ACA Blog

Joan Phillips
Aug 03, 2010

The Ethics of Billing

If you are like me, when I think of ethics I think of confidentiality, multiple relationships, competence, boundaries, impaired practioners, etc. I rarely, until recently that is, thought of the word “billing”. These days I do think of billing as an ethical issue, because I asked my state licensure board what types of complaints they are seeing the most of lately, and the reply was- billing! This refers mostly to allegations that someone bills for services not rendered, or bills inappropriately, or bills for services they did not have the appropriate supervision in place to be providing etc.

It’s kind of a scary thought- if you are like me and money is not my top priority of things to learn about. As a supervisor I do hear many scenarios that make me wonder who-is-billing-for-what-and-how and we do discuss the ethics of time documentation, service delivery and billing in general in supervision. However, my supervisees may at times be at an agency run by a non-licensed administrator who seem to have varying levels of awareness of, or adherence to, the ethical and even administrative restraints on billing. A supervisee is loathe to question the administration on these issues, quite understandably. That is the person that pays them and possibly hired them.

This all brings billing into higher relief, as something we all need to learn about. In private practice additional billing issues are emerging for me as I see clients’ insurance plans not really communicating the terms of the coverage very well. Mostly by omission these misunderstandings take place. For example, many clients do not understand that mental health coverage may be at a very different rate and may have a separate deductible than their overall plan. Some don’t know that the “customary” rate their insurance has set as reimbursable, is also the rate the insurance requires for their co-pay- thus basically negating any benefit at all to having that insurance.

One company I deal with sets the co-pay at $50 and then also informs me that since they have determined $50 to be the acceptable rate- then the company owes me nothing and the client is out the “co-pay”. Another plan requires a co pay of $$35 and the plan pays me $30. Clients are very surprised when they learn that their insurance requires them to pay more than the company itself will. To me these are shady dealings from insurance companies that no doubt convey some “benefit” in selling the insurance they sell. Another private billing issue is that of “balance billing”, i.e. billing the client directly for part of the bill that insurance did not or will not pay. Many contracts I have prohibit balance billing, and luckily I have read the fine print and know that. But I know of many private practitioners who routinely balance bill and don’t know for sure if the insurance contracts they have prohibit that or not.

In fairness to clients we need to know. Now that Medicaid is functioning in some cases more like private insurance, depending on the state and the population served, many more areas of billing practice, documentation, and oversight arise. It’s all enough to make me want to put my head in the sand! But I’m glad I put that call in to my state board to see what sorts of complaints there are. Knowing this is an area of emerging complaints motivates me to learn more about the whole thing. Certainly to be more aware. I hope this blog has raised your awareness too.



Joan Phillips is a counselor, art therapist, and marriage and family therapist. She maintains a private practice and teaches at the University of Oklahoma.

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