Tag Archives: Private Practice Management

Private Practice Management

Preparing for private practice

By Katie Bascuas April 6, 2022

For many counselors, making the leap into private practice can feel like something of a stab in the dark.

As Logan Williamson, a licensed professional counselor (LPC) in New Orleans, points out, most graduate counseling programs don’t teach aspiring clinicians how to run a business. “It’s unfortunate because universities seem to think that the only thing you’ll be doing for the rest of your professional life as a therapist is talking to people and writing notes,” he says. 

So, while many counselors are well-versed in theory and techniques, they often find themselves learning the administrative side of running a private practice as they go. But there are lessons to be learned from clinicians who have already blazed a path and established successful practices. 

That’s how Williamson learned much of what he needed to know to get started with his practice, New Orleans Counseling, nearly 12 years ago. “I just talked to people,” says Williamson, who was unafraid to approach other therapists and even other business owners for advice. “There is time that goes into figuring it out, and I guess that’s an animal unto itself, and you really have to put the work into it.” 

Erin M. Moss, an LPC based in Buffalo, New York, had a somewhat similar experience to Williamson when she started her practice, Erin M. Moss Mental Health Counseling, six years ago. “I had no road map or role model to look to,” says Moss, who struggled to find other African American clinicians in her area whom she could relate to and who had already established private practices. “There were about two other people that I knew of that looked like me,” Moss says. “I didn’t realize that I was filling a void in my community.”

Meanwhile, for Duncan Price, an LPC in Washington, D.C., launching a full-time private practice seemed like the next step in his career after working in community mental health and managing a part-time practice on the side for several years. Yet the shift to full-time private practice still provided Price with some surprises, from working through the administrative side of running a business to confronting issues that challenged his personal and ethical beliefs.

In reflecting on their experiences, Price, Moss and Williamson all have invaluable advice to offer other counselors who are hoping to go out on their own. While all three clinicians faced similar challenges on their road to establishing private practices, they also encountered some unique experiences and opportunities that helped to shape not only their practices but also their identities as mental health professionals. 

As Moss acknowledges, there is no one way to do private practice. And that may represent one of the most important pieces of advice about running a business as a counselor.

Prepare for insurance hurdles

One of the biggest learning curves associated with starting a private practice involves dealing with insurance. Navigating the insurance landscape can be intimidating and may even keep some counselors from maximizing the potential of their private practice.

“The good thing about taking insurance is that it keeps you very busy,” says Price, who admits that he sometimes questions his early decision to accept insurance because of the added work and responsibility that accompanies it. “I don’t think I was quite aware of the level of administrative duties, particularly with electronic filing and all the entities that are involved to get a claim processed. It took a while to get it working smoothly.”

Price adds that he has sometimes grappled with the idea of whether to take insurance at all. “It would be nice to make more money, but I can’t see myself only seeing clients who can afford to pay out of pocket or to wait for an out-of-network reimbursement,” he says. Price’s practice, DC Recovery Counseling, accepts both private insurance and Medicaid so that he can maintain a connection with the clientele he worked with in community mental health. 

Meanwhile, for Williamson, fear of the insurance world kept him from establishing a full-time caseload of private practice clients as soon as he would have liked. “I felt that there was always a sense that I wasn’t going to get paid by the insurance company for the work that I would do,” Williamson says. “So, I didn’t want to put in time to not get paid.”

After his initial hesitation, however, Williamson eventually began accepting insurance and says his practice grew substantially. “I would say that after I started taking insurance — and I only take two [providers] — it took me six months, maybe, to get a caseload where I was at 20 patients a week.”  

Williamson advises those who are interested in taking insurance to start the credentialing or paneling process early, especially if they are jumping into private practice full time as opposed to building it up on the side. The entire process can take several months — possibly longer with errors or oversights in the application process — and it can turn into a frustrating waiting game with financial consequences. 

“Insurance companies will put you through a process and after three months, they’ll kick something back to you, and they’ll say, ‘You didn’t initial on page 12 at the top,’” Williamson relates. “Now you’re kicked back another month at least or two. That’s really deflating when you’re trying to build up a business.”

Dealing with administrative headaches, which can often be insurance related, was also a bit of a shock for Moss. “There are kinks in every organization — you hear that everywhere you go,” she says. “What you don’t realize is that when all of that is under you, there are a lot of fires that you have to deal with.” 

For example, despite outsourcing her billing, Moss still encounters issues where an insurance company disputes or retracts a payment. When that happens, the onus of fixing the issue falls on her, whether that’s rectifying the problem herself or spending the money to have someone else fix it. “When you’re working for someone else, you don’t have to worry about those things,” says Moss, who acknowledges that managing the operational side of her practice has been one of her biggest challenges.

Tap prior experience

Moss, Price and Williamson all note that the realities of the administrative side of running a private practice can come as a shock. At the same time, all three point to the value of previous work experience in helping them navigate the process of establishing a practice.

Williamson, for one, acknowledges that his path to full-time private practice was a windy one, with several pit stops along the way. After leaving a thriving group practice in Colorado to move to New Orleans to be closer to family, Williamson worked several jobs in the mental health field before returning to private practice full time. He credits those jobs, which included a stint at a university counseling center, time running an applied behavior analysis clinic at a local school, and a position at a major insurance company doing inpatient psychiatric reviews, with providing him good insight into business management. 

“It was on-the-job training that I was able to take with me,” says Williamson. For example, the firsthand experience of managing billing and credentialing for an organization gave him greater confidence and understanding that he could do it later on for himself in private practice. “I think that was helpful to understand — knowing that if I needed to, I could do it, that it’s not impossible.”

