You, Your Insurance and Privacy of Our Work, Pt III

October 13th, 2010

OK, now for the kicker. The something more. This information that lives with your insurer and their insurers isn’t finished yet. What happens if you apply for life insurance? An auto loan? Change jobs and need to sign up for other health insurance? Apply for a credit card? Have you guessed yet?

That’s right. These worthies will often turn to an agency that they hire to collect your information, your protected health information, and that agency will then turn to me and request the records of your treatment. They will sometimes accept a summary but I have to tell them that’s what they’re going to get. What you’ve signed, after you first told them that you had this treatment (if they ask, and for life insurance they sure will,) is a consent for release of information for your medical records. That means they are going to be requesting my session notes (which are part of your official medical record.) This also means that this 4th party outside of the triangle of you, me & your insurance company (and their backers, but I included them in the triangle – so what if it’s got 4 sides? I’m a psychotherapist not a geometer) has your protected health information in its data bank. Yes, the release you signed is HIPAA compliant. They know the law & know that that’s what they have to give you. It doesn’t mean that they are as careful about disclosures as your psychotherapist (me, in this case.)

Does this chill you a bit? If it doesn’t then you’re not following the flow of your information. Wider and wider circles of dissemination.

Now, I’m not saying that if you and I keep things between us and you leave your insurance out of our relationship that you won’t at some point decide that you want life insurance and they won’t ask about treatments you’ve received. If you do they will. I won’t tell you not to tell them about treatments. That would be telling you to commit fraud and I won’t do that. I won’t tell you to lie on the application. I will tell you that, unless you are asked about treatments, in most cases (within the limits of the laws about confidentiality) it stays between you and me (maybe your accountant and Uncle Sugar if you claim it on your taxes, but I’m not going to go there.) There are limits imposed on confidentiality by law, such as if I think you are an immediate danger of committing harm to yourself or somebody else, or in case of suspected cases of child abuse but within the law what’s between you and me stays between you and me. Personally, I like it that way.

Another time I’ll tell you why I don’t like “diagnosis” as used in the DSM (or ICD,) but that’s not part of this. Let’s call it a day and I’ll go back to enjoying my cup of tea.

You, Your Insurance and Privacy of Our Work, Pt II

October 13th, 2010

OK, where was I before I started brewing my tea – a nice Oolong with lots of flavor, good aroma & gentle bite? Oh, yeah, about codes and privacy. This section gets a little technical but hang in there, fans – it’s worth it.

I said that those codes don’t leave much of an artifact (footprint, trace, record) that’s going to make any difference, right? Wrong! There’s a procedural code for every procedure that goes on a claim form, whether it’s medical, dental, surgical, psychotherapeutic, etc. The procedure performed becomes part of your permanent medical record in your insurer’s database. “So what” I hear you say. So this: it’s not just in your insurer’s database. It’s in their insurer’s database. They’ve gotta lay their bets off somewhere. That’s with a meta-insurer (think AIG or similar.) Someone who does risk-management and determines how much they can back the bets your insurers make. Think of it as the insurance company has sold your marker to someone. You said it was Jake for them to do that when you signed the line that said that your information could be disclosed for the purpose of obtaining payment. And you thought it was just between you, me, and your insurance company. Have another thunk because there’s more.

Anytime there’s a procedure code there’s a diagnosis. Again, this is whether the work is medical, dental, surgical, psychotherapeutic, or whatever. Now we’re beginning to where it gets sticky. Diagnosis is a serious word. It means that, based on criteria established by the Taskforce that created the Diagnostic and Statistical Manual of Mental Disorders-IV TR, you get labled with a disorder. You are no longer “the worried well,” or someone who just feels anxious. You now have a recorded disorder. This is part of that marker. The fun doesn’t stop there….

