Sliding Fee Scale

Yearly Family IncomeFee
Yearly Family IncomeFee
Greater than $250,000$300

At this writing it is late November 2012, I suspect these notes will remain on my website for some time so please don’t think I’m ignoring this subject if you’re reading it in 2025. I just won’t have come up with anything brilliant to add.

For the past many years, I have been “in network” with most of the insurance companies that cover health care for people in our area. Being “in network” means that I have contracts with the insurance companies and they provide better terms to you, the client, than if I am not “in network”. For instance your co-pay would usually be less if you are seeing a provider who is in network versus not in network.

It should be noted that both the “in network” and “out of network” providers are generally covered, in some fashion, by the insurance companies but the terms and conditions can vary widely. Therefore it is generally beneficial to providers to be in network, because it is more attractive to clients to see clinicians who are in network, because it costs the client less out of pocket and often, the provider bills the insurance company, rather than the client needing to bill the insurance company. Therefore clinicians get more clients if they have contracts with the insurance companies and clients pay less out of pocket.

Clearly this arrangement has advantages for both the client and the clinician, and it works well up to a point. In fact, for a clinician to chose to not be “in network”, or to not interact with insurance companies at all, definitely has negative consequences for clients’ pocketbooks and paperwork requirements. I acknowledge this and apologize before going any further. However, it is my intention, to stop being “in network” with most insurance companies at the end of this year.

A reasonable person might ask; “why are you going to do that if it will cut down on the number of people who will choose you as their therapist and it will make you more expensive for clients?” Good question. And there are a few reasons, when taken together, which have led me to this decision.

First, I work with people from all parts of the economic spectrum. Some have lots of money and/or good jobs; insurance and etc. Some are middle of the road on as far as income and insurance goes and others have little, or nothing. Therefore I have a sliding fee scale. This means that those who are wealthy, or have higher incomes, are supposed to pay me more than those with lower incomes or no jobs.

The problem is, when I am in network, I have a contractual obligation to the insurance companies where I cannot charge high income, or wealthy people, more than the insurance company dictates. So I don’t. But this leaves me a problem.

When I can charge my wealthy, or high-income, people a higher rate, they subsidize my $5, $10 and $20 clients. Unfortunately, I often can’t do that because, generally, as you might expect, my high-income people all have insurance and most of them use it. Therefore, instead of my better off clients all subsidizing my less fortunate clients a little, I am left subsidizing my poorer clients a lot.

As it is, I feel that it is important to provide services to those who cannot obtain them elsewhere and there are a lot of people who cannot afford services, even from the government and not-for-profit providers. So I intend to keep providing those services, but I also need to take care of myself and that reality has influenced this decision.

The second reason, I am making this change is because I am finding myself more and more opposed to the way the insurance companies run their businesses. Although most of their staffs are pleasant, decent, people, I think the insurance companies themselves are, huge drains on the health care system, the American people, and the economy. I am not going to say that they are simply ongoing criminal enterprises, but I will say that they do not provide benefits on a par with their costs; economic, psychological, and social.

The third reason for leaving the networks is philosophical, in the sense of how I view the work I do and what that work entails. I work with people with all sorts of problems and “issues”. Many come in with alcohol and drug problems; anxiety, depression, and other emotional and psychological problems that clearly fit in to the medical concept of “pathology”. Others come in with business or work issues, or couples’ problems and we find that underlying these complaints are the same factors mentioned above. Still others come in with similar complaints about business, marital, child rearing, or work related issues and there is no real pathology.

From a billing standpoint, the fact is, I can come up with a valid diagnosis for almost anyone. One can always find a DSM Code (Diagnostic and Statistical Manual, from which one currently bills insurance companies for mental health services) that will both be billable and technically accurate for an individual. As a clinician, there are many times when, in my opinion, I am helping a person grow beyond what a normal, emotionally average person, experiences into a person who is emotionally, or psychologically above average. So, if I’m helping a person grow beyond the norm, should that work be billable to insurance companies?