Moss similarly credits jobs earlier in her career with giving her a strong foundation in not only business skills but clinical skills. “I worked everywhere, and my case management background has always been strong,” she says. “There was a client sitting with me yesterday, and she said she wanted to open a business, and right away, I gave her the contact for the Canisius Women’s Business Center. It was those early years of going into homes and linking people with services — I can still go back to that stuff.” 

Price advises counselors interested in starting a private practice to not underestimate the importance of developing strong clinical skills. “I think it takes more experience than people think it does,” Price says of clinical readiness. “I’m not saying you have to be a master, but I think it helps doing it on a part-time basis with supervision while also getting really solid training in different modalities.”

Price recommends that clinicians, especially those just starting out, seek additional training at local schools or workshops to continue expanding their skill sets and keep pace with evolving techniques. “I would strongly suggest if someone is thinking of starting a private practice, to make sure that they’re ready clinically and that they’re also investing in continued education,” he says.

Create a support network

Seeking out continuing education can also be an avenue for counselors to expand their professional networks, which can in turn be a valuable resource for private practitioners who are working solo. 

“It’s tempting to think of it as it’s only on you, but if you don’t have a professional network of people that you trust to help you make decisions, then invariably you’re not going to make the right one and put yourself at risk,” Williamson says. 

He gives the example of working with a client who was going through a divorce and having his clinical notes requested by the client’s attorney. Not wanting to be involved in a legal matter, Williamson called a clinical colleague who specializes in client issues related to divorce and asked for advice. “He helped me write my note for that session so that I could send it to the lawyer and not be called into court,” Williamson says. He also provided the client with several therapy referrals that he received from another professional contact who had a wider network in the New Orleans area. “So, I was able to take care of the patient, protect my license and also protect my time because I didn’t have to go through all of that,” Williamson says.

A solid professional network is not only a good place to turn to for advice and consultation. It can also provide socialization and collegiality, which can be lacking in private practice.

“There’s no one next door to say, ‘Hey, girl, what are you eating for lunch?’” says Moss of the lack of office camaraderie that can come with running one’s own business. She adds that she recognized the solitary nature of private practice early on. Over the years, she has actively created opportunities to build in socialization, whether that takes the form of doing administrative work occasionally at a coffee shop where she can be around other people or serving on boards and joining associations and groups where she can volunteer. 

“I’m always at the table learning from like minds in the mental health community and groups that represent some of things that speak to me and my clients,” says Moss, who currently serves on the boards of two mental health organizations in her area. “Even though I’m my own boss, I have always had my foot in the community.”

Williamson also recommends the idea of board membership and suggests that it can be a good way to give back to the community, especially if a counselor’s private practice is less community oriented. “It’s super rewarding, and it’s a low barrier for entry,” says Williamson, who served for six years on the board of a local public service provider. “The commitment is only what you want to put into it.”

Establish boundaries

Given the time commitment that comes with running a business and managing one’s professional network, and then balancing all of that with one’s personal life, setting and sticking to boundaries is another invaluable strategy to implement early on when starting a practice.  

“I used to take clients as they came,” Price says. “And just emotionally, physically, mentally, you can only work with so many clients, especially if some have difficult cases. Trying to find that balance has been hard for me.” 

It can be challenging to turn clients away, especially given the current climate of high need, but prioritizing boundaries and work-life balance is key to avoiding burnout, Moss says. “We’re processing trauma, so it’s so important to have space to not do that,” she emphasizes. “It’s important to have space and time that is just yours, whether you’re connecting with your family or friends or just yourself.”

Moss credits her early years of working for organizations and agencies with helping her realize the value of establishing a healthier work-life balance. “One of my first clinical jobs right out of grad school, they gave me a laptop and a BlackBerry, and I was so excited — like, ‘Who has a BlackBerry?’ Little did I know that was the beginning of my phone never stopping ringing,” says Moss, who now implements a hard stop for herself at 6 p.m. every day. “There’s never enough time, and there’s always something to do, so you literally have to say, ‘I’m done working.’”

Structure for the long term

Although managing a private practice — like any job — may come with certain headaches, it can also afford counselors the opportunity to create and build their dream business. 

“Essentially, private practice is what you make of it,” says Moss, who knew early on that she wanted to create a “super practice” while also developing a professional identity as a mental health advocate. “This is really your show.” 

As part of a small community of African American counselors in Buffalo, for example, Moss realized while building her practice that her scope of practice might not resemble that of other counselors, especially white counselors.

“For me, building a practice and gaining clients, it wasn’t as simple as opening the doors,” she says. “Black people needed to know that it was OK to come to therapy. I had to do a lot of work breaking stigma and free speaking to let people know that this is normal and this is a good thing.” Through that early groundwork, Moss realized a desire to become an advocate and public speaker on mental health issues. That goal has become part of her larger business strategy for her practice and her work as a mental health professional, which she hopes to continue to expand. “I’d love to do more outreach to the Black community,” Moss says. “It’s so needed.”

While having a personal brand or specialty can set private practitioners apart in the market, so can good customer service skills and transparency, says Williamson, who employs a strategy of fostering long-term relationships with his clients from the outset of their work together. 

“I set up the expectation that this is more like a primary care visit for their mental health and they’re developing a relationship with me that can last a lifetime,” he says. “So, we work on the problem at hand and get that taken care of, and they feel good and are discharged, but they always have the ability to come back and talk to someone who knows them and cares about their experience.”