Anything that is contained in the DSM-IV is contained in a book called the ICD-9 (going on ICD-10) – “The International Classification of Diseases” published by varoius publishers all putting out the same book (it’s used world wide – International, right?) This means that where ever your record is read they all read the same diagnosis. Great, right? Maybe if the people reading that record were also psychotherapists, psychiatrists, or some kind of mental health professionals, but they may not be. Yes, some insurance companies do utilize us for review but not all the reviewers are. This means that your case is being reviewed by a clerk of some sort. This clerk gets to decide (among other things) how many sessions we can have during a given year for a particular disorder, if any at all. They can also decide that treatment has gone on long enough based on the tables they have and what instructions they’ve been given. At this point it involves more work; usually for me and for which I don’t get paid but, again, even though I mention the do-re-me it’s not about the bucks. It’s about the time it takes to appeal the decision & meanwhile the treatment and who’s going to pay for it is in Limbo (which is often somehow contiguous with Hartford, CT or someplace in Texas, maybe offshore. Who knows?)

These clerks aren’t under the same constraints about the privacy of your information (remember, that’s what this is about) as I am. They are allowed to bundle it for research as well as developing their actuarial tables and other statistical purposes. Your personal information (PHI – Protected Health Information) is not as protected anymore.

But wait, as they say on the infomercials, there’s more. See part III, coming up shortly….

You, Your Insurance And Privacy of Our Work Together

October 13th, 2010

“Do you take insurance?” Yeah. I’m in-network (“par,” in insurance terms – participating) with several plans and take assignment. I’m not in-network (“non-par” – I don’t par…never mind. You get the idea) with many more than I’m in with. There’s various reasons for that, none of which really matter here. Feel free to email me if you really need to know but, trust me, that’ not what this is about.

Personally, I’d rather you not use your insurance. That way we can keep things just between us (the two of us, not the two of us and a lot of other people.) I know that you want to have your insurance company pay me (“par”) for part of your treatment or reimburse you (“non-par”) for some of what you paid me. It makes absolute cents. Dollars and cents. Unless you work for the exceedingly rare, and growing rarer all the time, companies that pay your entire premium, you pay a lot for your share of the premium on your health insurance. You want to get something for that hard earned cash that’s not going into your paycheck. Even if your policy doesn’t cover “behavioral health,” you may have a flex or cafeteria plan that you can use to cover some of the period of treatment, some sessions, something.

I get it. I feel the same way about my health insurance. I want to get something back for the money that’s paid in. It’s why we have insurance, right, so that we don’t have to pay the whole ginormous cost of examinations, treatments, medications, devices, etc., etc? Yeah, that’s all real swell but there’s a good reason, maybe several, why you should consider not using your insurance for your psychotherapy/psychoanalysis/mental health treatment. Can you guess what it is?

Money? No. That’s not it. Yeah, sure, I can ask for more money from you if you pay out-of pocket than the fees that the insurance companies “negotiated” in the contract for “par” situations. Even if I can charge you more if I’m non-par because I don’t have to accept the rate the insurance company wants to pay, it’s still not about the money.Please believe me on this.

OK, I’ll give you a hint: look at the title again. The part that says “…Privacy of Our Work Together.” That’s my big concern and needs consideration on your part before you simply say “I pay for the insurance and I want to use it where ever I can.”

Have you stopped to think about how I get paid or you get reimbursed? Of course you have. I do something that goes to the insurance company and they send me a check (or deposit to my account) or I give you something, you combine that with something else, send it to the insurance company and they send you money. Simple. As easy as 3.1416.

Not so fast, Kimosabee. What’s on that claim form that goes to them? The CPT code (that tells them what procedure was performed, e.g., 90806= O(ut)P(atient) psychotherapy, 45-50″ (minutes,) no med(ication) eval(uation.) That tells them how much they pay out for what went on in the room. We can all agree that this is pretty harmless and doesn’t really do much in the way of leaving an artifact, right? Wrongo! Let’s move on to part II of this and I’ll explain more. For now my tea is ready to brew. See you in a bit!

