06_Record Keeping and Fees

Question 1

Maintenance of Records:

Overview

Answer 1

Psychologist must create, maintain, store, and dispose of records in ways that allow them to be used effectively and appropriately

Question 2

Documentation Guidelines:

Four pieces of info related to each substantive contact

Answer 2

Date and duration of session

Type of services provided (assessment/treatment)

Nature of intervention or contact (modality)

Summary of the client’s status

Question 3

Number of years required to keep full patient records

Answer 3

Adults: 7 years after late last date of service delivery

Minors: 3 years after reaches the age of majority
whichever is later

Question 4

`Confidentiality of Records:

Guidelines

Answer 4

Records must be kept in a locked filing cabinet or room

Limited access to records stored on electronic databases

Specific protocol in place, and identified professional to manage records in the event of death, illness, or withdrawal from practice

Question 5

Client Access to Records:

Overview

Answer 5

Legal/Institutional matter, Not part of Ethics Code

Usually, ownership of physical records granted to practitioner/institution, but clients have the right to inspect and amend the information contained in the record

Question 6

HIPAA:

Protected health information (PHI) vs Psychotherapy notes

Answer 6

PHI = used by healthcare professionals or entities related to care, contain identifying information that has been transmitted or maintained in any form or medium

Psychotherapy notes = notes in any medium, maintained separately from the patient’s medical record

Question 7

HIPAA Privacy Rule:

PHI vs Notes

Answer 7

Patients are allowed to inspect and obtain a copy of PHI contained in a designated record set (medical/billing records)

Psychologists do NOT have to release notes, unless required to do so by state law

Question 8

Family Education Rights and Privacy Act (FERPA)

aka Buckley Amendment

Answer 8

Prohibit schools from disclosing personally identifying information from student records without consent of parents of students (or students aged 18 or older)

Parents and eligible students have the right to inspect educational records and challenge their content
(except personal notes in sole possession of provider)

Question 9

3 FERPA exceptions

Answer 9

Education professionals who have a legitimate educational interest in the student

For purpose of financial aid decisions

Another school to which the students transferring

Question 10

Fees And Other Financial Matters:

Overview

Answer 10

Psychologist cannot withhold records because of nonpayment of fees when records are needed for emergency treatment

Many laws and regulations may not recognize nonpayment of these is a legitimate reason for withholding records under any circumstance

Question 11

Discussion of Fees

Timing

Answer 11

As early as is feasible

Question 12

Discussion of Fees:

Key information to share

Answer 12

Therapist’s hourly fee

Policy regarding missed appointments

Arrangements with third-party payers

Procedures for collecting unpaid bills

Question 13

Guidelines for notification

Guidelines for notifying a Collection Agency

Answer 13

Notify the client about that intent

Give them an opportunity to pay the outstanding fees

Provide collection agency with only minimal information needed to seek payment

Question 14

Considerations for payment by insurance company or other third party

Answer 14

Only bill for services provided

NOT bill insurance company for missed appointments, unless this arrangement has been agreed to by the company

Billing code must reflect therapy provided
[individual/group/couple/family]

Cannot change the date of the beginning of therapy or the onset of a disorder to circumvent insurance restrictions

Cannot assign inaccurate diagnosis to qualify for insurance payments

Cannot waive a copayment without company being aware of this arrangement

Question 15

Barter Payment

Answer 15

Acceptable when not clinically contraindicated and not exploitative

Factors arise when services are not performed satisfactorily

Client and psychologists are both vulnerable to feeling exploited

Question 16

Referral Fees

Answer 16

Referral fees are not prohibited

When paid to an individual professional competitor referral service, they must be based on the actual cost of the services provided and not the referral itself

Question 17

Sliding Fee Scales

Answer 17

Acceptable as long as the use of a sliding fee scale is fair and serves the best interest of the client

The actual fee is not as important as the manner in which it is set, communicated, managed, and collected