Establishing strong relationships with clients is not only good for business but can also help remind clinicians of their reasons for entering the field or starting a practice, which often lead back to being of service and helping. That sense of purpose can be a source of motivation and encouragement when weathering the more challenging times of business ownership, Moss says. She advises other clinicians wanting to step out on their own to avoid too much overthinking and lean into the process. “Relax and rely on why you got into this in the first place,” she says.

Branislav Nenin/Shutterstock.com

****

Katie Bascuas is a licensed graduate professional counselor and a writer in Washington, D.C. She has written for news outlets, universities and associations.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

What the No Surprises Act means for counselors

By Lindsey Phillips January 28, 2022

The American Counseling Association’s January town hall focused on the No Surprises Act, which aims to increase transparency in medical costs and protect clients from “surprise” medical bills caused by out-of-network care. Catherine Brandon, a partner at ACA’s lobbying firm Arnold & Porter, discussed three main requirements of this act, which went into effect on January 1:

  • Prohibiting balance billing or surprise billing (i.e., when a health care provider bills a patient for the difference between the amount the provider charges and the amount the insurance pays) for out-of-network providers in an in-network facility
  • Requiring a good faith estimate (GFE) of expected costs before scheduled services for uninsured and self-pay clients
  • Ensuring continuity of care and accuracy of provider directories

Balanced billing

Sometimes people carefully select an in-network hospital and medical provider only to discover their medical bill is much higher than they expected because they unknowingly received medical care from an out-of-network provider during their stay. This balanced billing requirement aims to prevent that potential sticker shock by prohibiting providers who are out-of-network with a client’s insurance from charging more than their in-network costs when clients receive care at the in-network facility.

Billion Photos/Shutterstock.com

This aspect of the act will probably not apply to most private practitioners, Brandon noted during the town hall held on January 19, only those providing services outside their private practice at in-network facilities. So, if a counselor works at a hospital or performs telebehavioral services while a client is staying in a hospital, for example, then they could only charge the client at the in-network rate, not the out-of-network rate.

Although the act does not dictate the out-of-network payment amount between the insurer and provider, it did establish an informal dispute resolution process to oversee any potential disputes on payment.

GFE

One of the key provisions affecting counselors is the requirement to provide a GFE to uninsured and self-pay clients before services are rendered. It is the responsibility of the provider to ask clients if they will file a claim with their insurance to know if this rule applies to them, Brandon said.

The GFE should include a clear description of provided services, including diagnostic and expected services codes, and the expected charges associated with each service. Assigning a diagnosis code before seeing a client could pose a problem and ethical issue, but ACA suggests using a general diagnosis code such as “no diagnosis” before the first session, and then counselors can issue a revised GFE after the intake assessment.

The Centers for Medicare & Medicaid Services has a Good Faith Estimate template form that counselors can use to ensure they include all the appropriate information.

The time frame requirements for issuing the GFE are as follows:

  • No later than one business day after the date of a scheduled appointment that is three to nine business days away.
  • No later than three business days after the date of a scheduled appointment that is 10 or more business days away.
  • No later than three business days after the date of requested services without a scheduled appointment. (Another GFE must be provided within these time frames if the client decides to schedule an appointment.)

Counselors can provide clients with a single GFE for recurring services (such as ongoing counseling visits), which is good for one year. But if the information, including costs, services needed or billing codes, changes at any point, then providers must issue a new GFE no later than one business day before the next scheduled appointment.

The GFE is just an estimate; it is not legally binding and may change at any point. However, if the actual charge is more than $400 above the estimate, the client has the right to dispute the charge through the new patient-provider dispute resolution process.

In addition to orally telling clients about the availability of the GFE, counselors should include a notice on their website, in their office and on-site where scheduling or questions about costs occur. And counselors should retain a copy of the GFE with the client’s record for six years.

Continuity of care and provider directories

If a counselor’s contractual relationship with a client’s insurance ends (i.e., they are no longer in network with the insurer), they must continue to accept the in-network rate for 90 days after the health plan or issuer notifies the client of the change in network status. This provision only applies to continuing care clients, Brandon noted, which include those undergoing treatment for a “serious and complex condition” — one that is “life-threatening, degenerative, potentially disabling or congenital” and requires “specialized medical care over a prolonged period of time” or that is “serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.”

This law also stipulates that health care providers who have a contractual relationship with an insurer must submit up-to-date provider directory information to the insurer. And providers must reimburse insured clients who inadvertently relied on an incorrect provider directory and received out-of-network care or paid more than the in-network sharing amount. Counselors could protect themselves and shift the liability to the insurer, Brandon said, by stating it’s the insurer’s responsibility to maintain an updated directory in their contract with the insurer.

The U.S. Department of Health and Human Services has not yet issued regulations that would further explain and define these requirements. This means there is currently not much guidance on these regulations.

 

*****

 

Watch the full video of the town hall on the No Surprises Act at ACA’s YouTube page: https://www.youtube.com/watch?v=gy3H3col07U

 

Learn more about the No Surprises Act and these specific provisions from the following resources:

 

****

Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Finding balance in counseling private practice

By Bethany Bray March 25, 2021

Managing a counseling practice takes strength of both heart and mind. To succeed, private practitioners must find balance between two roles: that of the caring, empathic and client-focused clinician and that of the shrewd business owner, which necessarily involves charging fees and making money.

Most people who enter the counseling profession do so first and foremost because they feel called to help others. At the same time, many counselors harbor dreams of one day owning their own practice, and that involves handling tasks that sometimes go against the grain of their helping instincts. Charging fees to clients who skip appointments or following up about nonpayment or a declined credit card can feel unnatural to counselor clinicians, especially after they’ve spent multiple sessions listening to the person talk about the painful life challenges they are facing.