What? You Want to Leave Treatment?

September 22nd, 2010

I got a call last Friday from a friend who said in her message that she told her therapist (it’s never “analyst” or “psychotherapist”) that she wanted to cut down her treatment to having sessions every other week. She said the therapist didn’t agree so she wanted to talk to me & explain her reasons for wanting to do this. She wanted me to call her back over the weekend, if possible, so she could explain it to me.

I didn’t call her over the weekend. Not because I don’t like returning calls. Doesn’t matter if the call is from a friend, patient, possible referral or whatever. I didn’t call because I didn’t quite know what to say because I’m a therapist. In point of fact, I’m trained as a psychoanalyst but because of the licensing laws I can’t say that I am one (yet another story.) So I didn’t say it. But that’s my training and I do practice psychoanalysis.

I didn’t call because there’s really very little for me to say. People want to leave treatment all the time. It happens.  We all know this.

Yesterday I received a different message from her. I was in the middle of a session and couldn’t take the call. Happily couldn’t take the call. In her message she said that she wanted to leave treatment entirely and was considering not even going to her next session. She thought she’d send her therapist an email explaining her reasons. She asked if she could send me the email first (I typed “fist” there and had to correct it. I wonder what Uncle Sigmund would think of that!) to see what I thought of it, but I’d have to send her my email address so she could do that. This message warranted a response.

Like I said, people leave treatment all the time for any number of reasons. We know this. We also know that the reasons aren’t always what people say they are. This is part of the work. I reminded her that I’m a therapist and, as such, I can’t go along with ending treatment with an email. I don’t like getting emails from my patients. Lack of confidentiality and all that. I tell patients not to email me. I don’t email them even if they do. I respond with a phone call. That’s another story.

Ending a course of psychotherapy (or psychoanalysis) isn’t like deciding not to see your doctor or dentist. There’s a more intimate relationship that’s been forged (or was supposed to be forged) during the treatment. Calling your therapist to say “It’s over” (or sending an email to say much the same thing except at greater length) is not “the easy way out.” We have an obligation to make sure that the loose ends that can be tied up are. We also want to know and discuss what is really going on.

In some ways it’s like telling telling the surgeon who’s just finished removing your appendix to not bother closing. No stitches for me. I’ll be fine, thanks. Just send me the bill. Anyone who would do that would be considered a bit (or a lot) bonkers. And psychotherapy isn’t like surgery for a ruptured appendix. You don’t have to have it. You can go through life the same as you’ve been going through life and you can keep getting the same results. It’s also not like recommended surgery for which you get a second opinion, at least not once you’re finished shopping around for the therapist who works best with you. One therapist can’t know what your treatment was like with another therapist, no matter how much you try to explain it. That’s why someone asking me to listen to his or her reasons for leaving a current therapist is not something I’ll do. I can’t know what went on. The reasons may or may not seem valid but WDIK, y’know? I can’t listen as “a friend” because of my profession and I can’t treat a friend for the same reason. If this were a professional consultation I’d be saying the patient should (one of the few times I’ll use that word) swing back around and talk with his or her current shrink to settle up what’s unfinished.

The process is called “termination.” It means an ending. It’s a process. It’s that simple. Don’t just go away mad and don’t just go away. You owe it to yourself and your shrink. I’m not here to talk you into staying in treatment. I may try because of work left unfinished. You and I may agree that it’s time to go (it happens – really!)

Sorry friend. I can’t tell you anything other than I did. Not showing up isn’t the easy way out. It’s just messy. Doesn’t mean you can’t skip out, just that it’s leaving before the party’s over without saying goodbye.

