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The Mentors’ Corner |
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Student/Early Career Professionals |
Jeffrey Barnett, Psy.D. & Michael Murphy, Ph.D. |
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Jill Christopher asks: I have been practicing for 2 1/2 years in a university setting and will begin a part time private practice in July. I am joining the list to obtain advice on starting a private practice. I specialize in evaluating children (1-18 years) with developmental disabilities. I also do behavioral/emotional evaluations. I would like to stick with evaluationsand avoid therapy. My first questions are: How much should I charge for an evaluation? Should I charge by the hour or per evaluation? Should the charge be the same for all types of evaluations (i.e. LD, ADHD, autism, etc)? I will be practicing in a small town in Indiana and will be the only child psychologist. I am afraid of charging too much as the community is not very wealthy. I’m going to apply to be a Medicaid provider, but I hope to not take any other kind of insurance. Any advice would be appreciated. Frank Cushing responds: 1) How much should I charge?: Establish your rate by finding out about what other psychologists in the area charge per unit (insurance company language for “hour”--usually 45-50 minutes). Psychotherapy Finances (a publication that does a national survey yearly) recently indicated mid-western psychologists charge in the neighborhood of $100-125 per hour on the low end to upwards of $185-200 on the high end (doing this from memory so actual statistics may vary). In my private practice office that has three psychologists, the charges range from $150 to 165 to 185 per unit. Set your rate based upon your overhead (which can be anywhere from 25-50% of collections- including bad debt or uncollectible), your specialized training and expertise (who else can do what you do in your area--and as well as you do), and the “usual and customary” fees of other psychologists. Consider the fees of psychiatrists for an equal amount of time--our training is at least equal to theirs and our psychological assessment skills exceed theirs. DO NOT UNDERVALUE YOUR SERVICES--remember the 10 years you spent honing these skills and paying tuition and being supervised and not earning any (or very much) income. Now is the time to recoup the cost of that training and pauper life style. Do not be embarrassed to charge what you are worth. 2) Do Not Charge by the Evaluation. Insurance companies will NOT pay flat rates for evaluations. They will reimburse based up each (hour) unit. Set a fee for service hourly charge but and charge it out each and every time for each and every hour spent in the assessment process. However, if you join managed care panels, they will chop that fee in half or more many times and you must accept the fee you agreed to with each separate company. The “adjustments” or write-offs of the difference between your fee for service charge and the managed care fee can be written off each account as the charges are paid for. If you are not yet aware of CPT codes, you better become acquainted with them. They are the Procedure Codes you must use in billing out to insurance companies. An initial diagnostic session, for example, is a CPT code of 90801. It is best to use this code for the first session of taking history and background and insurance companies usually pay more for this code than for the code for Psychological Testing (96100). 3) You charge for your time and the procedures: not for the type of evaluation or referral question. Some evaluations might take more hours of psychological testing/assessment than others and thus might end up being more expensive. ALL time spent administering tests, scoring and analyzing the test data, and reporting on the psychological test data is all appropriately billed under 96100--do not short change yourself by not charging for your scoring and report writing time-–however, if you tend to obsess and take 4-5 hours to write up a report, most insurance carriers and fee for service clients are not going to pay that much. I do not bill anything under REPORT fee anymore because insurance companies will not pay for it. If the same time is billed under 96100 (psychological testing) it is paid because reporting is included in that code. 4) Medicaid pays horrendously. You may be eliminating yourself from much business because people will rely on their insurance to get these services as it may be too expensive for them to afford out of pocket. If you are going to accept Medicaid you might want to rethink your position on other insurance carriers at least until you are so busy you can resign the worst paying panels. 5) I have developed a process over the years that I refer to as a “CHILD STUDY”. The purpose it to evaluation the child’s functioning in all areas (intellectual, academic, emotional, social, behavioral) so as to differentially diagnose the issues that are contributing to the child’s problems. The process uncovers LD, ADHD, developmental issues including Autism/Aspergers, as well as childhood emotional problems (anxiety, depression, bipolar, childhood schizophrenia, PTSD, etc) and allows for developing a comprehensive treatment plan for that child. The report is used by family physicians, psychiatrists, school personnel and therapists as well as parents to implement appropriate medical, educational, behavioral, therapeutic and parenting interventions and strategies based upon the child’s needs. The standard battery includes the following:
In some specialized cases I use an the CLEF-R, an Autism scale, the Denver, and/or the KaufmanAt the end I prepare the written report and have the parents in for a 75 minute interpretation session (CPT code 90808--I charge $250 for this—insurance companies reimburse more than for the 45-50 minute psychotherapy session) to review all of the findings, test results and scores and interpretations, diagnostic impressions and recommendations (the comprehensive treatment plan). They take 3 copies of the report with them for the school, the therapist, and their own records. I send copies to the family physician and/or psychiatrist.These evaluations have been well received by referral sources and patients and paid for by insurance companies and “out of pocket” for almost 25 years. Steven Walfish adds: I think Frank gives excellent advice about fee setting. For my edification, and I think list members may appreciate this as well, I would like to know how he deals with the issue of “reasonable and customary charges” as determined by insurance companies, managed care negotiated rates, and how that affects his billing. For example, my fee for a 90801 (initial session) is $ 175 and for 90806 (individual therapy) is $ 140.For companies where I am a preferred provider they set their fees lower than this. For example (and off the top of my head) the local Blue Cross allows $135 for a 90801 and $105 for 90806. They then pay a percentage of this (usually 80%) and the patient then pays the other percentage. However, I write off (by contract) the difference between fee charged and fee allowed. These numbers vary by insurance company.For companies where I am a managed care provider these fees are further drastically reduced. However, by contract, the difference still cannot be charged to the patient.Note that only a portion of my practice is subject to these reductions. I receive excellent fees for SSI evaluations that I complete, the workers compensation people that I treat, people involved in motor vehicle accidents where insurance is paying, and civil forensic evaluations. I have few full-fee private pay patients. I have been practicing in a working class town (though this is about to change) where developing, in my opinion, a non-insurance based practice is not feasible. Geri Weitzman asks further: Can you talk more about how you find clients who will pay that much – both in terms of locating clients and in terms of talking about your fees to them? I’m newly licensed, and newly in private practice in a major metro area that has ‘tons’ of psychologists and other therapists. Getting onto insurance panels is difficult at this point, and I’m not really wanting to go the managed care route anyway if I can avoid it. I’ve been reading some of the books on how to generate referrals, and I’m pursuing some of the recommended routes, but live examples are great too.Some of the things I’m doing / contemplating doing:
Thanks! Elaine Rodino responds: You are contemplating some good ideas. Regarding getting to where you can find clients that can pay full fees out of pocket, that isn’t as hard as you may think. Many people will go out of their network. People have been spending for alternative medicine practices even though these are not covered by insurance. To have this happen involves a combination of doing things like you mentioned and your own inner attitude. With an additional income per hour you will have more free time to do pro bono work for your own charitable interest, rather than for a Managed Care CEO earning millions per year. If you will be attending APA in Chicago, hope you can attend a short program on Friday, August 23, 1-1:50 PM for Students and New Professionals “Finding your Mentor”. The title of my presentation is “Money Matters”. This will be based on one of the chapters of my book www.DrElaineRodino.com “Saying Good-Bye to Managed Care: Building Your Independent Psychotherapy Practice” by Sandra Haber, Ph.D., Elaine Rodino, Ph.D., Iris Lipner, CSW., Springer Publishing Company, www.springerpub.com, TollFree: (877)687-7476 Lana Shimp asks: I am preparing to testify (for the first time) in a case where a woman is suing a perpetrator for childhood abuse (I did a psychological assessment of the woman). I was wondering if anyone could give me any pointers on how to prepare, as well as suggest any useful references / resources. Thanks. Eric Kirschner replys: Was your assessment done for the purposes of the court case? What tests did you use? What questions were you trying to answer? This info will help guide what you can and can’t say. Frank Cushing responds: Eric’s questions are on target. What was the referral Question? Who referred this woman to you? How did you evaluate possible Malingering? What did the Validity and Reliability scales of which tests say? Did you have any prior contact with this patient--such as in Therapy? All that having been addressed, I would recommend the following books to help prepare for testimony (listed in descending order according to value in preparing you): EXPERT TESTIMONY: A Guide for Expert Witnesses and the Lawyers Who Examine Them by Steven Lubet, 1998, National Institute for Trial Advocacy ISBN: 1-55681-595-6 TESTIFYING IN COURT: Guidelines & Maxims for the Expert Witness by Stanley Brodsky,1991, by the American Psychological Association Order Number: 460-0220 THE EXPERT EXPERT WITNESS: More Maxims and Guidelines for Testifying in Court by Stanley Brodsky, 1999, by the American Psychological Association ISBN: 1-55798-597-9 The three books below are small paperbacks that are relatively inexpensive and VERY PRACTICAL in terms of do’s and don’ts on the witness stand. For much more in depth information (expensive but quite useful) about forensic psychology, I have found the book listed below to be extremely valuable: PSYCHOLOGICAL EVALUATIONS FOR THE COURTS: A Handbook for Mental Health Professionals and Lawyers, 2nd Edition by Gary Melton, John Petrila, Norman Poythress, and Christopher Slobogin, 1997, by the Guilford Press ISBN: 1-57230-236-4 For specifics on Sex Abuse Evaluations, Richard Gardner’s book: Protocals for the Sex-Abuse