“This is a tough area to navigate for many therapists, myself included,” says Dawn Altman, a licensed professional counselor (LPC) with a practice in Bryn Mawr, Pennsylvania. “It has been my experience that the most difficult area to navigate is my own money mindset and feelings of worthiness. … Most therapists come to this field with a sheer desire to help people work through emotional difficulties and live a more enlivened life. It feels somehow ‘sticky’ to ask for money for supporting someone who is struggling. The lines become blurred between what comes naturally to most of us — helping others — and requiring payment for our services.”

Money, money, money

One major aspect of maintaining balance between the heart and mind aspects of private practice involves setting — and enforcing — rates and fees.

When she first started her practice, Altman set her fees low because she doubted her own value. “Looking back, what came up for me was what is known as impostor syndrome — that internal experience of believing that you are not as competent as others perceive you to be. This is true of so many women in particular,” Altman says. “I had to get really deep with myself and ask myself, ‘Do you fear success as a business owner more than you want it?’ The answer was, of course, no, so I had to just rip the Band-Aid off and feel the fear and bill [clients] anyway.”

Now, after years in practice, Altman has found that her caseload feels balanced when she reserves three slots in her schedule for clients who pay on a sliding scale. If a potential client requests to pay on a sliding scale and those three slots are already filled, Altman has a list of practitioners to whom she can refer the client so they are not left without options. “I find that this system works for me because I can still provide a service to those who may not be able to afford my normal fee, but I don’t get resentful that I am working for pennies,” says Altman, a member of the American Counseling Association.

Norm Dasenbrook, a licensed clinical professional counselor (LCPC) with a practice in Rockford, Illinois, believes that counselors’ ethical mandate to keep up with self-care includes financial self-care. It’s not greedy to charge what you’re worth; it’s necessary, he says.

“If I’m thinking about how I’m going to pay the rent for my office when I’ve got a client in front of me, that’s not the best care,” says Dasenbrook, who also runs a consulting company that offers trainings and workshops on managing a therapy practice. “Charging what you’re worth is the best care for clients because you’re not thinking about that stuff when a client is in front of you. We [counselors] work hard and should get paid for that.”

Dasenbrook advises that private practitioners who are starting out should ask local colleagues about their rates to find the “community standard.” From there, they should decide on comparable rates and fees and stick to them. Private practitioners should also keep in mind that most clients are not going to shop around and choose a therapist based only on their hourly rate, he says. Rather, that decision revolves around many factors, from a practitioner’s area of expertise to their reputation.

From Dasenbrook’s perspective, the business and empathic sides of private practice are not mutually exclusive. Practitioners can find ways to accommodate clients with empathy while still getting paid, he says. For instance, with clients who are having financial difficulties, Dasenbrook will work out a payment plan allowing them to pay in small installments, or he will offer them half-hour sessions for a lesser fee. In other cases, he will refer clients to local charities or agencies that offer free or reduced-price therapy. These measures all ensure that clients are treated with care and continue to get the help they need, which is empathic, Dasenbrook says.

“To me, [the caring and business sides of counseling] go together. You’re providing a service and collecting a fee. There’s nothing mutually exclusive in there. You can do both with empathy,” says Dasenbrook, who has provided private practice consultations at the ACA Conference & Expo in years past.

Counselors in private practice who struggle with the idea of charging fees should look at how other service professions approach it, Dasenbrook says. He points out that plumbers and car mechanics don’t feel guilty about charging what a service is worth, and he stresses that counselors shouldn’t either.

“Don’t lowball your fees,” he urges counselors in private practice. “Think of other professions. A cardiologist that’s just out of school charges the same as one who has been working in the field for 10 years.”

Bethany Lato, an ACA member with two office locations in the Milwaukee area, also finds that the empathic and business sides of practice management can be interwoven through intentionality and commitment to purpose.

“One way I [incorporate empathy] is by maintaining a clear vision, purpose and foundation for what my business is and who it is for,” Lato says. “When focusing on tasks such as finances, sales and marketing, web presence and long-term business planning, I tend to wear more of the entrepreneurial hat. I think about it from the business perspective: What makes the most financial and business sense in order to achieve that mission?

“From there, I circle back around to empathy: How is this serving my clients and the people that I hope to reach? Am I making sure that I am taking care of my needs while also providing care to others? By beginning my work and concluding my work from a place of empathy, I aim to find that balance and never get too caught up in the business side or in simply making money. Sometimes this comes naturally, and other times it takes a conscious effort to maintain focus on the true mission and what feels truly aligned for myself and the clients I work with.”

Caseload questions

Determining caseload size and finding the “right” number of clients to see per day in private practice is an individualized decision. Counselors must charge high enough rates and take on enough clients to make money and stay solvent, yet still keep their caseloads and daily schedules from becoming so packed that they can’t give clients (or themselves) the time and attention they need.

It’s a balance that varies for each private practitioner and one that must often be determined through experience. Kristy Crump, an LCPC in Bel Air, Maryland, continued to work three days per week in an agency setting as she began her private practice in 2014. Within a year, she was fully booked and able to leave the agency, transitioning into private practice full time.

Finding the right balance was a matter of trial and error, she says. “You have to evaluate how you feel at the end of the day, at the end of the week. I was seeing 10 or 12 clients in a day and would be exhausted and struggling to keep up. It just took time to learn what’s right,” Crump says. “Now, my balance is six [clients per day]. I have some colleagues who say, ‘Four is plenty for me,’ and others who say they can do 10. You have to figure out [a schedule] where you still feel like yourself at the end of the day.”