6 Ways to Cure Foot-In-Mouth Disease

August 11th, 2010

Watching Family Feud years ago I saw one of the funniest examples of Foot-In-Mouth that I’ve ever seen in my life. Funny to me, funny to Dickie Dawson who was doubled over with laughter so bad he had to sit down on the stage and try to stop. It was the “lightning round.” He started to ask the mother of the family a question: “In what month…” At the word “month” she blurted out “March!” That got ol’ Dickie going. What was so funny about “March” says you? Because the full question was “In what month of pregnancy does a woman start to show?” It wasn’t the name of a month, it was a number he was looking for. Her answer was so out of whack with the question that he just couldn’t stop himself from laughing. Hard. She, of course, was somewhat mortified but got over it quickly. It’s a game show, after all.

Not so funny when Foot-In_Mouth happened to someone I know. He was having a conversation with a woman. It was going well right up to the end. She said she had to leave to go to work. He said he had the day off. She said “Enjoy your day off.” He said, “You too.” She said, somewhat less that elatedly (to say the least) “Thanks.” He felt flattened. No, he felt like he made a total jerk of himself. She’ll get over it, probably did in about 2 seconds, but it stayed with him all day. What did he do wrong?

How to avoid Foot-In-Mouth Disease:

1. Listen to what the other person is saying.  I know you want to speak. Especially when things are going well and you want to show someone that you’re being attentive to her but wait. Let her speak. Listen to what she’s saying. If you don’t hear what is being said how can you even think of responding?

2. Wait to answer. Yeah, time is of the essence. Take to long to answer & somebody’s going to think you’re a dimwit, right? The “wrong” answer also makes you look like a dimwit. Even dimmer. It can turn a great exchange into a “goodbye.” Is that what you want?

3. Pay attention. It’s not enough to “listen” and wait until the other person’s finished. Those are rules for using the sink in a public washroom. Is that what’s going on? If so, then all I can say is Insert foot  in mouth and chew vigorously. You gotta pay attention to what’s being said & not just wait until the other person’s finished. It’s not about “It’s my turn to talk.” You’re trying to respond.

4. It’s a dialog, not a duologue. What’s a “duologue?” Something someone I knew made up or stole from someone else (just like I stole it from him) to describe two people talking at each other. Two monologues that look like a conversation from the outside. Neither is listening to the other except to hear when to start speaking. Like when one pauses for a moment. This doesn’t make for conversation. It just makes for making noise at each other. You got something important to say? So does your partner in the conversation.

5. Relax! This is the big one. Even if you do make a faux pas you can recover from it unless you just screwed the pooch, in which case you’re dead meat anyway. Most of the time your partner in conversation will accept your acknowledgment that you have just started chewing on your foot, especially if you spit it out immediately. Embarrassing? Sure. Can you laugh at yourself? Important to learn. If your partner in conversation laughs with you as you spit toenails, you’re in. If not, apologize for not hearing correctly. Apology not accepted? How bad was what you said? Probably not so bad as you think, it was just the wrong moment. Give it time. Relax because you can

6. Make a good second impression. Really. Try applying the steps above next time. No next time? Maybe not with that person. How about someone else? You are going to speak with someone sometime, aren’t you?

That’s it. Oh, yeah. One more thing. The cure for Foot-In-Mouth is like the way to get to Carnegie Hall: practice, practice, practice. Learn to listen – listen to learn. Fish & whistle – oh wait: wrong song. OK. Listen, wait, pay attention, etc. Courage! Faint heart never won fair whatever.

Credit Cards & Psychotherapy Fees

July 27th, 2010

Credit cards for psychotherapy fees? No. I don’t. It says so right on several of my listing pages. If you haven’t seen them you can find them at Help Pro:


Psychology Today’s find a therapist:

There’s another couple of them floating around out there, including one where I can be rated by patients (no one’s gotten there yet – be the first on your block!) In any case, no, I don’t take credit cards but….

There was a recent discussion of the “ethics” of accepting payment of fees via credit card on one of the list serves I subscribe to. I mean, why shouldn’t we? Your dentist does. So does your MD, well as every other professional and, in fact, everybody including the butcher & baker. What’s the big deal about “ethics?” It’s just another way of paying for services, right?

