3 Ways Managed Care is Hurting Your Practice

3 Ways Managed Care is hurting your

This is not the first time you've heard me share my perspective on the problems of building private practice based on managed care. The original intent of these third-party companies was to ensure equity for those who receive treatment, but the actual results have been far from successful and have caused a myriad of problems. Some have even described managed care as the cause of the mental health care crisis. And while managed care wreaks havoc on the field as a whole, this system is also problematic for private therapy practices. As a clinician, I can certainly attest to this. My guess is that you can too. Here are the 3 main ways that using managed care panels may be hurting your practice:

1) Micromanagement of Treatment

Managed care panels have a way of micromanaging you in a supposed attempt to make you accountable. This means that a therapist often has less say and control in the type, length, and modality of treatment provided to the client, who has also has less input in the process. Think about it: an outside, commercial middle-man is dictating how you, the professional, help your client. It's easy to see how such a system lends itself to inadequacy and substandard care.

The mandatory diagnosing of clients is arguably the most deplorable part of using managing care panels. You are often required to provide a diagnosis, even if you do not believe your client has one. Even worse, some companies only accept certain kinds of diagnoses, which only further restricts your ability to provide ethical and accurate information and care.

2) Business Inefficiency

Communicating with managed care companies is a nightmare. There's excessive paperwork to fill out and phone calls to make. The hassle is never-ending, and it takes away from what you want to do: use your professional skills to serve your clients. Not only is your business inefficient and time-consuming to operate, but by looking at the math, you'll discover that your overall costs are increased as well. Even analyzing things solely from a business perspective, it's evident that using managed care is not a desirable model.

3) Payment Problems

When working with managed care their contracted rates were 40-60% of my full fee. Not only was there a low fee, but there was also the frustration of denied or delayed payments. There would sometimes be problems with the paperwork, or things would get lost in the tedious communication, and I wouldn't get paid for weeks or even months. I wasn't being sufficiently compensated for my work, and I wasn't always being paid in a timely manner. It was disheartening to say the least. It is emotionally and financially draining, and we deserve better.

These are three of the major ways managed care can hurt your practice (although there are certainly more). Thankfully, there's a better way. A way you can work less and earn more. I'm excited to share you with in upcoming posts about how transitioning to a fee-for-service model helped me build a thriving practice.

Click here to access my webinar, "Breaking Up With Managed Care" to learn even more tips and strategies.

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The Power of Online Presence: Blogger Dawn Friedman uses her Advanced SEO Skills to Rank High in Google

Discover how some very successful mental health professionals use blogging, social media, and other technologies as powerful tools for their therapy practices.

Dawn Friedman, MSEd LPC, is a clinical counselor specializing in issues surrounding family building, including infertility, adoption, pregnancy, and parenting. An early adopter of technology, Dawn started a blog that became the basis of her strong online presence and has helped her grow a thriving practice. Read about her story here:

When and how did you first start putting time and effort into maintaining a strong online presence?

Back in 2001, I started a personal blog that I continued for about ten years. In that time, blogging went from a fairly introverted way to journal to a massive (and competitive) industry. Because I had started early, I got to see the field of blogging really take off and learn it as it happened. So when I turned to blogging for a private practice I hadn't opened yet (about a year before I planned to launch), I already had a strong understanding of how blogging and other social media work. 

Starting my professional blog a year before my practice opened gave me time to play around with the design (in WordPress) and think about how to lay it all out. It also gave me the space to find my blogging voice. I wasn't sure how to switch from personal writing to more careful disclosure as a therapist, and it took some time and bumbling around to figure out how to be friendly, open, and myself without giving away so much information that it might overwhelm a potential client. I started out way too impersonal and over time let myself loosen up and have more fun with what I wrote. The advantage, too, of starting a year in advance is that having a living, breathing web site that was already getting some traffic made it much easier to start showing up in local searches once I was ready to launch. The blog was already going, and I just needed to focus on creating the pages that described my services, hosted my paperwork, etc.

Please describe what social platforms you currently use.