Dasenbrook recommends that private practitioners start with an end goal in mind when determining their optimum caseload. Do they want to maintain a second source of income, such as teaching or consulting, while operating a private practice? How many vacation days do they want to take each year? Do they want to ease into semiretirement in a few years? Once private practitioners determine their long-term goals, they can work back from there to figure out how many clients they will need to see to meet (or to leave time for) those goals, Dasenbrook says.

Developing a reliable list of referral sources is also an important part of managing caseloads as a private practitioner, Altman notes. Over the years, she has discovered that she operates best when seeing fewer than 20 clients per week. This helps her maintain balance with other facets of her life, including time spent with family and her identity as a “lifelong student.”

“I quickly found out that seeing over 20 [clients] per week does not work for me. I feel pulled in too many directions, and my family life suffers, as does my own physical and emotional well-being,” Altman says. “I am very intentional about the type of client that I want to see, and while it is hard to turn people away, I now have a waiting list for those who want to wait specifically for me, and I have a list of five or six trusted therapists in the community to whom I refer when I cannot accommodate the client. … This alone has made a huge difference to me in my work-life balance because I enjoy each of my clients, and I am not burned out at the end of each week.”

Out of whack

Bryan G. Stare, an LPC and counselor educator who has experience working in private practice, is a critic of what they call the capitalist U.S. health care industry. Many of the decisions counselors who own private practices must wrestle with — whether to see fewer clients, whether to waive fees, whether to do pro bono work — have an effect on the bottom line of their business. This is an issue that often contradicts the counseling profession’s commitment to pursue social justice, Stare says.

“You’re put in a difficult position in private practice. You’ve paid a lot of money for this education, whether it’s a master’s or a Ph.D. To live comfortably, there’s often pressure to charge more for your services. But many of us have entered this profession because of a call to help or for social justice. … It does create some strife there,” says Stare, an assistant professor and director of the clinical mental health counseling program at the University of North Carolina at Charlotte. “We need to take care of ourselves and our business to take the best care of our clients. If I’m not doing that, I’m not able to create a safe space to care for my clients. If I’m spread too thin, I won’t be able to provide ethical and competent care to clients. [But] the system isn’t designed for that; it’s a profit-driven system designed to garner corporate wealth and leave people suffering.”

Navigating this balance requires that private practitioners keep consistent tabs on how they’re feeling about their workload. Only counselors themselves can recognize when their balance is out of whack and they’re spending too much time either on business tasks or client care.

For Crump, it comes down to how she feels at the end of the workday. If she’s irritable or exhausted, it means she needs to reassess her workload. “If I’m not at 100%, I’m not helping [clients] much,” she says.

Crump acknowledges this balance got thrown off when the COVID-19 pandemic caused her to shift all of her client sessions to a virtual platform. Crump specializes in anxiety disorders, and she says some of her clients became needier amid the stressors of the pandemic. In conducting sessions and other aspects of her practice from home, the boundary line between when she was working and when she was “off” began to blur. Crump says she had to check herself and take a step back to regain her balance.

“Of course I want to take crisis calls, but I would soon find myself three sessions over my limit [for the day]. It’s a struggle because you do have that control. You can say yes. I don’t have a front desk that will say, ‘Sorry, she’s booked for today,’” Crump notes.

Stare, an ACA member who counsels a small caseload of clients in addition to teaching and research work, agrees that emotions are a barometer. Private practitioners should recognize signs of burnout and regularly process their own feelings. Stare’s support circle consists of trusted friends, colleagues and mentors with whom Stare can consult.

Multiple private practitioners interviewed for this article say their bodies give them clues — such as feeling tired, worn out or achy — that indicate their professional balance is out of alignment.

“We teach our clients to do this, and we have to listen to our own body and our own needs too, and nurture ourselves as we tell our clients to do,” Crump says. “We have to take steps back and reflect. It gets very stressful. Some days are really hard. I’m a full advocate that every therapist should have a therapist — they can help keep you in check too.”

Lato notes that somatic cues tell her not only when her workload is imbalanced but also when things are going well. When her work is in balance, “I find myself genuinely excited about my business and my practice, rejuvenated by my sessions with clients, and with vivid dreams and visions of what the business can be in the future,” Lato says. “It is that vision that often gets me through the difficult, out-of-balance times as well. I spend a lot of time journaling, meditating and vision boarding around the future of the business and my practice, and find it is always important to know where you are heading. With this clear vision and direction, it becomes easier to recognize when things are out of balance.”

Put it in writing

The counselors interviewed for this article agreed that one of the best ways private practitioners can minimize the need to have difficult conversations with clients about payment is to offer clear, thorough communication about fees and expectations before any counseling takes place.

Crump provides a full explanation of her policies in the informed consent that clients sign at intake, but she also talks the policies through with each new client before they begin counseling work. “It took me a while to get a flow to be able to speak about that to clients,” admits Crump, an ACA member. “It’s hard to say, ‘Hi, hello, I have a cancellation policy.’ … [But] if you are genuine, you’ll get that in return. When I let [clients] know my boundaries and no-show fees, I’m being honest. I explain that it’s ‘housekeeping.’ It’s important to talk about it, get it out of the way and separate sessions into counseling and noncounseling work.”

Enforcing professional boundaries, such as imposing cancellation fees on a client who repeatedly no-shows, also models healthy behavior for clients, Crump adds. “I’m teaching boundaries to all of my clients, so I want to make sure I have boundaries myself,” she says. “I make sure to set boundaries with clients from day one. I’m direct, and if I answer a crisis call in the evening, I talk about how this won’t become a regular thing.”

