent's credit card on file. Mm-hmm. But these are legal adults.
Mm-hmm. Mm-hmm. And so there's a, there's a dynamic about communication. So we can't necessarily call the parents. Yeah, unless we have release to say, Hey, we need you to update the credit card, or this is, and so it becomes a conversation with the client, but it's not the client's direct funds. And so that becomes a thing.
And so oftentimes that's where it can be, um, uh, that pressure can be felt, but that's where it, it's having a policy in place. And because therapists of mine will have to say like, Hey James, I'm sorry, I can't see you. Um, Because we've, we've got, you know, outstanding balances for two sessions and the policy of the, the, the clinic is that we can't have, we can't book any more sessions if that's the case.
Um, And it's who's staying on top of to know if is there an outstanding balance? And again, in my practice that's a therapist's responsibility. But therapists are paid based on money received, not money billed. And so that incentivizes therapists to note have I has, have I,
James Marland: have I collected? Yeah. Cuz they could
David Hall: be doing Yeah.
Cause it, it affect their pay for no money. Yeah. It, it affects their pay. And I'll, I'll say we, we have a mutual friend who. Found out after he had let somebody go, that he had somebody who had been getting paid for sessions but who had not been billing and it was like, had not been billing this. This therapist was responsible to like put in the bill but had not been billing for months.
And it was by the time it was discovered as way beyond reasonable collection. And this therapist was getting paid as if they, yeah. Billy and, uh, oh man.
James Marland: That's like gut punch. Yeah. You know, heart falling down.
David Hall: Uh, yeah. And so what, what's your system? Yeah.
James Marland: How do you, how do you manage that, I guess? Do you have a, a report, I guess you, you we have
David Hall: report.
Part of it is, is that we do pay once a month. Okay. And, uh, and for. Payroll to be run. It's closing out the books for the month, which is something we do in our E H R. And when we're doing that, it can be seen of, are there any outstanding balances? And then that becomes a communicator, you know, that gets communicated from, you know, our clinic management to whatever therapist, but like, Hey, your client still owes for such and such.
And, you know, what sort of follow up conversation needs to have? Sometimes it's from the therapist. Not always. Sometimes it's, it's, um, some of the, the management level we don't have a lot Sure. But we, we'll do a little, depending on what it is to, to say, particularly if the client is not an active client, um, we'll take on that conversation differently.
But, but you need to have a point where you can check in. And so for us, it's almost like we're re we're doing a monthly audit of the books. To see that. And if you didn't have a system like that, how long could it go before someone would notice?
James Marland: That's scary because you don't always have systems until you realize you need the system.
Mm-hmm. Right? Uh, and so I. The, the, the, especially when it comes to money and billing and being able to pay people and pay your bills. Mm-hmm. Uh, having that system in place that uses the report that you have, the communication in place, the therapists know their roles. I'm sure the clients, whether they read it or not, have a policy paper on what you do with the, with the outstanding balances.
So it's just a lot of communication just for this one. Um, air quotes little thing. Mm-hmm. To, to manage. Mm-hmm. Um, ha Have you, uh, so what do you, what do you think about your policy that you like and what are something that might, you think maybe could improve or, you know mm-hmm. It, you want it to be different, but it's not because of your policy.
So what's the best and worst things about your policy?
David Hall: My policy is very Mary Poppins. Practically perfect in every way it is. No, I mean, I, I don't have any, it's why it's my policies. I don't have, because I, I could tell things about other people's policies, but it's the, but there are structural things.
Like I, I wish that it wasn't difficult. I wish that, um, uh, you know, I wish lot. I, I, I wish that, um, You know, counseling was easy to people, for people to pay for, and it's the, and, and easy to provide. Like I, there's this tension of, because I, I do find myself having to explain to clients, like, you know, why don't you take my insurance?
Mm-hmm. And we have an FAQ in our website and I direct people too. And part of it is, you know, there are lots of reasons. One is it would require more overhead to take. Insurance. Cause I would need to have dedicated somebody to bill insurance, whether either that would be somebody that would be an employee, someone that was hired, or I would be a contracted service.
That Right. But it would cost in some way, um, to do that. And reimbursement is less, uh, than what the market rate is for what we charge. If, if insurance paid well, uh, for this, if insurance paid. Just what they pay other people for the same service. I, I discovered this later that for certain billing codes, if a, if a physician is doing some of the billing codes that are common for therapists, they'll get paid significantly more.
Even though for what? That particular service, they're less qualified for, they're less qualified to do psychotherapy. But if they bill for some of those units, they get reimbursed at a higher rate. Oh, wow. Doesn't seem fair. And so it's the well, but I think insurance companies are, are gauging like, well this doctor's probably not gonna bill a whole lot for that.
