Janet has a full roster of clients. She schedules 35 sessions a week, which means that she’s busy, but her workload is manageable and she feels well compensated for her efforts. However, lately Janet’s been receiving client requests that are leading her to work overtime. Three clients, who are each going through a divorce, have asked for copies of their clinical records to be mailed to their attorneys. One client, who has been missing his college classes, has asked her to write a letter to the registrar confirming his depression diagnosis, treatment, and that his symptoms could be inhibiting his school performance. Lastly, Janet needs to testify in court next week in regards to a client’s child custody case.
With all these requests, Janet knows she’s headed toward burnt out. Also, she’s making less money because she’s had to cut back on her client sessions to accommodate the administrative demands.
What happens when a client makes a request for her clinical record, asks for a treatment summary, asks for a letter, or perhaps even subpoenas you to testify in court?
Too often, counselors don’t have policies in place for such requests. Hence, when they occur, they don’t always know what to charge, or if they should! Without publishing fees for ancillary services, providers can feel pressured to work for free when clients request services above and beyond their therapy sessions.
Of all the administrative requests clients can make, a request for clinical records is the most regulated when it comes to fees. Under the Health Insurance Portability and Accountability Act (HIPAA), a covered entity can charge reasonable cost-based fees for providing medical records to patients (45 CFR 164.524(c)). In addition, many states have published guidelines for what constitutes “reasonable” fees (you can find state-by-state guidelines at https://thriveworks.com/blog/record-request-fees). For example, Georgia’s most recent regulations are as follows:
- A charge of up to $25.88 may be collected for administrative costs. In addition;
- A fee, not to exceed $9.70, for certifying the medical records may also be charged. In addition;
- The cost of postage may also be charged. In addition;
- Fees for copying documents may be:
- $0.97 per page for the first 20 pages
- $0.83 per page for pages 21 through 100
- $0.66 for each page copied in excess of 100 pages
- For medical records that are not in paper form, the provider shall be entitled to recover the full reasonable cost of reproduction.
In contrast, Massachusetts’ regulations specify for allowable rates:
- A $19.84 base charge for clerical expenses. In addition;
- A fee to cover the actual cost of postage. In addition;
- $0.67 per page charge for the first 100 pages copied; and
- $0.35 per page charge for each page in excess of 100 pages.
While many state-specified fees will cover the costs of practices with administrative staff, the low rates are a tough pill to swallow for solo-providers, who are taking a drastic pay cut for any time spent producing medical records.
Writing a Treatment Summary
At times a client might ask for a treatment summary. In contrast to a records request, the cost of producing a treatment summary is at the discretion of the provider.
Writing a Letter
Your attorney will always write you a letter. You want him/her to write a letter to your grandma, demanding that her meatloaf be less spicy, and cooked longer? Sure! Your attorney will write it. It will cost you, but he/she will write it.
I recently met with a clinician who experienced a situation wherein a client—during her third session—requested a letter detailing that her depression was inhibiting her ability to attend class. She responded that she would only write a letter if the client was in treatment for at least two months, responding, “we’re not a letter writing service.”
When I spoke with this clinician in more detail, I found that there were two specific reasons for her reluctance. First, her office had no rates in place for this type of task. Therefore, every time she would write a letter, it would be gratis. She wanted to reserve these time-consuming “special favors” for long-term clients.
Second, she felt that such a letter would be in support of the client’s assertion that her depression was the cause of her truancy. While she agreed that the client was depressed, she wasn’t comfortable writing a letter that drew a firm causal relationship.
Issue one is easily solved by publishing fees for letter writing. Wisconsin–based counselor Kendall Crook charges $37-$150 for documents, varying by document type (records requests are $0.31 per page, plus postage). These fees are presented to clients during their first appointment, as part of their larger fee agreement. Regarding his rates, Kendall says “We [his practice] use templates, which saves time, so we’re able to charge less. Depending on the nature of the letter, we can usually complete the project within 30 minutes. While the reason for the fee isn’t to deter patients, once clients hear that there is a fee, they consider whether they actually need the document they’re requesting.”
Second, counselors’ letters can be descriptive, not interpretive. Using the example above, a letter could say, “Client X has participated in three sessions of counseling with me. During these sessions she has reported trouble waking up in the morning, feelings of despair, and a difficulty completing everyday tasks. She reports that her symptoms are making it difficult for her to attend class. Following the guidelines of the DSM-IV, I have diagnosed Client X as having Major Depressive Disorder.”
How to Determine Price?
It is reasonable to charge for the time it takes to compose documents, plus any postage fees incurred. However, this does not mean a provider needs to charge by the hour. It may be wise for providers to simply charge a flat rate that includes all costs. This helps to avoid a client conflict such as “Did this really take you X minutes?” and (more likely) to avoid self-conflict such as, “This took me an hour. Did it take me longer than it should have? I’m a slow typist—should I really charge for this? Did this envelope need four stamps?”
When setting rates, counselors should consider the actual amount of time they will need to complete such a task. Note that one’s “actual” time might be double the ideal amount of time (put simply, something that you think should take 20 minutes, will probably take 40). In addition, counselors should consider what level of financial remuneration will make completing various administrative tasks a positive and rewarding experience. Providers should not feel pressure to charge less to produce documents than they make in therapy (BTW, my attorney will charge his full fee whether he’s providing expert advice or checking my spelling). In fact, it isn’t unreasonable for providers to charge above their usual therapy rates, as they are providing a special service.
Attendance in Court
Texas-based counselor Todd Daehnert, states in a document to his clients titled Court Action/Legal Fees, “Clients are discouraged from having their therapist subpoenaed…Even though you are responsible for the testimony fee, it does not mean that my testimony will be solely in your favor. I can only testify to the facts of the case and to my professional opinion.” For those who fail to heed counselor Todd’s discouragement, the following fees are in effect:
- Preparation time (including submission of records): $220/hr
- Phone calls: $220/hr
- Depositions: $250/hour
- Time required in giving testimony: $250/hour
- Mileage: $0.40/mile
- Time away from office due to depositions or testimony: $220/hour
- All attorney fees and costs incurred by the therapist as a result of the legal action.
- Filing a document with the court: $100
- The minimum charge for a court appearance: $1500
A retainer of $1500 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice there will be an additional $250 “express” charge. Also, if the case is reset with less than 72 business hours notice, then the client will be charged $500 (in addition to the retainer of $1500).
Finally, all fees are doubled if counselor Todd had scheduled plans to go out of town.
I spoke with counselor Todd, who has appeared in court over 40 times in the last 7 years, mostly for child custody cases. According to Todd, “The first couple times I appeared for clients I didn’t charge. Then I thought, ‘I’m never doing that again.’” Todd began charging his usual therapy rate of $115 an hour, “…but I didn’t want to go. I’d rather make less money and not be at court all day.” To make it worth his time, he raised his rates to where they are now. Todd explains, “Clients are paying thousands, or tens of thousands, of dollars [for their case]. They don’t balk at my fee. It’s worth every dime.”
Honest and Fair
Administrative fees are not the “hidden fees” of seeing a therapist. They are honest and fair charges for additional services that clients may want. Post your fee schedule in your office. Include it with clients’ intake paperwork. Good clients will understand why these charges exist, and respect that counselors need to charge for their time.