Wrongo. Money & psychotherapy (psychoanalysis) have been inextricably linked ever since Uncle Sigmund was writing out his confusion into clarity (and then confusion, but that’s another story.) Credit isn’t a payment by you to me. It’s you asking your bank to pay me. But wait, I hear you ask, isn’t that just like paying you by check? No (unless you’re using overdraft, and we need to talk about that.) When you pay me by check you’re paying me out of your account.  It’s your money. Credit is somebody else’s money (OPM.)

I know, I know. Everybody does it. You pay for everything with credit. It helps you keep track of your spending. You couldn’t pay for it otherwise (again, we need to talk – see the next blog post.) Well, no, they don’t. Not everybody. Besides, it puts somebody in between us (is that what you want?  We really need to talk.)

It’s not that I’m hungry for money or my cash flow needs an infusion of ready money. It removes you from the interaction of us, and that’s just where we need to be.In case you haven’t figured it out, I’m kinda old school about some things and the relationship between us is important to me as a really vital part of the work. Got it? Money is one of the ways that people exchange energy between each other and also one of the ways, one of the really frackin’ big ways people show what’s important to them. Credit changes that. It removes the exchange between us and makes everything equally (un)important.

Yeah, I know. Who wants to be bothered carrying cash or checks around? Good question. Wish I had an easy answer for ya. As for the “ethics,” that’s also part of the next blog.

Catch ya next time.

ADD & Taxes Pt. II: The Folly of Working Hard: Completeness is the enemy of sense

July 14th, 2010

My last post was a bit of a disappointment to me. My “voice” was missing (what, you couldn’t hear me because it’s written, not spoken? Shirley, you jest.) I was missing a simple ingredient. Simple. That’s what I was missing.

See, I was trying to do too much in one shot. There’s only so much stuff I can cram in a 5-pound sack & I was looking at about 2o pounds. Then tried to tie it closed with a string. In the middle. The result? An overflowing, non-flowing pile of stuff that wasn’t satisfying to me, I don’t know about you.

The “simple” answer to the issue of ADD/ADHD and taxes is that there’s no “simple” answer that I can give. I can make suggestions but that’s already me imposing my thoughts. The simplest answer I know is to try things, no matter how logical, illogical, whimsical or insane they may seem until you find the method that works. If it works for you and Uncle Sugar it’s a bingo.

As for the other “simple” answer: I forgot the simple rule: Don’t work hard. Work smart. I was working too hard to try to get all my thoughts into one post. Phaugh! What a headache. It was a bad idea even if I could have done it. It was too much to organize (especially doing it inside that crowded melon between my hat & my neck.) Hard work never helped. Look at John Henry. He “…was a steel-drivin’ man (lord lord”) and, yeah, he beat that steam drill, but he died and his wife had to finish the job for him. He wasn’t even bustin’ up the mountain, he was just drilling pilot holes for the blasters (if you’ve never heard them, you gotta give them a listen. They’ll knock yer socks off) so they could bust up the mountain. The guy with the steam drill? He got to go home & have his soup. John Henry “…laid down his hammer an’ he died (lord lord.”) Where’s the percentage in that? He got a folk song written about him, but so did the guy with the steam drill. Don’t think so? Listen to the song again. It’s all about John Henry vs the Steam Drill.

What’s my point?  Zeit nicht meshugeh! There’s no “right” way to do your taxes (or anything else) as long as your in compliance with the codes, but working harder isn’t necessarily better. Working smarter, thinking about what you’re doing before you do it is often better. If someone accuses you of being lazy, go ahead and agree. Tell him (or her) that sure, you’re being lazy, but not unproductive. Remind him (or her) about John Henry. “He laid down his hammer and he died (lord lord.”) Does that sound good to you? Not me, cousins. I’ll use the steam drill any day rather than swing that sledge and go home, have my soup and, if necessary, come back tomorrow and finish up. The opposite of hard work isn’t “hardly workin.'” It’s workin’ smart.