I used to do social media consulting on the side back in my personal blogging days. What I told clients was to go and claim your online real estate, which means grab the Twitter handles, the Instagram names, etc. Even if you're not going to use them, you don't want someone else to have them. So technically, I have most of the social platforms, but I don't use them all. Many of them you can keep alive passively (WordPress blogs will automatically post to Twitter, LinkedIn, Google Plus and Facebook if you're using JetPack). Once you have all your accounts lined up, you can figure out which ones make the most sense for you to put more work into.

For me, I put the greatest effort into my blog and website.  I've worked very hard on my search engine optimization (SEO) and am on the front page for most of the local searches that I've targeted. The second place where I put in effort is on my Facebook page. I have a professional page and a personal account. My personal account is on lockdown with the privacy settings but I assume anything posted on the internet could potentially show up on a client's screen, so I bear that in mind when I'm posting. That said, I've found that Facebook is the social media site that will drive the most traffic -- especially local traffic, which is what I want -- to my site. I have my blog automatically post new updates to my professional page, and then I share from my page to my personal account. Since doing this, I've seen an increase in traffic, and more people have liked my page. So overall, I do invest some time into Facebook, but I'd rather spend more energy on my blog. It's a very personal choice, and there's no right way for everybody.

About how much time do you devote to your online presence? How do you balance it with your other work responsibilities?

Back in my journaling days, I would blog daily. Now, if I can post six to eight times a month, I'm pretty happy. I'd like to post more because I really enjoy it, but I just get too busy. Other than putting out new content, I also spend a few hours each month updating my site, playing around with my theme, changing out my front page picture, and looking at my stats to see where I can consolidate pages or tighten up my menu. I keep an eye on the number of hits the different pages get. For example, I realized that the part of my site that people clicked the least amount was "Services," so I turned it into a menu header. This led to an increase in clicks directly to services people are interested in. I also am always tweaking and adding things that might help my search engine optimization, which I think is a lot of fun because it's like a game!

What kinds of things do you use to inspire your content creation; what do you write about?

I usually write about things that tend to come up a lot in sessions. For example, many of the children I see struggle with anxiety, and I get quite a few questions about that subject too, so I wrote a three-part series on child anxiety. I also write about books I've read -- counseling related or not -- share fun music videos, and highlight local events that my potential and current clients might be interested in.

I will add that sharing local resources helps me in several ways: It gives me a writing topic, it allows me to share good information with readers who will welcome it, it lets me to network to get that resource up on my blog, and it improves my local SEO. I mean, it's fun to get readers from all over the world but unless you live within driving distance to my office, you're unlikely to become a client or refer me to someone you know. Sharing local events makes it clear that I want to be a resource for my community here in town, and it's also much more likely to be shared by locals on Twitter or Facebook. Win/win!

Back when I did social media consulting, I'd tell people to share the kinds of things you might find yourself talking about at a dinner party. What interesting, fun anecdotes do you have? What thought provoking things have you come across? Even though things like SEO and header tags are important, sometimes you have to put aside the worry and just write. Find your voice first, and your blog will benefit you even if you don't do all that social media stuff "right." Trust me on this. If people like what you write, they will share it, and that will help your traffic. Also, people who click to you from a directory or a Google search will have the opportunity to get to know you, which will increase the chance that the people who call you will be a good fit for your practice.

Just write!

How do you best balance personal and professional in your online activities? Please give examples.

This was a tricky thing to figure out, and it's something that I still reflect on regularly since I think ethics demand that we always be thoughtful and aware about what we share and how that might impact our clients. I do know that I tend to be more comfortable with disclosure than some therapists, and I think that's a matter of personal style. On the other hand, I've seen therapists share way, way more than I'd be willing to do (And I say this having lots of published essays out there that will give any client with Google the opportunity to learn my kids' names, my political beliefs and my personal philosophies on a whole bunch of things). 

Generally, I've decided that I will share anything on my blog that I might share in a session. For example, I might write about a parenting challenge I've faced personally to illustrate a developmental phase presenting in a client's family because that's something we might talk about together in my office (Note: I always get my kids' permission before posting stories about them). When I want to write about something that might make a client even slightly worry that I'm talking about him/her, I'll write about a fictional character. In the series on anxiety, instead of using a fake Jane Doe, (which might lead a client to think I'm writing about his or her child) I wrote about Goldilocks. This allows me to illustrate ideas without threatening anyone's therapeutic relationship. I've written about Harriet the Spy and Ramona Quimby, too, to talk about kids. Other therapists might like using characters on television shows or movies. Using fictional characters not only protects clients from thinking they're seeing themselves in what you write, it's also a fun way to call out cultural touchstones that speak to you.