There are often times, even when I have started out working with a person who was emotionally or psychologically pathological, but we address the pathology over time: they quit drinking; the depression leaves; the job stress is no longer crippling. We find ourselves eventually spending our time helping that person grow well beyond the elimination of pathology. Now, some of the time, our work will still be about things that will help the individual avoid regressing into pathology, in the long run, but where does one draw the line regarding what should really be fairly billed to an insurance company?

I admit it’s ironic that, I, who really dislike how insurance companies run their businesses, find myself inclined to identify some of the work that I do as being of the type that I don’t feel good about billing them for. By leaving the networks, this view will be more in the forefront when clients and I are handling billing. It’s my thought that, this intermittent discussion about the nature of what we are doing in my office will also help clients realize that they are not “screwed up”, that we are, in fact, not working on overcoming pathologies, we are working growing above and beyond what most people ever contemplate achieving.

Finally, and importantly, the last factors that are influencing my decision to leave the networks are their reporting requirements and related issues. Simply put, any information that goes to insurance companies is out there forever. Although there are strict laws regarding protecting the confidentiality of clients information, I am not confident that these safeguards are effective. I am not totally confident that employers, lawyers and etc., cannot turn information that must be submitted for, either initial or ongoing, billing into problematic questions later on, if one were ever to have work related, marital, or legal problems that end up in court or the proceedings that can lead to court.

This last issue is more complex and nuanced than can be addressed on this note to clients and prospective clients but it is one upon which all consumers of health care should educate themselves.

Going Forward

So what does this all imply? Starting the first of the year 2013, I will no longer be in network with most insurance companies. I am notifying them now, of my intentions, as required by our contracts. I have updated my sliding fee scale for the first time in years and that should end up attached to this missive if I haven’t screwed up.

After the first of the year, new clients will pay me at the rate agreed in our first session, based on this sliding fee scale. I will plan to get paid each week via cash, check, or credit card. I will give my clients receipts with the information on them that insurance companies generally require for reimbursement. For ongoing clients, I will give these receipts once a month. It will be up to the client to check on his or her eligibility for insurance payments and any pre-certifications or on going certifications that their insurance company may require.

I will only be requesting my current clients to pay me the amount that they would have had to be paying me, out of pocket, under the current “in network” arrangement. In other words, if, in the past, your insurance company paid me $50 for a session and required you to pay a $20 co-pay and now, that I will have gone, “out of network”, they will pay $40 and expect you to pay $30. I will accept the $40 from them and $20 from you as total payment. If you stop seeing me for an extended period and then return, I will expect you to pay under the new terms. (Extended term means a few months or more)

An implication of this plan is that, in the short term, my current clients will often be paying me less than new clients for the same services. So it goes.

Sliding Fee Scale

When I finish updating my sliding fee scale, I expect my payment range, per session, to be from $5 -$150. The factors that are considered when determining the fee per session are, 1) family income and/or wealth, 2) number of dependents, 3) Insurance availability, and 4) the type of work we are doing. We will discuss the meanings and implications of these factors at the first session. If you are seeing me for business consulting issues, your fee will be at the top end, although we may discuss payment terms.

At our initial session, when we are discussing payment, one situation that comes up is when a person’s income puts them at a certain level on the sliding fee scale and they have insurance. Let’s say they make $30,000 per year, so if they didn’t have insurance they would only have to pay somewhere between $10 and $35 per session (under my old sliding fee rate) depending on their number of dependents. Now, in this instance they have insurance but they don’t want to use it because they don’t want a diagnosis in their file, yet they do have a bonafide problem-say alcoholism. In this case, they will need to pay me at a rate as if they were using their insurance, if that rate is higher than the sliding fee schedule calls for without insurance.

In closing, I expect there to be glitches as I make this transition. One that I expect will be for insurance companies to not notice that I have left their network and therefore insist that you can’t bill them and that I must. I will work with my clients and the insurance companies to resolve any snafus.

I have never, not seen a client because of money issues. I will not start doing so now. I also will, in all likelihood, not get angry or be upset with individuals and/or institutions as we shift things, although I’m betting I’ll be better with individuals than some of the institutions, if the past is ever a predictor of the future.

Feel free to contact me with questions or concerns.



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