I establish clear expectations around cancellation policies at the beginning of treatment. In general, if a patient has a recurring session in my calendar, they pay for it, regardless of whether they attend, or of when they inform me they won’t be able to (subject to my making good-faith efforts to reschedule). If there’s confusion or misunderstanding the first time this comes up – and sometimes there is – I generally allow the first such misunderstanding to be resolved in favor of my patient – i.e., I don’t insist on their paying for a session they didn’t know/remember they would have to pay for. But. Going forward, I manage my policy as described above.
I similarly establish clear expectations around payment at the beginning of treatment: I ask that people pay me at each session for the first month or so (though I am flexible about this, as I don’t generally accept credit cards), and, thereafter, I tell them that I will ask them to pay me by presenting a (paper) bill in the first session of each month for sessions the prior month, and I will expect them to pay that bill no later than our second meeting of the month. Of course, people are, sometimes, delinquent. When they are, I strive to bring their delinquency into the treatment – to understand the meaning of their having “forgotten,” or having been “unable” to pay.
I don’t generally charge people’s credit cards or keep credit cards on file. First, because, as a rule, I don’t accept credit card payments (I have made exceptions to this policy, but it is my policy). More than that, though, this is because I think doing so deprives my patients of an important venue in which to act out. If they don’t want to pay me – because they’re angry at me, or need to communicate a feeling for which they don’t yet have the words – then my simply charging them vitiates any possibility of communication, privileging my short-term, small-stakes, financial interest over their treatment.
This isn’t in any way a criticism or judgment of those who do otherwise; it’s simply how I work, how I think, in my practice. A patient who isn’t paying me is telling me something. I want to hear what they’re saying.
When delinquencies persist – and this only has happened very rarely in my practice – I inform a patient that I will not carry more than three months’ balance – that is to say, after the third bill has gone unpaid, I (would) stop meeting – would no longer have sessions, or hold the time in my calendar. I never have gotten beyond saying that: thus far, my patients all have paid me in time to not have to miss any sessions. In general, I like to presume that the vast majority of financial issues presenting themselves in treatment are not truly financial, that they are more likely to be clinical/affective. (This is not to say that there is no reality, that patients don’t, from time to time, have financial difficulties. Rather, it’s to say that when a treatment is structured well, when the fee is set properly, that structure and level of payment frees the patient to communicate about their insides – and not their financial situation – in the treatment.)
Payment habits present ripe opportunities for us to do work on my patients’ hostility and resentment and powerlessness and fear, their need for me to experience some of what they feel in terms of victimization and pain.
I’ve, occasionally, had ongoing patients terminate with me with a balance as high as two months’ worth outstanding. In those cases, I simply bill them with personal notes on a monthly basis and, in every instance thus far (knock wood), I’ve been paid, ultimately – typically within 1-3 months of termination.
I think I’ve probably written off a grand total of four or five sessions in my career – all patients with whom I met just a few times, and who never became bona fide “patients,” people who were kicking my tires, and deciding, ultimately, not to work with me.
I never have, or would, hire a collections agency. As I’ve said, the way I think, part of my work is to manage delinquencies/money within the treatment, and if a patient owes me more than I’m prepared to walk away from at any time, then I need to stop working with that patient. As I said, though, this has yet to happen.