What is some tangible evidence that your online presence has grown your business?

I've had many clients come to see me because of something they've read on my blog. Someone will share something I wrote on Facebook, and another person will see it, click through, and see that I'm a therapist and then call me. I've also had people go looking for a therapist and stop to read my blog first. Sometimes people tell me that they've read my blog for several weeks or months before making that leap. Having that updating, ongoing resource made it easier for them to feel safe making the call. Some clients say that they want to see me even though I don't take their insurance because they like what I said about a particular topic or feel like they would be comfortable with me. In other words, they want to see me, not just whatever therapist answers the phone first.

Also my blog and attention to SEO has kept me on the front page of local Google searches for my target market. That's huge and has definitely been a tremendous help in my practice building. It's not just potential clients, either. Referral sources use Google, too.

Besides attracting clients, what other ways has your strong online presence helped you?

My blog has helped me secure speaking and writing gigs. I've stepped way, way back on my professional writing since working on my practice, but both my personal blog and professional blog have brought editors to me. Networking is also easier when you have a great web site. It's fun to meet someone for coffee and have them say, "I already know this about you..." It makes starting those conversations easier.

What have been some of the biggest challenges you’ve encountered creating and maintaining your online presence?

There were some technical challenges I had when I first started my professional blog. I was using the URL I had used for my personal blog so that I wouldn't lose out on traffic. I had to change the URL and needed a 301 redirect to maintain that traffic. This is one of those things that sounds scary and complicated, but is actually pretty easy. There's a great explanation of how to do this on Wordpress if you're ever in need.

Beyond that, it's easy to become overwhelmed or to think you need to use every bell and whistle available. I tend to try out new things for a little while, then drop them if they're not useful. Part of this is that I just like learning this stuff, but I do have to watch my time constraints. It's way more fun to me to create a great, shareable image on Canva than it is to write up my case notes, so sometimes I reward myself with online tweaking when I'm all caught up on paperwork.

Also it's tempting to save things. Like save that great metaphor for my next talk, or save that terrific example for writing I might publish elsewhere. I've since learned that the more I give, the more I have to give. Memoirist Annie Dillard said:

"One of the things I know about writing is this: spend it all, shoot it, play it, lose it, all, right away, every time. Do not hoard what seems good for a later place in the book or for another book; give it, give it all, give it now. The impulse to save something good for a better place later is the signal to spend it now. Something more will arise for later, something better. Anything you do not give freely and abundantly becomes lost to you. You open your safe and find ashes."

It's true. The more you write, the more you share, the more you will create. To hold back is a little bit like never adding weights to your lifting routine because you want to save it for when you're stronger. It's the exact opposite really.

What tips or resources can you recommend to help therapists who are new to the online world of blogging, social media, SEO, etc.?

I really like Amy Lynn Andrews for her series on starting a blog. I send her information to people all of the time. It's clear, it's easy to implement, and it works. I also like her newsletter for staying up to date on different tools that might be useful. She's not specific to counseling, but I always learn something, and even though she's super beginner-friendly, she also points to other resources for when you're ready to dig deeper into social media and SEO.

Dawn Friedman MSEd LPC

Website: www.BuildingFamilyCounseling.com
Facebook: www.facebook.com/BuildingFamilyCounseling

4 Ways a Private Pay Practice Model Benefits Clients

The value of using a private pay model (instead of a managed care system) for your therapy practice is clear: less stress about additional paperwork requirements, greater autonomy to provide the services you deem are in the client's best interest, and immediate payment of your full fee are some of the main advantages. But some therapists are understandably hesitant about how to make the switch because of the potential impact this choice it might have on their clients. Some common fears are “Clients might stop getting the therapy they need because they can’t afford me” or “charging a higher fee is selfish and means I care more about money than helping people.” When I was considering making the switch, I too had thoughts like these cross my mind. But I discovered that the opposite was true; breaking up with managed care and embracing the new way of structuring my practice actually benefited clients who received services. Here are 4 ways that a private pay model benefits clients:

1) No Mandatory Diagnosis

Many managed care systems require that you diagnose a client's specific mental health condition condition prior to paying you for your services. In some cases, insurance companies will only pay for certain diagnoses. Often, relationship issues are not covered. However, this can turn in to serious ethical problems.