Next up: Credit cards & psychotherapy fees.

Taxes & ADD/ADHD

June 22nd, 2010

TAXES? Is he kidding? I don’t have to think about that until next April. How about something useful like relationships, school, relationships at school, stress from relationships & school. How about fishing or hiking? Exercise? Why this now?

Why this now? Because now is the time to catch up on getting taxes for this tax year organized. We’re already halfway through it and you don’t know where all your receipts are, haven’t kept the checkbook balanced and/or haven’t entered everything into your accounting program that you haven’t updated, etc.

The simple fact is that taxes are a year-round reality, not just something that happens in April and, as Inspector Harry Callahan said, “Man’s got to know his limitations.” Sure, you’ve been downloading all your credit/debit transactions into your accounting program, but what about the cash purchases that you can’t download? Does your accounting program properly itemize or hasn’t it been set up to do that properly? What about the receipts for the donations of clothing, etc. to your favorite thrift store? Do you know where they all are?

ADD/ADHD comes in different “flavors:” Disorderly/energetic, distracted/daydreamy & highly structured. These aren’t distinct categories and hardly anyone is all one “flavor,” but knowing or recognizing what type you are can lead to different strategies for dealing with taxes (and money in general.)

The highly structured kind has the easiest time with taxes, right? Everything is in its place and everything is OK. But is that true? I did ask about “all” the receipts for expenditures, tracking of income, donations, etc. All means just that: ALL. One missing receipt can throw the highly organized person into a frenzy of activity, holding up everything until that one missing piece of paper is found, often just before April 15th, with all the resultant anxiety and recriminations that go with not having everything under control and in place.

The disorganized and distracted types often have the opposite problem. Instead of everything being in “its place” everything’s place is everywhere and anywhere. Receipts were put away to keep them together only now that location is forgotten and so others get put in another place or nothing was really “put away” but was left to sit where ever a wallet or something got emptied. Stuff is all over and the end of March/beginning of April is a frantic search to assemble a year’s worth of documentation, enter it somewhere, and get the taxes completed in time.

Any of this sound familiar? Many people go through this same scenario, whether they are diagnosed with ADD or just not thinking about money & taxes until the subject is shoved in their faces. It’s stressful, can lead to problems in relationships, takes time away from other things and can take over your life for a while. So what can be done?

Read the rest of this entry »


April 20th, 2010

A man walks into a psychotherapist’s office and says, “How am I?”

Why start out with a dumb joke? To get it out of the way, of course. There are loads of psychotherapist/psychiatrist jokes out there, so there’s one and that’s done. Now I can get down to the business at hand:

Out Of My Mind is a blog by a private practice and consulting psychoanalytic psychotherapist in New York City and for the general community. Some of what you’ll find here is written to and for other clinicians but mostly this is going to be aimed at informing the general public about trends in mental health practice, suggestions for ways to reduce stress or recognize stressful situations and other stuff about how “life issues” affect day-to-day effectiveness. I’ll  also be posting my  opinions about issues such as the state of delivery of mental health services, privacy practices and the situations that arise,  and sometimes just talking about a movie or book that might tie in to mental health issues (believe me, everything ties in to mental health issues, whether most people think so or not.)

I’ll be talking about “the unconscious,” sometimes meaning the people who seem to be, or are, walking around in their sleep.  I’m going to try to keep the clinical jargon to a minimum because I’m not a fan of speaking in code, though sometimes it may be unavoidable.

I do want to be clear at the outset that this is going to be an offering of information and my opinions and, unless stated otherwise, it’s going to be me speaking out of my head. This is not intended to substitute for psychotherapy and is not offered as treatment for any mental health issues except maybe my own need to speak my mind. It also in no way is purported to represent the views of the host for this blog or any of the intermediaries who get these words to you. This is me sharing my thoughts, ideas, and perhaps some useful information to you.