Yet Crump acknowledges that she still finds it hard to charge fees, even after years in private practice. It presses on her empathic reflex, she says, because she doesn’t want to discourage people from seeking counseling.

“I hate having the conversation to this day,” she says. “It’s hard because we’re in a helping role. We’re here to help, and it doesn’t feel congruent with what we’re taught. You’re imposing a boundary on them, but unfortunately, that’s part of the business. There’s no one to enforce that but me. It’s easier [when] you talk about it upfront, instead of waiting until it happens and then springing a fee on them. It’s a necessary evil that you have to do. At the end of the day, you’re running a business, and you have to pay bills yourself.”

Crump and the other private practitioners interviewed for this article say that before enforcing a cancellation fee, they usually extend a one-time grace period for clients who miss an appointment. They also make exceptions for late or lesser payments from existing clients facing hardships such as an unexpected job loss. However, they agree that charging fees to clients who are chronically late with payments or repeatedly miss appointments is a necessity.

“I will usually say to the client, in writing, ‘Twenty-four hours’ [cancellation] notice affords me the opportunity to offer your appointment time to a client who may be on a waiting list or who needs an urgent appointment. I hope you understand that I must charge you for missed appointments,’” Altman says. “Being upfront about fees and payment options is crucial in setting up a good relationship with the client and [establishes] the clear boundary that therapy is a valuable service for which payment is expected.”

Enforcing fees not only helps to ensure that a private practitioner’s finances stay in the black. It also sends a message that counseling requires commitment and intentionality from both parties — counselor and client.

“At the end of the day, if I don’t set a boundary, I may not be acting therapeutically,” Stare observes. “If we’re not meeting regularly or semiregularly, depending on [a client’s] presenting concern, we’re not going to make therapeutic gains. Ethically, I can’t provide services that aren’t going to help.”

Dasenbrook urges private practitioners to spend time crafting thorough informed consent documents. Including details such as the hourly fee for services provided outside of counseling sessions (e.g., letter writing, filing court documents) ensures that clients are fully informed prior to being charged, he says.

Language centered on client consent, privacy laws and other practice issues varies from state to state, so private practitioners should seek training and consult with local colleagues and their state counseling associations when creating informed consent documents. “These are the people who are going to know the funky laws” in your state, Dasenbrook asserts.

The language in informed consent documents needs to be thorough and firm yet welcoming and calming, Dasenbrook adds. Clients filling out these forms are seeking therapy, so they may not be in their best mental state, he points out. They shouldn’t be made to feel as if they’re doing something akin to signing the seemingly endless number of pages involved in buying a home. Breaking informed consent into sections — treatment of minors, telebehavioral health, fee schedules, privacy laws/release of client information, etc. — makes things easier for clients to digest and allows counselors to remove sections that do not apply to particular clients. Per the 2014 ACA Code of Ethics, practitioners must include information about alternative/continuing service options should the counselor experience an emergency or pass away.

Ultimately, the time spent creating thorough informed consent documents should mean fewer confrontations with clients regarding fees and other policies down the line. “The business piece [of private practice] should be all taken care of in your informed consent,” Dasenbrook says. “It should be communicated upfront, before we even say, ‘What brings you here today?’

“Put it in writing, and get it all out ahead of time. … You want to take the money piece out of it [counseling] as best you can, and that’s why [I do it] all upfront.”

Getting down to business

The professionals interviewed for this article shared the following tips and insights on blending counselors’ caring instincts with the business side of running a private practice.

>> Maintain separate spaces: Stare uses an existential humanistic approach that recognizes the importance of feelings of place. With that in mind, Stare recommends asking for and accepting client payments in a space that is separate from the counseling room. If possible, keep a credit card machine or other payment mechanisms in another room and walk there with the client to take payment. Not sitting in the same chair and in the same room where therapy takes place to accept payment helps separate the two concepts for counselor and client alike, Stare says.

>> Pay first, talk second: Crump recommends taking payment from clients at the start of a session, before any counseling takes place. Crump didn’t always follow this process but eventually adopted the approach to avoid the awkwardness of having to transition from discussion of heavy, therapeutic topics to request for payment.

Keeping a client’s credit card number on file for automatic charging can also be beneficial if practitioners find it a good fit. Dasenbrook notes that private practitioners now have many convenient payment options, including apps such as Venmo and PayPal, compared with when he started in the profession three decades ago.

>> Stay on top of housekeeping: Tackling those unappealing tasks right away can be a benefit to private practitioners and their clients. For instance, Dasenbrook says, if a client’s credit card is declined, call them right away; don’t put it off or even wait until they come in for their next session. Addressing it immediately gets the issue resolved and is more likely to result in payment.

Similarly, Crump stresses the importance of filing insurance claims and paperwork as soon as possible after client treatment. This is especially important with new clients, to find out whether the private practitioner’s services are covered or whether the client has a deductible to meet. The sooner a practice owner knows there is a gap in a client’s insurance coverage, the sooner payment arrangements can be made, especially while the session is still fresh in the client’s memory. “Even though those case notes take longer, it’s worth it [to file right away],” Crump says.

Altman notes that a tough-love approach is sometimes necessary when tackling tasks that might go against a counselor’s empathic nature. “I used to offer monthly bills, which the client could then submit for reimbursement. However,” she says, “I found that several clients would simply ‘forget’ to pay. Their bills were racking up, and I was feeling resentful over both not being paid and the time it was taking me to have to rebill every few weeks.