I remember years ago I was referred an urgent client - a child who was sexually assaulted. I determined that she had no clear-cut symptoms and didn't meet a diagnosis that her insurance benefits would cover. I was in a terrible dilemma: do I give an inaccurate diagnosis to satisfy the requirements of managed care, or do I get paid for the initial? No therapist should ever have to find him/herself in this kind of a situation, and no client should be subject to this either.

One of the best parts of employing a private pay model is that there is obviously no such requirement. Diagnosis can be used as a tool, but you are not obligated to provide one. By eliminating the need to diagnosis a condition that may or may not fully exist, you can ensure that your clients receive ethical, honest, and accurate care.

2) Higher Quality of Service

Back when I used a managed care system, I was receiving approximately 40-70% of my stated fee. This meant I was in survival mode, seeing more and more clients just to try to get by and meet my own financial needs. And all the while, I still had the stressful task of running the business side of things. It’s not surprising then that I wasn’t able to give as much to my clients. As much as I tried, unfortunately the standard of care I could provide was compromised. That was unfair to me and unfair to the people who were paying me to help them.

By changing to a private pay model, I was able to see fewer clients and, which reduced my stress, which allowed me to be more present for my clients. I also no longer spending hours per week on phone calls and paperwork that came with using a managed care system, which freed up my energy to give to those I served.

3) Better Therapist/Client Match

A private pay model also lends itself to a better fit between the therapist and the client. If you have fewer clients, you can be selective about the ones you see. The opposite is also true; if someone is willing to pay more for professional therapy, it’s likely that he/ she has done his/ her research and sought you out because of your specialty and the expertise you provide. To put it simply, you want them, and they want you.

I’ve found that using this financial model attracts highly-motivated clients. Although they are required to pay more, they place high value on therapy and budget accordingly.

4) More Clients Reached

A private pay therapy model allows you to have a greater outreach and help more clients. This may initially seem counter-intuitive; how does seeing less clients serve more people? The answer is that if you have a surplus of potential clients or have people come to you with needs that are different that the expertise of your practice, you can refer them to trusted outside resources. You’re helping other therapists while simultaneously ensuring that clients receive the best care specifically for them.

The other thing I have found is that the income stability provided by a private pay model allows my colleagues and me to do more pro bono work. Paradoxically, because we earn more, we can provide more volunteer service when we choose.

All in all, switching to a private pay model was one of the best business decisions I made to benefit not only myself, not only my practice, but the clients and the community we serve. Charging a higher fee does not mean you are inconsiderate or selfish; it means you are valuing yourself and providing the best quality care to your clients.

*If you find that finances are legitimately a concern for some of your clients, you may decide to provide alternative choices, such as reduced fee sessions with Masters’ student interns. My practice Wasatch Family Therapy does this, and it works well for those looking for a more affordable option.

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5 Common Barriers to Building a Fee-For-Service Practice

Building a fee-for-service practice can be scary, especially if it means resigning from insurance panels and finding other ways to attract clients. Others may have already made the switch, but don't know how to successfully navigate the change. I have found some strategies to help ease the transition. Here are 5 common barriers to building a fee-for-service practice and ways to overcome them: 1) "I'm uncomfortable marketing myself"

I often hear therapists say that marketing themselves feels like bragging or tooting their own horn by self-promoting. In order to move past this barrier, it's helpful to reframe the way you think about marketing. Consider it instead as REST: Relationships, Educating, Serving, and Trust Building. You are building relationships with potential clients who might see your website or other media, you're serving your community by educating them about important topics related to your niche, and you're establishing rapport and building trust with those who encounter you through your (online) content (REST is essentially why you're in the profession in the first place, right?). If you can focus on these 4 things, you can (and will!) attract clients who will pay your full fee. While your "marketing" strategy (I'm not a fan of that word, by the way) REST strategy is meant to benefit you by helping your community become familiar with you and your services, it's really about those who you can potentially help through receiving services through your practice. Don't be shy in getting the word out about yourself; it's a way for you to use your professional skills to serve and educate your community.

