Standard 6: Record Keeping & Fees Flashcards
6.01 Documentation of Professional and Scientific Work and Maintenance of Records
6.01 Documentation of Professional and Scientific Work and Maintenance of Records:
Psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to
(1) facilitate provision of services later by them or by other professionals,
(2) allow for replication of research design and analyses,
(3) meet institutional requirements,
(4) ensure accuracy of billing and payments, and
(5) ensure compliance with law.
6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work
(a-c)
- 02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work
(a) Psychologists maintain confidentiality in creating, storing, accessing, transferring, and disposing of records under their control, whether these are written, automated, or in any other medium.
(b) If confidential information concerning recipients of psychological services is entered into databases or systems of records available to persons whose access has not been consented to by the recipient, psychologists use coding or other techniques to avoid the inclusion of personal identifiers.
(c) Psychologists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists’ withdrawal from positions or practice.
6.03 Withholding Records for Nonpayment
6.03 Withholding Records for Nonpayment
Psychologists may not withhold records under their control that are requested and needed for a client’s/patient’s emergency treatment solely because payment has not been received.
6.04 Fees and Financial Arrangements
a-e
- 04 Fees and Financial Arrangements
(a) As early as is feasible in a professional or scientific relationship, psychologists and recipients of psychological services reach an agreement specifying compensation and billing arrangements.
(b) Psychologists’ fee practices are consistent with law.
(c) Psychologists do not misrepresent their fees.
(d) If limitations to services can be anticipated because of limitations in financing, this is discussed with the recipient of services as early as is feasible. (See also Standards 10.09, Interruption of Therapy , and 10.10, Terminating Therapy .)
(e) If the recipient of services does not pay for services as agreed, and if psychologists intend to use collection agencies or legal measures to collect the fees, psychologists first inform the person that such measures will be taken and provide that person an opportunity to make prompt payment. (See also Standards 4.05, Disclosures ; 6.03, Withholding Records for Nonpayment ; and 10.01, Informed Consent to Therapy .)
As a rule of thumb, most businesses turn unpaid bills over to a collection agency after 60 to 90 days.
6.05 Barter with Clients/Patients
6.05 Barter with Clients/Patients
Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if
(1) it is not clinically contraindicated, and
(2) the resulting arrangement is not exploitative.
6.06 Accuracy in Reports to Payors and Funding Sources
6.06 Accuracy in Reports to Payors and Funding Sources
In their reports to payors for services or sources of research funding, psychologists take reasonable steps to ensure the accurate reporting of the nature of the service provided or research conducted, the fees, charges, or payments, and where applicable, the identity of the provider, the findings, and the diagnosis.
6.07 Referrals and Fees
6.07 Referrals and Fees
When psychologists pay, receive payment from, or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, or other) and is not based on the referral itself.
According to the Record Keeping Guidelines developed by the APA Committee on Professional Practice and Standards, Board of Professional Affairs (APA, 2007c), the level of detail and adequacy of content included in records is determined by the information necessary to
(state 7)
(a) provide good care,
(b) assist collaborating professionals in delivery of care,
(c) ensure continuity of services in the case of a psychologist’s injury, disability, or death or with a change of provider;
(d) provide for relevant supervision or training;
(e) provide documentation required for reimbursement or required administratively under contracts or laws;
(f) effectively document any decision making, especially in high-risk situations; and
(g) allow the psychologist to effectively answer a legal or regulatory complaint. (p. 995)
Overdiagnosing a client/patient to receive health care benefits is insurance fraud and thus a violation of Standard […]
It is also inconsistent with Principle […], under which psychologists do not engage in fraud, subterfuge, or intentional misrepresentation of fact.
Overdiagnosing a client/patient to receive health care benefits is insurance fraud and thus a violation of Standard 6.04, Fees and Financial Arrangements.
It is also inconsistent with Principle C: Integrity, under which psychologists do not engage in fraud, subterfuge, or intentional misrepresentation of fact.
T/F: Psychotherapy notes are * not * privilege and are *not * immune from subpoena. They cannot be disposed of at any time.
FALSE! Psychotherapy notes (also known as process or personal notes) are considered a work product privilege and are immune from subpoena (Mental Health and Developmental Disabilities Confidentiality Act of 1979) Accordingly, psychotherapy notes can be disposed of at any time, unless state law provides otherwise.
Patients do not have the right to access psychotherapy notes.
True or False: when other individuals are involved to provide collateral support for an identified patient, these individuals are also the “client/patient,” and the psychologist should maintain separate health records for them. Information provided by the collateral that is relevant to the primary client’s/patient’s treatment is not entered in the client’s/patient’s record.
false!! when other individuals are involved to provide collateral support for an identified patient, these individuals are not the “client/patient,” and the psychologist does not maintain separate health records for them. Rather, information provided by the collateral that is relevant to the primary client’s/patient’s treatment is entered in the client’s/patient’s record.
Under 6.01, Documentation of Professional and Scientific Work and Maintenance of Records, psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (state 5)
(1) facilitate provision of services later by them or by other professionals,
(2) allow for replication of research design and analyses,
(3) meet institutional requirements,
(4) ensure accuracy of billing and payments, and
(5) ensure compliance with law
Scientific work: Records must be maintained for at least […] years following the completion of the project and the filing of the final progress and financial reports.
Scientific work: Records must be maintained for at least 3 years following the completion of the project and the filing of the final progress and financial reports.
What is standard 6 and its substandards?
Standards on Recording Keeping and Fees
- 01 Documentation of Professional and scientific work and maintenance of records
- 02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work
- 03 Withholding Records for Nonpayment
- 04 Fees and financial arrangements
- 05 Barter with Clients/Patients
- 06 Accuracy in reports to payors and funding sources
- 07 Referrals and Fees
