Transcript Maintaining Ethical Integrity and Minimizing Risk in

Gerald P. Koocher, PhD, ABPP
Simmons College
ethicsresearch.com
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453 complaints (59% board complaints).
 Suicide 17
 Sexual abuse 12
 Employment practices 5
 Non sexual boundary violations/multiple
relationships 4
 Billing Impropriety 2
 Homicide by patient 1
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Sex
Suicide
Child Custody
 Release of records
 Role confusion/conflict
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Confidentiality
Record Keeping
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Uncertainty
 What’s happening in my profession and the health care system?
 Will I get/keep a job?
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Economic insecurity
 What’s happened to my income?
 What’s happened to my savings?
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Lifestyle changes
 Will I ever retire?
 Must I return to work?
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Technological advances
 How can I keep up from a knowledge and economic
perspective?
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Consumer demand
 Can I provide what consumers want?
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Denial-Anger-Bargaining-DepressionAcceptance? (per Kübler-Ross)
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Stages of change: Precontemplation –
Contemplation – Preparation –Action –
Maintenance ?
(per Prochaska & DiClemente)
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Do nothing, things will get better.
Change something(s) about my practice, job,
career while maintaining my integrity and
considering the best interest of my clients,
patients, employees, and students.
 Innovate?
 Reinvent?
 Retire?
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 Branded Therapies
 Executive Coaching (Life Coaching)
 Forensic Practice
 Child and Geriatric Services
 Trauma Therapy
 Remote Service Delivery (telemetry)
 Rx Privileges
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In most instances branded therapies do not have
trademark protection and use of the term
“therapist” does not require a professional license.
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Use of the term “coach” remains largely
unregulated by governmental authorities and the
mental health professions.10
Life-coaches all the
rage
By Karen S. Peterson,
USA TODAY
Personal growth is
hot. Diagnosis is not.
That is one reason
America has seen a
boom in the number
of people offering
their services as "life
coaches."
Confessions of a PsychologistTurned-Coach
by Pat Williams, Ed. D
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Treating depression and anxiety can seem passé …
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How can I do it in an
ethically responsible
manner?
Trauma Therapy &
Coaching as examples
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How do I become an
executive/organizational/personal coach
or trauma expert?
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Ask an expert colleague.
Get additional education and training if
necessary.
Focus on evidence based practices where
they exist.
Stay mindful of biases
 (e.g., “I can do it because I’ve been through it!)
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Remember: you can’t hide behind a new
identity, if you cite your profession.
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Ino Itall, Ph.D. has a degree in counseling
psychology and a license to practice in NE. A
university dean hires Dr. Itall to consult on the
political science department at a university in
SC where faculty are feuding, because his
experience as a psychologist in academic
settings. Dr. Itall comes to SC and interviews
many people on campus with a pledge of
confidentiality and intent to coach the faculty
on improving relationships.
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Itall then offers coaching advice that
breaches the confidentiality of others. When
challenged ethically, Dr. Itall responds: “I
wasn’t functioning as a psychologist when I
did the report. I was acting as an
organizational coach and the ethics code did
not apply.”
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 “We” have a strong commitment to
reach out to children – consider this:
 Tragically, 65% of these children have
experienced trauma and abuse. *
 35% of our adults have experienced
trauma in their lives.*
▪ *These numbers only represent cases that have
been reported. (Actual data per ACF and Census
Bureau = 1.2%)
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“National Statistics:”
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"... 30 to 46 percent of all children are sexually
violated in some way before they reach the age
of 18." Levine, P., & Kline, M., (2007). Preventing
and Healing the Sacred Wounds of Sexual
Molestation. The Meadows Cutting Edge, Spring,
pg. 5.
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The Meadows Cutting Edge a non peer reviewed
newsletter cited the authors’ book, published by
North Atlantic Books.
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Company Profile
 Founded in 1974, North Atlantic Books has been
located in Berkeley, California since 1977. North
Atlantic publishes on alternative health, astrology,
dance, martial arts, and spiritual titles...