2) "I'm afraid of the ethical issues surrounding social media"

Those new to the world of social media may be wary to fully embrace it because of the potential ethical problems that may arise. Potential for unethical dual relationships, confidentiality concerns, and lack of knowledge are common fears. But these fears (and others) can be overcome: having an official social media policy included with your intake packet, avoiding directly soliciting your additional products or services to existing clients, being familiar with privacy settings online, and overall just using your ethics training and common sense will help you be prepared to face these potential issues.

Click here to read a more comprehensive article about overcoming fears associated with social media.

3) "I'm not good with technology"

The internet gives us incredible opportunities to communicate and reach an audience that is unprecedented in size. However, for those unfamiliar with all the ins and outs, it can also be intimidating, overwhelming, and frustrating to start. Mari A. Lee, an LMFT who specializes in sex addiction recovery, understands this feeling all too well. She describes being scared and resistant to learning new technologies. But she was able to overcome her "technophobia" by starting with manageable goals, finding a patient and persistent mentor, asking lots of questions, and setting aside time to devote to learning and practicing new tech skills. Her success in building an online presence paid off big time; she's currently a best-selling author! "If I can figure out how to blog, attend and facilitate webinars, host online trainings, navigate my Facebook business page, and so forth, anyone can... If this 52 year-old former tech scaredy cat can do it, so can you!" Mari explains (read more about her experience here). 

Understanding and applying the language of technology does not happen overnight. Be patient with yourself, as there's certainly some trial-and error learning here. Remember that everyone starts somewhere. And just like Mari, look for a mentor to guide you and bounce ideas and questions off of. You've proven yourself to be an apt and competent learner by becoming a licensed therapist; have the courage to learn another skill set as well.

4) "I can't do media appearances or speaking engagements because I hate seeing and hearing myself"

Therapists tend to get shy about media interviews. It's one thing to sit in front of a client and offer counsel in a one-on-one session, but speaking in front of large audiences can bring out anxiety in even the most confident clinicians. But remember how much you know; you are a trained and experienced expert. The aesthetic and "performance" aspect of media appearances will come with time. The more prepared you are, the more comfortable and relaxed you'll be. And if by chance you do feel like you bombed a television interview or radio podcast, learn from it and try to move on. It's not the end of the world if you make a mistake!

Read here for more tips on how to look good and sound professional in your media appearance.

5) "If I'm a great clinician, my work will speak for itself"

Some therapists plan to rely on their hard-earned reputation as an excellent mental health professional to be their main source of client referral. They then focus solely on refining their clinical skills, as they don't see the need to engage with their community beyond private sessions. While referrals can be an effective strategy to build your clientele, depending on others in the field to refer to you should not be the only way you attract people to your services. The harsh truth is that there are a lot of excellent therapists who fail in developing a successful private practice. Everyone has to start somewhere, and it takes time and experience to gain a loyal following and individuals who actively seek you out.

You may find that by being persistent in building trust in you and your services over time will be the major benefit to the growth of your practice. Because we have worked hard to establish ourselves as trusted professionals by embracing social media and building our online presence, my practice, Wasatch Family Therapy, receives most of our referrals from Google searches. This is something I feel very grateful for, and it's largely due to the fact that I stopped participating on managed care panels and consequently had to work within the community to build trust directly with potential clients.

Embracing a private pay practice model brings more than a few questions, unknowns, and worries. But by using these strategies, you can overcome barriers and build a thriving practice.

Besides the obstacles presented in this article, another major reason why clinicians may be wary of switching to private pay involves how they think their clients will be affected. I address (and debunk!) these fears here.

Click here to view my webinar and learn more strategies and tips about breaking up with managed care!

Join my Private Practice Toolbox Facebook group and connect with 2800 therapists around the globe in 2 simple steps: 1) Click request to join the group and 2) Fill out this brief questionnaire before you'll be added to the group.Get practice tips and blog updates in your inbox.