“One client in particular would not pay me in a timely manner, and his bill would go unpaid for several weeks. I sent multiple reminders via email that he did not respond to. When the bill was a month overdue, I emailed him the bill one final time and told him that I was unable to provide the Zoom link for our next session until he had cleared up his account. He paid the bill immediately, and at our next session, I began with [talking about] the issue of payment. We agreed that moving forward, he would simply pay weekly, which he has done since that time.”

>> Play by the rules: Crump recommends that practice owners determine their “hard and fast” rules and endeavor to stick by them. For Crump, this includes taking Friday and Sunday off each week. She blocks those days off on her client schedule. In addition, although she doesn’t mind working in the evenings on occasion, she will build time into her schedule on a subsequent morning or afternoon to catch up on administrative tasks.

Another rule Crump has established for herself is never to send a client to collections for nonpayment. “I don’t see the need to cause unnecessary harm to those [clients]. If they could pay, they probably would have. It just doesn’t feel right,” Crump says. “Also, it [collections] is just one more thing to learn how to do and keep up with.”

>> Don’t do it all: One good way private practitioners can keep from becoming overwhelmed is to wield technology to their advantage, Dasenbrook says. This includes building a practice website with client intake and screening forms that ask for a person’s home address, insurance details, emergency contacts and other basic information. This negates counselors having to spend time asking for and transcribing this information in person or over the phone.

Dasenbrook also recommends that practice owners consider using software or hiring a professional to handle administrative tasks that they dislike or struggle doing themselves. That’s what Dasenbrook does with billing. “If there are tasks that you don’t like, then hire it [out],” he says. “You can try and do it yourself at first to learn and save money, but ultimately it makes sense to hire out if it causes a headache and takes too much time. Once your practice grows, start farming some of that stuff out.”

>> Seek and value supervision: “The No. 1 tip I would offer is to spend the money for high-quality supervision,” Altman says. “I had an incredibly gifted supervisor whom I worked with when I began, and it made a huge difference in the amount of time that I had to spend ‘winging it.’ Most of our supervision hours were spent on case discussion, but sometimes we talked [about] the business of private practice. It was enormously helpful to me as a business owner. Peer supervision is another great way to connect with others to share tips and insights and to just have a sounding board for cases or for life as a therapist in private practice.”

****

Necessary skills

Private practice management demands a wide variety of skills, from overseeing scheduling and billing to determining one’s caseload size and handling client referrals. A successful private practitioner must also hone a number of skills beyond the nuts-and-bolts tasks of managing a practice, says Norm Dasenbrook, a licensed clinical professional counselor with a practice in Rockford, Illinois.

Dasenbrook considers the following qualities “musts” for private practitioners:

  • Clinical competency and excellence
  • Healthy self-esteem, self-awareness and the ability to set boundaries: This involves knowing what you’re good at and what you’re not, Dasenbrook advises.
  • The ability to know when you’re over your head professionally: This involves realizing when a client’s needs go beyond your skills and that you should seek consultation. Dasenbrook has been a counselor for three decades and still runs into issues for which he seeks consultation from peers. “It happens to everybody — when you’re sitting in session and you have no idea [how to help a client]. We’ve all been there. I’ve been there many times,” he says.
  • A business mindset and inclination for bookkeeping, scheduling, keeping medical records and other administrative tasks
  • Being comfortable with taking risks: “Sometimes we fail, but we keep on going,” Dasenbrook says. “You need to see yourself as an entrepreneur. Some things won’t work out, but you learn from it and move on.”

What skills would you add to this list? Post your thoughts in the comment section of this article, below.

 

****

Action steps to learn more

****

Pro bono: Yea or nay?

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

What role does pro bono work play for private practitioners who are trying to balance their empathy with the financial side of running a business?

Explore this topic further in an online companion piece to this cover story, “Pro bono counseling: How to make it work.”

 

*****

Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Pro bono counseling: How to make it work

By Bethany Bray March 24, 2021

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

This is an important tenet of the counseling profession, and one that pulls at counselors’ empathy and call to social justice. However, counseling clients for a reduced fee or for free – pro bono – in a private practice setting comes with some caveats.

John Duggan, senior manager of continuing and professional education at the American Counseling Association, stresses that private practitioners who have any kind of third-party contract, such as agreements to accept clients from an employee assistance program, Medicaid or elsewhere, must take positive steps to avoid risk if they charge anything other than the same rate for service for 100% of their caseload. This is due to several reasons:

  • Charging different rates for services reimbursed by federally funded programs opens the practitioner to risks of fraud accusations or investigations by the U.S. Centers for Medicare & Medicaid Services (CMS). In general, Medicaid and other third-party insurance plans prohibit practitioners from waiving copays.
  • Insurance companies may be unwilling to honor a fee schedule if a practitioner charges different fees for the same contracted service to different clients.
  • Offering remuneration to clients is unethical and potentially illegal (see Standard A.10.b. of the 2014 ACA Code of Ethics). While there are exceptions, waiving copays/fees and underbilling are potential HIPAA violations.

Lastly – and perhaps most importantly – Standard C.5. of the ethics code prohibits discrimination in professional counseling. Offering different fees to different clients could potentially make a counselor’s health care business vulnerable to accusations of discrimination or lawsuits, Duggan says.

The only private practice scenario that would be exempt from the above points is if a counselor does not have any existing third-party contracts and treats 100% self-pay clients, without insurance, he notes.

“It is ethically essential to prioritize our work that’s pro bono,” says Duggan, a licensed professional counselor and licensed clinical professional counselor. “However, the bottom line is that professional counselors who manage a health care business should also operate as ethical businesspeople. Always consider ethical, legal and compliance issues before reducing fees, copays/fees or underbilling.”