 Our mission is to affect planetary consciousness,
nurture spiritual and ecological disciplines,
disseminate ancient wisdom, and put forth ways
to transmute cultural dissonance and violence
into service…
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 Raising fees
 Extending credit
 Sliding fee scales
 “Waiving” co-payments
 Billing and collections
 Bartering
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Inform clients about fees, billing and
collection practices routinely at the start
of a professional relationship.
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Repeat this information later if necessary.
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Follow the procedures you specified.
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Take care to explain the nature of services
offered, the fees to be charged, the mode of
payment to be used, and other financial
arrangements that might reasonably
influence the potential client’s decisions.
Many practitioners find it useful to put such
information in a pamphlet or hand-out for
clients with other basic information, such as
confidentiality and emergency coverage
notices.
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Never contract for services without first
explaining the costs to the client and mutually
determining that the costs affordable.
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Do not mislead the client into thinking that
insurance or other third-party coverage will
bear the full cost of services when it seems
reasonably clear that benefits may expire
before the need for service ends.
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When treatment is in progress and a client
becomes unemployed or otherwise can no longer
pay, try to be especially sensitive to the client’s
needs.
 If you cannot realistically help a client under
existing reimbursement restrictions, and the
resulting process might be too disruptive, it may
prove best to simply explain the problem and not
take on the prospective client.
 At times it may become necessary to terminate
care or transfer the client elsewhere over the long
term, but avoid doing this abruptly or in the midst
of a crisis period in the client’s life.
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3.12 Interruption of Psychological Services
 Unless otherwise covered by contract, psychologists make
reasonable efforts to plan for facilitating services in the event
that psychological services are interrupted by factors such as
the psychologist's illness, death, unavailability, relocation, or
retirement or by the client’s/patient’s relocation or financial
limitations.
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10.10 Terminating Therapy
 (c) Except where precluded by the actions of clients/patients
or third-party payors, prior to termination psychologists
provide pretermination counseling and suggest alternative
service providers as appropriate.
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Increasing fees in
the course of service
delivery poses
dilemmas.
 If a commitment is
made to provide
consultation or
conduct an
assessment for a set
fee, it should be
honored.
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 Likewise, a client who enters psychotherapy at an
agreed-upon rate has a reasonable expectation
that the charges will not be raised excessively.
 Once service has begun, the provider has an
obligation to the client that must be considered.
Aside from financial hardship issues, the
psychologist may have acquired special influence
with the client that should makes it difficult for
the person to object.
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Some practitioners require clients to pay
certain fees in advance of rendering
services as a kind of retainer (e.g., in
forensic cases or other complex
assessments).
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This is an unusual practice in psychology,
but not unethical so long as the
contingencies are mutually agreed upon.
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The most common use of such advance
payments involves relationships in
which the practitioner is asked to hold
time available on short notice for some
reasons (as in certain types of corporate
consulting) or when certain types of
litigation are involved.
 Such situations require careful
accounting.
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 Four basic elements:
 First, a false representation is made by
one party, who either knows it to be
false or is knowingly ignorant of its
truth. This may be done by
misrepresentation, deception,
concealment, or simply nondisclosure
of some key fact.
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 Second, the misrepresenter's
intent is that another will rely on
the false representation.
 Third, the recipient of the
information is unaware of the
intended deception
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 Fourth, the recipient of the
information is justified in relying on
or expecting the truth from the
communicator. The resulting injury
may be financial, physical, or
emotional.
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If you plan to use this policy in your
practice, give proper advance
information about this practice to clients
and obtain their consent.
 Never bill an third-party payer for
unkept appointments.
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 The key to navigating these ethically
 Know and honor your contractual
obligations, while
 informing clients and
 protecting their rights.
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The “moral hazards” of insurance
 Ex ante – people don’t buy it unless they
expect to use it.
 Ex post – people with insurance demand
more and better service commensurate with
coverage.
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Solutions
 Co-insurance: deductibles and co-payments
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Disguising services not covered
“Upcoding” diagnoses
Musical chairs in family therapy
Billing for services not rendered
Burying the deductible
Waiving the co-payment
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State and Federal laws define debtor creditor
relationships, including:
 Collection practices
 Actions of a creditor’s agents
 Credit policies (e.g., interest and surcharges)
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Include any such plans in the client contract or
consent notifications.
