Absences
When I began practicing, I had a 24-hour cancellation policy. That’s to say, if a patient let me know more than 24 hours before a scheduled session that s/he wouldn’t be able to attend, I wouldn’t charge. Further, if the patient let me know less than 24 hours prior to a session’s scheduled start, if I was able to accommodate a shift in time, I might do that (depending on the patient, and the circumstance). If a patient was sick, and asked if s/he could see me two days later, if I could do that, I would.
Over time, this worked better for me with some patients than with others. Some people never canceled. Some did, but only rarely. And some would tinker around on the edge of the 24-hour mark, canceling at 25 hours (or sometimes, 23). And a couple of patients – predictably, my highest-fee patients at my most desirable times – would cancel routinely, with 48 or 72 hours notice – leaving me with neither income nor the slot for recurring, paying patients.
Of course, all of these different profiles of patient relationships to cancellation and payment provided clinical content. Unfortunately, several also presented business problems for me – unsustainable configurations.
I had a supervisor, in my first year of practice, who questioned my 24-hour policy. “Why 24 hours?” she asked. I didn’t really have a good answer – “Because that’s what all the therapists I know do.” She told me that she has a one month cancellation policy – that if you don’t tell her one month in advance, you pay. And that, notwithstanding that, she’s happy to try to reschedule a session, but only within the calendar week in which it happens. At the time, this felt incredibly, indefensibly cruel to me.
As it turns out, I’ve moved to a somewhat similar policy with most of my patients. Increasingly, my policy is, if a patient wants me to see them at a recurring time, they need to pay me for that recurring time, regardless of whether they attend or not. I offer some flexibility, both with regard to vacation (I don’t charge for patients’ vacations) and with regard to rescheduling (if a patient needs to miss a scheduled session, I generally try pretty hard to come up with a time that works for both of us within 7 or so days on either side). And/but…. if we’re not able to find a mutually agreeable time, I charge.
This has produced all sorts of interesting situations, and opportunities. I’ve lost one patient over it – a new patient, who was so enraged over the outrageousness of the policy that he concluded he couldn’t possibly work with me. (I was the third therapist he fired in as many months – query the meaning of his reaction.) I have an ongoing patient with whom I implemented the policy in conjunction with a fee reduction – in a discussion of his income, I introduced the real-life impact on me, on my income, of his habit of canceling. And with another patient, one who has struggled mightily to feel, express, anger, it’s been enormously useful. If not especially pleasant.
So that’s where I am today. I still have a few patients on my old 24-hour policy, but the bulk, I’ve shifted to the “leased-hour” understanding. This, honestly, feels better to me. It feels more fair (I incur a cost by setting aside an appointment time for someone), and it feels more clinically coherent. I don’t think of the service I provide simply as being doled out in 45-minute increments, any more than I think of any other relationship in my life being bounded by the times I’m together with that person.
If I had my way, I would simply negotiate a monthly or annual fee with patients, and then, have a scheduling policy – with patients’ being guaranteed specific times each week, and with an option to attempt to reschedule them, but not a right, or guarantee. This is, effectively, where I’ve moved to, although the pressure to conceive of therapy and analysis as being provided in 45-minute increments is so firmly established in people’s imaginations – and in insurance coding – that it’s an uphill battle.
Payment
My thinking and practices continue to evolve. Where I am today is that I don’t accept credit cards (from any except one patient, a patient whose treatment is just rife with enactments of all sorts). I accept bank transfers, cash, and checks unambivalently. And I accept Venmo ambivalently from two patients. But, in thinking about writing this response, I’ve decided not to accept Venmo going forward from new patients, and, perhaps, if possible, to back off accepting Venmo from those from whom I already accept it.
Here’s my thinking:
I don’t accept credit cards because I have no way of knowing whether the patient is paying me or not. I know that I’m being paid, but I don’t know that my patient is paying. At a minimum, there’s a gap between my receiving the $$$ and her/his parting with it. Worse, s/he could just be racking up huge debt, something I might, or might not, know. So that’s my thinking about credit cards. When I did accept credit cards, I was annoyed by the hundreds of dollars I was paying to do so, but it’s not, consciously, a big part of my thinking here. At the time, it felt like a necessary cost of doing business. Not spending that money feels more like a perk of what feels more clinically comfortable to me than a conscious motivation.
My thinking about Venmo had been that it was a sort of contemporary cash equivalent, a transfer of $$$ from my patient to me. But I realized, thinking about this, that Venmo has a credit card funding option. So… see my objection above. I link Venmo not to a credit card, but to my bank account – it effectuates bank transfers between me and others, intermediated by Venmo. I have no problem with that, when that’s how it works. But I suppose I don’t know what others are doing. (And, I suppose, I could ask.) Jay raises the issue of Venmo’s being “personal,” and not “business.” This feels less salient to me. It is, however, why I don’t use PayPal – because it requires people to choose whether I’m “friends and family” or a “business expense.”
Bank transfers (and Venmo, and credit cards) introduce one clinical complexity with which I’m slightly, but not, so far, prohibitively, somewhat uncomfortable: they create the option for patients to pay me at a time that we’re not together. They don’t require a physical acknowledgement of payment in the room, with the handing over of a check, or cash. I prefer that. And I have one patient who initiates bank transfers on his phone during sessions. (His phone, in session, is a huge part of his treatment.)
Mainly, what I prefer about bank transfers and cash over checks is their reality: the moment they happen, the payment has happened. Not so with checks….
I’m fortunate: my patients all pay me. All but one, timely. (Currently.) None fights me (currently) over payment for missed sessions.
This is how it all works for me. Right now. I expect it’ll continue to change as I continue to think, and as I continue to learn from others’ thinking on the subject.
Postscript
On frequency…. I have a page on my web site devoted to it. I simply won’t work with someone less than once a week. Others will, can. I can’t. It just doesn’t work for me. And it’s not infrequent for me to say to patients that I fear meeting at a frequency of once a week feels more like colluding in maintaining a status quo than it does like working toward change.