Duggan points out that there are many ways a counselor can do pro bono work that do not involve counseling clients on their practice caseload. Volunteer or reduced-fee work in the community – anything from public speaking or leading workshops to mental health response during disaster situations – can be a rewarding way for counselors to give back.

There are also organizations and agencies that facilitate the counseling of clients outside of a clinicians’ existing caseload. Duggan points to the Pro Bono Counseling Project (probonocounseling.org) as an example. The Maryland-based nonprofit pairs clients with limited incomes who are uninsured or underinsured with volunteer practitioners for free mental health care.

When it comes to navigating the nuances of pro bono work, Duggan suggests counselors refer to ACA’s numerous resources, most notably the 2014 ACA Code of Ethics (including standards C.1. and I.1.b.) and The Counselor and the Law: A Guide to Legal and Ethical Practice by Anne Marie “Nancy” Wheeler and Burt Bertram, particularly Chapter 3 (available at counseling.org/store). Practitioners may also want to consult an attorney for guidance.

****

2014 ACA Code of Ethics, Standard C.6.e.

“Counselors make a reasonable effort to provide services to the public for which there is little or no financial return (e.g., speaking to groups, sharing professional information, offering reduced fees).”

  • See the full ACA Code of Ethics at counseling.org/ethics
  • ACA members who have further questions can schedule a practice or ethics consultation with ACA’s counseling specialists by emailing ethics@counseling.org. 

****

Pro bono: Opportunities

  • Remain cognizant of the potential for exploitation of clients, attend to their vulnerabilities, and consider their best interests in all professional decisions.
  • Look for opportunities to serve your local community by providing some pro bono services that capitalize on your unique interests and skills (e.g., speaking, teaching, mentoring, leading support groups, volunteering at a local nonprofit clinic).
  • Remember: Pro bono services are subject to the same rigorous ethical standards as all other counseling services. Practitioners offering clinical mental health services must also remain compliant with state and federal laws.

Source: John Duggan, senior manager of continuing and professional education at the American Counseling Association

  

****

Read more

Counselors who enter private practice often find themselves confronting the push and pull between their desire to provide empathic, client-focused care and the need to turn a profit. Counseling Today will take an in-depth look at this topic in the magazine’s April cover article, “Finding balance in counseling private practice.”

 

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Voice of Experience: Managing requests for client information

By Gregory K. Moffatt February 23, 2021

In nearly four decades of practice, I’ve experienced a number of attempts by various individuals to gain access to my client records. Here are a few of them.

  • Two police officers showed up in my office asking for records regarding a former client. They told me that the person was of interest in a very serious crime and they were trying to close that case. Would I please give them my records for that client? When I told the officers that I would be happy to comply with any order from the court, they pressured me. “Really! You are going to make us get a subpoena?” Yep.
  • An attorney sent me a very official looking letter that I believe was deliberately drafted to look like a court order. It was full of legal jargon and demands for information regarding a former client. I could have simply thrown it in the trash, but instead I called the attorney’s office. I knew the attorney would be waiting on my call. Sure enough, when I told the receptionist who I was, she immediately patched me through to his office. He answered on the first ring.

“I’m calling regarding your ‘request’ for information from me,” I said. Not waiting for him to make a comment, I continued, “I’m sure you know I cannot even acknowledge who my clients are without a court order or the client’s permission. Do you have either of those?” Of course, he did not. The call was polite and short. I never heard from him again.

  • A parent called my office seeking “any records whatsoever” I had pertaining to my therapeutic relationship with his son, who was a minor at the time. Ordinarily, I would have been happy to chat with a parent. However, I knew that this father’s custodial rights had been terminated by the court (my client’s mother had provided those documents to me), so the man calling me had no legal right to his son’s records. I declined his request.

Without experience, it might be easy to be intimidated by police, angry parents or clever attorneys. But you cannot be arrested (as I was threatened on one occasion) for following counseling ethics and HIPAA requirements regarding client information. In fact, you will likely be in greater trouble if you concede to these “requests” and thus violate our code of ethics.

To make your life a little less stressful, let me suggest three simple statements/rules that will help you know when to divulge information and when to stay silent.

First, never forget this line: “Who my clients are or are not is confidential information.” The two officers I mentioned above began by saying, “We are here to talk about M— S—, one of your former clients. Do you remember her?”

They were playing me. If I had acknowledged that I remembered her (as, in fact, I did), they would already have been on their way to pressuring me for more information. I simply delivered the line above and then shut my mouth.

Second, remember to ask, “Do you have a court order?” No court order is verbal. Police officers, lawyers and others have tried to tell me they had a court order and wanted me to provide information. I always state that I’m happy to comply with any court order that I receive. Unless a court order is provided to me, that is nearly always the last I will hear about a request for information.

Even if a printed order is provided, it must be signed by a judge. The lawyer who tried to scam me knew he couldn’t forge or fake a judge’s signature without risking losing his license and perhaps going to jail. I always first flip to the last page of the order to see what judge signed it. No judge’s signature, no information.

Finally, ask, “Who has legal right to this information?” Without a court order, that legal right generally lies exclusively with the client, but in the case of minors, those who have legal guardianship can request records as well. That can get complicated, as I indicated in the scenario above. If I hadn’t anticipated the question of legal guardianship, I might have provided client records to a person who had no right to see them.

If you have no experience with court orders, always consult with your professional organization or a trusted and experienced colleague. If you have questions about a court order, you can call the court to confirm or clarify.

One final caveat: I am not an attorney. I know some jurisdictions may have systems in place that differ from what I’ve described, so check with legal counsel in your area before you need it. You will then be prepared.

 

****

Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.