Mm-hmm. And, uh, we need. To have them credentialed because it's this hospital system and we have to, so it, it's a, you know, and you're a solo practice or a smaller group practice psychotherapist, your ability to negotiate with insurance companies isn't necessarily great. And so, yeah. Oh,
James Marland: well. So what are some mistakes?
But what, wrapping up this discussion then, um, because your policy is perfect. It's Mary
David Hall: Poppins.
James Marland: It's practically perfect. Practically perfect. Uh, what, what are some mistakes people might make with, uh, the collecting or the, uh, outstanding balance policy?
David Hall: Be too nice and be too mean. I see
James Marland: people be too nice or be too mean.
Yeah. Can you unpack and, and they, that sounds.
David Hall: They're related too. Yeah. Oftentimes people will be too nice in that it's this idea of they don't, they're, they're not being good boundaries. Uh mm-hmm. They're not having good boundaries as they're approaching it. They're not holding people accountable. And that's a lot of, oh, well, you know when, whenever you get a chance, whenever you go, like, this is, yeah, it's okay.
It's okay. And then what typically happens for that, here's the cost of that, cuz it's got it, someone has to pay for that and here's how you pay for that. You're spending. Being nice in a very shallow, superficial, unhelpful way. And the bill comes due. And then you've lost your patience. Yeah. And you feel taken advantage of.
And then oftentimes that leads to that, the flywheel catching, and then there's the other side, and then you're overly angry. And then you're, and both being too nice and being too mean is different manifestations of being unjust to the client. You're not being, by being too coddling, that's not being very just right and being too, uh, confrontational, depending on the circumstances, is not necessarily very just so how do you do this in ways that is balanced and just is what I, I think about and yes, having a good policy and boundaries in place where you're not being mean, you're being boundaried.
Now, some clients don't know how to distinguish that. Yeah. I, I do, I, I have a very low value on niceness. I want to be kind, but kind and nice or not synonymous. Mm-hmm. Nice is a very superficial, shallow thing. It's not bad by itself, but it's not particularly deep because you can be kind to somebody that can look very confrontational at times.
Very firm, can look very not nice to be truly kind to somebody. And there are ways that are being, that you're being nice, that you're being very unkind in your niceness.
James Marland: Right. It's not helping them. Yeah. It's, yeah. I think I, I think the phrase that comes to mind is like, tough but fair. Yeah. Like you are, you're, you have, you have some firmness.
But that you're also fair about how you apply it. So
David Hall: like I said, I wanna, I want to very much be kind to my clients, but part of kindness is manifesting good boundaries at the beginning. Yeah. And I want my boundaries to be ipl. And so thinking about like what is, here's a, here's an example of a good boundary.
I say this to clients, and the same thing goes to policies. What is the policy that you can enforce regardless of your mood? That where it's still a good policy, like this policy has to be a good policy, whether or not you're feeling sympathetic. Mm-hmm. You're feeling forgiving, whether you're feeling angry, whether you're feeling put upon whatever your feeling is.
Is this a good policy and it needs to be a good policy regardless of your mood, and that is a sign of a good policy. Good. All right.
James Marland: So that, that's a good place to stop on, uh, boundaries with clients, uh, around financial matters. Uh, great discussion. Uh, let's do to, let's go to our one thing you want people to take away from this episode.
Uh, my, I'll go first. I think just, uh, value your time, like your time is valuable and, uh, you, you, um, Doing things for people is fine and nice, but also there there's a time where you have to say, you know, I, I need to get paid for certain things. Like the paperwork or your No, your no-show or the cancellation type stuff.
Like don't value yourself solo, that you're not gonna get paid for some of that work. So value your time is my, is my one thing to take away. How about you, David?
David Hall: Have it written down. Have a policy, have a policy yet, like you, you've gotta, you, you can adjust a policy until you get to the Mary Poppins level, as I said.
But like, you can, uh, it's not writing it in stone, but you have to have it down and you have to have it down and has to be understood by your clients and your clinicians if you're a group practice owner. Because to, to make it up on the fly is not, it's not good policy. You need to No set it. You can adjust it.
But you need to have something set. Great.
James Marland: All right. Great advice, great discussion. Um, I think that's the end of this week's show. So, uh, for James Marlon and Dr. David Hall, thank you for listening to the show. We'll see you next week. Bye. All right, you.
Thank you for listening to the scaling therapy practice. I hope you enjoyed the show. I want to remind you that the content shared today is for general information and entertainment purposes only. It shouldn't be considered as legal or tax advice. If you need a professional advice in those areas, please consult with a licensed attorney or accountant, but thank you so much for listening.
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