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 HIPAA compliance essential
 Have business associate agreements
 Do not withhold medical records for
non-payment of fees.
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Collection agencies – you retain
responsibility
Small claims court – acceptable, but risky
Best bets
 Discuss all with client in advance and ongoing.
 Do not allow significant debt accumulation.
 Consider retainer in some types of practices.
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Bartering is ethically permissible, but
complicated multiple role situation.
 Establishing the value of the products/services
poses challenges.
 Bartered products/services are taxable and legally
reportable.
 Multiple role hazards abound.
▪ Clinical contraindications
▪ Dissatisfaction with products/services
▪ Feelings of exploitation
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Reply to: [email protected]
Date: 2008-12-07, 12:09PM EST
My husband is a capable and (sic) effecive counselor,
licensed...but he is not good at home repairs/construction. I
will trade his expertise for your time with him as a counselor
if you can help us with tub and tile repair and plumbing. We
had a termite problem that we fixed but the place needs a
new floor and other stuff...if you are struggling with
depression or bipolar, he is your man...maybe your spouse,
child, etc. He is truly an excellent counselor. We have our
own non-profit and give to others without charging so our
financial situation is limited, but looking to trade! thanks.
Location: NE Grand Rapids
PostingID: 948491022
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 Considerations in closing a practice
 Client notifications and records
 Wind-down payables and receivables
 Partners, staff, referral sources
 Covering your tail (professional liability
insurance protection)
 Self care
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Notify and refer clients as needed.
Make arrangements for clinical records
management that comply with state and
federal laws.
Make arrangements for business records that
comply with state and federal laws.
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Erin Mendez & Sean Leidigh , WGNTV NEWS, May 30, 2009 , CHICAGO
Years of Chicago Public School student's confidential, sealed records somehow
made their way to a Lakeview alley dumpster, totally filled with special education
records, clearly labeled by name and containing highly personal information;
photographs, home addresses, parents information, results of psychological
tests. Also buried among the paperwork were social security numbers, SAT
scores and a slew of taped envelopes, with the words "to be opened only by the
psychologist.“
There was a common thread on the students records. A signature from Lakeview
High School's now retired case director of ten years, who had this to say about
the dumped files, "Those records are highly confidential and as far as I'm aware,
should be kept sealed indefinitely.”
wgntv.com /wgntv-cps-documents-found-in-alley-may30,0,195726.story
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What does the practice include?
 Furniture, an office, psychological test
equipment, the name and good will of the
practice or clinic, a group of clients making
use of the practice?
 One can sell the furniture, real estate, and
equipment. But, selling the clients, their
files, and access to this information raises
significant ethical issues.
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 Practitioners cannot ethically transfer clinical
responsibility for clients or confidential client records
in a private practice without the clients' consent, but
can work to allow clients continuity of care freedom
of choice, and safe records management.
 One can delegate fiscal management of residual
payables and receivables, but the psychologist may
retain vicarious responsibilities for the misdeeds of
others
 See: works by Woody and Walfish & Barnett
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 One solution - - -
 Phasing out retirement or relocation
to the buyer in close collaboration
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Trailing claims in professional liability coverage
– covering your “tail”
 The “tail” = an Extended Reporting Period (ERP).
 Occurrence vs claims made policies
 With APAIT: the tail is free if you retire, become disabled
or die while insured with a claims-made policy. Check
your policy if insured elsewhere.
▪ Notify the carrier within 60 days of the termination of your
policy to issue the free retirement tail.
▪ Plan to have someone notify the carrier within a year in the
event of your death or disability.
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 Stay mindful of your own feelings
(eagerness, sadness, ambivalence,
burnout) and focus on the duty
owed to current and former clients.
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If you've been out of practice for a few years, you
might have to:
 get yourself re-licensed, get caught up on all the
continuing education you missed, and perhaps join a
formal re-entry program.
 contend with your own employability and demands
for you to know new information technology.
 deal with a potential employer’s interest in a
guaranteed long-term relationship.
 prior acts liability insurance (nose-coverage)
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