Evaluation is quite useful Published by Creative Therapeutics, 1995 ISBN: 0-933812-38-8It has chapters on “Evaluation of the Accuser (within and out of thefamily)” and “Evaluation of the Belated Accuser/Victim” Steve Walfish adds: For those doing forensic work let me also add to Frank’s helpful list that you read “Accepting Forensic Case Referrals: Ethical and Professional Considerations” by my friend and colleague Allen Hess, which appeared in Professional Psychology: Research and Practice, 1998, 29, 109-114. He also has a chapter titled, “Serving As An Expert Witness” in the book he edited with Irving Weiner, The Handbook of Forensic Psychology, (2nd Ed), NY: Wiley. Lana Responds: Thank-you everyone for the suggested resources and questions to consider. I have a couple of other questions I’m hoping the list can help me with:I charged my regular assessment hourly rate for conducting the assessment and preparing the report. I am wondering if I should be charging a higher rate (and if so by how much) for time preparing for the testimony and actual time testifying. I also have to travel 4 hours each way to get to the court and I’m not sure how to charge for this time / expense either.I have asked the attorney who is calling me to provide me with a list of questions that he plans to ask me, as well as likely questions in cross-examination. He indicated that he would not be working on this part of the case until the weekend prior (I testify on a Tuesday, so I assume that I wouldn’t get them until Monday, which I will be spending seeing clients and than travelling), but would supply me with a list of potential questions that were generated by an articling lawyer, assuring me that his questions would be of a similar nature. I am concerned that I won’t have enough time to prepare or discuss possible concerns with the lawyer regarding the specifics of the actual questions prior to the court date. I am not sure if my concerns are born of my first-timer anxiety or if this is common and acceptable procedure - any suggestions about how I should proceed would be appreciated. Frank Cushing replies: Many psychologists charge a significantly higher rate for all forensic work. I charge 150% of my clinical fee for anything and everything related to work with attorneys. That includes all aspects of the assessment, report preparation, reviewing all documents, travel, reviewing data and preparing to testify and testifying. I always chargea minimum of 4 or 8 hours for court testimony (depends on how far I have to travel–if I were traveling 8 hours round trip, I would charge a minimum of 12 hours). I ask for that minimum ( 4 or 8 or 12 times my hourly forensic rate) up front--before I leave the office to testify. In some cases, I accept a letter from an attorney guaranteeing payment from the law firm.Many people charge different rates for travel than for the other things. I do not do this because the travel is stressful (rethinking the case—it won’t leave your mind coming or going). I would demand that the attorney be available for a pre trial preparation meeting with me. If it was too far away, it could be done via phone. In this meeting, I would want to go over all questions he/she was to ask me, areas of likely cross examination, style and demeanor and manner of the other attorney. I would also want to talk to the attorney about the specifics of my qualifications to ensure my strengths were pointed out in the qualifying phase prior to testifying...and that I was not asked questions at that time about things that did not apply to me: e.g. “howmany articles have you published?” “where did you go to medical school?” You would be amazed at how ill-prepared some attorneys are and you don’t want to look foolish because of an attorney’s failure to properly prepare. A good pre trial preparation meeting between an attorney and an expert witness should last at least 90 minutes--especially if either of you is relatively new to this game or if you haven’t worked with one another in the past. I would also want to see any court documents, depositions of other witness (especially experts) or other expert witnesses reports that I have not yet seen prior to the meeting with the attorney and prior to testifying. I would want to understand the other side’s position and then would want to research this thoroughly before testifying. For example, if you were saying that the person showed signs of dissociation that was consistent with sexual abuse...and the other side had experts saying that the patient was schizophrenic....I would want to see their reports, their raw data (what did they base their diagnosis on) any reports they had access to that I had not yet seen.....and I would review all research about diagnosing dissociative disorders vs. schizophrenia vs. PTSD, etc.......I think you are appropriately concerned about not having enough time to prepare....and I would be proactive to avoid this trap. I would inform the attorney that “I do not work that way”. I would say, I don’t only want “questions of a similar nature” (they would be helpful) but I also want the specific questions this attorney will use on directexamination....even if he has to fax them to me the night before..and I may want to call him that night to discuss any problem areas....or meet with him early the morning before testifying (I have met at 5 a m with attorneys) to go over the particulars.This attorney’s procedure seems slipshod and below standards to me—it is NOT common and acceptable. This attorney may be very experienced and not concerned about how he/she performs but, should be more serious aboutpreparing you. Testifying is not that stressful if you are well prepared but lacking adequate preparation, your first timer anxiety will be exacerbated...for no good reason. Ken Pope adds: Lana asked about charging “for time preparing for the testimony and actual