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3 Ethical Fears of Being a Therapist Online and How to Resolve Them

Every therapist knows that ethics is a critical component of working with clients. Once you add social media into the mix, things can get even more complicated. I’ve noticed that unfortunately, some in the profession are resistant to embracing technology and building an online presence related to their practice because of fear of the potential ethical problems. It’s true that there are risks involved in going online, but we don’t need to be run by this fear; the risks can be managed, and, as we’ve talked about so many times before, the benefits are staggering.

Here are 3 Ethical Fears of Being a Therapist Online, and How to Resolve Them:

1) A Client Breaking Professional Boundaries

If you’re findable on the internet, naturally you’re easier to contact as well. And while we find that most clients respect boundaries with their therapist, some may choose to disregard common rules of protocol, especially when a professional’s online presence facilitates their ability to do so.

Mari A. Lee, an LMFT who specializes in sex addiction recovery, prevents this by having her clients sign a social media form as part of the intake packet. “I do not allow clients to post to my business Facebook page or private message me,” she explains. “I do not accept friend requests or professional links from therapy clients on LinkedIn.” Mari describes how the few times that a client has attempted to add her, she simply redirects them back to her policy. By doing, she has never encountered an incident of professional boundaries being crossed (read more about Mari’s experience here).

Overall, being clear about what is and is not acceptable for your clients with regards to social media will all but prevent problems from occurring. Develop a social media policy for your practice, include it in your initial client paperwork, and have it available on your website (read more about developing a social media policy here). While you must be firm about your boundaries, try to communicate your expectations in a way that is not alienating or harsh. A client reading your content online is a good thing, so you don’t necessarily need to discourage all forms of social media engagement; it is direct contact that is prohibited.

2) The Risky Possibility of Dual Relationships

We all know that therapists in private practice should be cautious when entering dual relationships with clients and be mindful of  the potential risk of exploitation or harm to the client. This caution extends to online dual relationships as well. If you as a therapist have an online presence and engage in multiple professional activities (publishing, consulting, etc.), you might be worried that a client could feel pressured to purchase additional services or products from you. Whereas before you were a person that your client saw in an isolated setting, you are now an established figure that he/she can read about or follow anytime on the internet.

This fear really is unfounded. It’s okay for someone to find you online and understand that you are selling something in addition to seeing clients. As long as you’re not soliciting these things during a private session, you don’t need to try and hide the fact that you do other things. Your ethics courses taught you what need to know about avoiding these kinds of interactions.

If you think there might be a legitimate possibility that your outside professional activities encroach on the ethical integrity of your counseling, consider the following: Dr. William Doverspike, a licensed psychologist and president of the Georgia Psychological Association, proposes a very simple ethics test when contemplating dual relationships. Ask yourself these 5 questions to determine whether or not your online activities are ethically sound in relation to your clinical practice:

Is there a chance of:

1. loss of effectiveness of the professional?
2. loss of objectivity of the professional?
3. loss of competence of the professional?
4. risk of exploitation of the client?
5. risk of harm of the client?

If you can answer an honest no to all of these questions, you’re just fine in pursuing your other activities.

3) Posting TMI

Most of us have witnessed someone who gets too personal on Facebook or on other social media outlets. These platforms can be great for sharing information and photos and keeping in touch with one another, but sometimes people go too far.

Being cautious with social media activities becomes even more important for a therapist with an online presence. Where does your personal life begin and your work life end? Would your relationship with your client be jeopardized by something you posted about your own life? Is it possible for something to be appropriate for your personal page but not for your business page? Keep in mind that social media platform privacy settings are constantly shifting and that there is no guarantee that some information posted on personal profiles may still be accessible.

I trust that my friends reading this right now aren’t the type who post blatantly inappropriate or disrespectful material, but it can still be challenging to find that line. Here is the rule that I’ve created for myself that has worked well for me: if I wouldn’t feel comfortable with anyone in the world viewing it, I won’t post it at all. It’s that simple.

Once again, this potential ethical problem is easy to avert. Use common sense, your ethics training, a social media policy, and your best judgment. Overall, just trust yourself as to what to post; you are a professional after all!

The point of this post is that you don’t need to be run by fear when it comes to social media engagement. I encourage you to embrace the technological world and let it benefit both you and your clients.

I wrote an in-depth article about social media ethics. Click here to read it.

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