time testifying” and for travel. There are lots of approaches that make sense, but one that Jim Butcher, Joyce Seelen, and I recommended in our APA book is to figure out an hourly fee for forensic services that makes sense for 'you,' and applying it to everything you do related to the case: reading files, phone consults, keeping notes, phone and in-person meetings, travel, deposition, waiting at the court house to testify, etc.Because so many psychologists report exceptional delays and other problems getting paid, even when they have a signed contract with the attorney and solemn promises from the attorney about prompt payment, we recommend considering a standard policy (you can always make exceptions) of working only on retainer: you receive an initial retainer of, say, 10 times your forensic fee before beginning work. Once this retainer is exhausted, you cease work until you receive another retainer for the same amount. This means that the law firm never owes you any money, and you spend no time, effort, or paperwork trying to collect what is owed to you. At the end of proceedings, you refund the unused portion of the latest retainer.All the details are spelled out in an agreement with the attorney, signed in advance of any work. The agreement states, for example, that if you don’t receive each retainer when due, you will stop all work and vacate all appointments, in which case the attorney assumes sole responsibility for any and all damages or expenses that may result to the attorney or the attorney’s client. One of the appendices in the book provides a sample agreement between psychologist and attorney (for a list of appendices, see http://kspope.com/mmpi.shtml). Lana also asked about preparation with the attorney, asking for lists of questions, etc. This is another topic we spend considerable time on in the book (a chapter on how the psychologist prepares; a chapter discussing 100 basic deposition and cross-examination questions) because psychologists report so much difficulty dealing with attorneys in the days and weeks leading up to a deposition or court appearance. Many psychologists find it useful to give the attorney a list of questions to be used in the qualifying phase of direct examination. What set and sequence of questions will enable the attorney to help you communicate your background, training, credentials, and experience as clearly, accurately, and efficiently as possible? For many attorneys, you’ll need to educate them in detail about the issues you’ll address in your testimony. There are many steps you’ll find helpful in preparing, but one that may save you a lot of grief is to review once again all of the documents you’ve prepared, the notes you’ve kept, the raw data and scoring of any standardized psychological tests, and anything else you’ve written that may be a subject of your testimony. If you’re human, you’ve probably made some mistakes, and it is ‘so’ much better for you to discover them--and to let the attorney know about them, so that they can be brought out during direct examination—than for them to be brought to your attention for the first time during cross-examination. In the cases where I’ve been a consultant and reviewed the documents prepared by the expert witnesses on each side, it’s hard to think of any where there haven’t been some errors in, for example, the way items have been scored on one of the Wechsler instruments, or that scores have been added up, or that scores have been looked up in tables, etc. I think most psychologists are at least a little nervous the first few times they appear in court. You may find it helpful to remind yourself that ‘your reason’ for being there (which may differ from the attorney’s reason for hiring you) is ‘not’ to win the case or to present yourself as a perfect psychologist, but to help the jury (or judge, if there’s no jury) understand issues that are considered beyond the customary knowledge of the lay public as clearly and fairly as possible, and to help them understand your professional opinions and how you arrived at them.Good luck, Lana! Ethics Codes for Therapy, Counseling, & Forensic Practice: http://kspope.com/ethicscodes.html
Lana closes saying: Thanks to everyone for responding to my questions regarding testifying in court and related issues. I have survived the 4 hours of fairly grueling testimony and the suggestions and recommended readings were invaluable in terms of helping me prepare. There were numerous lines of questioning that I was faced with that were dealt with in the materials suggested (e.g., being given a book I didn’t recognize and being asked to read and comment on specific paragraphs, dealing with an extremely aggressive manner of questioning (“It’s psychologists like you, Dr. Shimp, isn’t it, who make up all of this PTSD stuff...?”), attempts to discredit the profession as a whole by asking about things such as psychologists’ difficulty predicting dangerousness (nothing to do with the case), attempts to intimidate me prior to the trial by commenting that I was much younger than expected, etc.). I’m particularly grateful for the suggestions / materials, as when I asked the attorney who hired me what he thought I could expect in cross-examination, he advised me that it would be wise for the other side to just sit down and not ask a thing!! (wishful thinking I’m afraid) Mind you, the one thing that I was faced with that wasn’t addressed, was what to do when I discovered that the other attorneys were discussing my cross-examination at the table next to me while eating breakfast prior to the commencement of my testimony - the temptation was great, but I managed to make myself leave and not get the inside scoop - always a good reminder I suppose for everyone to watch what they discuss in public places! Thanks again for everyone’s help. |
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