Fees and Billing

Originally published in Volume: 1 Issue: 3 of HeadLines

The Professional Misconduct Regulation and Standards of Professional Conduct, 2017 do not specifically address the issue of whose name to put on an invoice.  Therefore, one must ensure adherence to the broader rules when deciding about how to proceed regarding what information to put on an invoice or receipt. The most important thing is to ensure is that any document, including an invoice or receipt, could not reasonably be seen as, 20. Making a record, or issuing or signing a certificate, report, or similar document that the member knows or ought to know is false, misleading or otherwise improper. [O.Reg 801/93 Professional Misconduct]

In cases where multiple members of a family are treated at different times and in different constellations,  it would be reasonable to make a principled decision and apply the same logic whenever similar situations arise, regardless of the wishes of the particular client or what their insurance coverage allows.

In this particular case, if an intervention is intended to impart parenting skills to the parent, it might be reasonable to assume that parenting work is intended to help the parents change their behaviour and consider that the services were provided to the parents. This would be different than meeting with the parents in order to provide them with therapy progress information or information to help them support the work being done individually with the child.

Most of the time this question comes up in the context of a family with per-person insurance coverage limits. In situations like this, a parent may ask to revise invoices or receipts once a family member reaches their insurance coverage limit.  One must be careful not to issue an invoice in a manner where it could be alleged that the person issuing the invoice was participating in something that could be seen as misleading.

Wherever possible, it might be helpful to ensure an invoice provides clear information about the nature of service and identifies those to whom the service was provided. If a person to whom the service was provided is different than the person who is the focus of the treatment, it may be appropriate to note on the invoice something like services were provided to Mr. and Mr. Smith re: the treatment of their child James Smith.  Clients may also be asked to consult with their benefits providers about how to best maximize their coverage and the insurer’s preferences with respect to billing.

While it may feel helpful to assist clients in maximizing their insurance coverage, insurers are becoming increasingly vigilant about such matters and this could result in denial of benefits to the client and a complaint to the College. It should be left to the client(s) and their insurers to work out issues about insurance coverage limits.

The prohibition of fee splitting was difficult to understand and misunderstood by many, so it was decided that, because concerns about the adverse consequences of fee splitting are addressed elsewhere in the Standards and the Professional Misconduct Regulation, that the Standard regarding fee splitting would be omitted from 2017 version.

The Professional Misconduct Regulation still strictly prohibits:

• Receiving or conferring a rebate, fee or other benefit by reason of the referral of a client from or to another person (Section 1.26)
• Providing a service that the member knows or ought to know is not likely to benefit the client (Section 1.9); and
• Practising the profession while the member is in a conflict of interest (Section 1.10)

Additionally, the Standards still require that:

• Fees must be based on the amount of time spent and complexity of the services rendered (section 11.1); and
• A member must not exploit persons over whom he/she has supervisory, evaluative, or other authority such as clients, students, supervisees, research participants, or employees (section 13.4(2)).

As long as the practice you are describing does not occur in a supervisory relationship and your practice is compliant with respect to all of the above, you are now able to enter into percentage based arrangements.

As a supervisor, you are providing a psychological service and it is important that your own fee structure for this service complies with the requirement that your fees are based on the amount of time you spend providing the service and the complexity of the service you are providing. Charging a percentage of fees collected or the number of sessions a supervisee has with a client may not correspond to the amount of time you are providing supervision. Charging a flat fee for a time period, without regard to the specific number of hours spent within that time period, would also be inconsistent with the standard and would have the potential to also violate the prohibition against exploitation of supervisees (section 13.4(2), as a supervisee could possibly be charged for supervision which was out of proportion to the time spent.

The prohibition against fee splitting has been removed from the Standards but the prohibition against paying for referrals remains in force.  The Professional Misconduct Regulation still strictly prohibits:

• Receiving or conferring a rebate, fee or other benefit by reason of the referral of a client from or to another person (Section 1.26)

Many people found the language used to address the practice of fee splitting in the previous version of the Standards difficult to understand. The College decided that concerns underlying the former specific fee splitting rule are already adequately addressed within the Professional Misconduct Regulation, which prohibits:

• Providing a service that the member knows or ought to know is not likely to benefit the
  Client (Section 1.9); and
• Practising the profession while the member is in a conflict of interest (Section 1.10);

and by the following requirements which have been carried forward from the previous Standards to the new ones:

• Fees must be based on the amount of time spent and complexity of the services rendered (section 11.1); and
• A member must not exploit persons over whom he/she has supervisory, evaluative, or other authority such as clients, students, supervisees, research participants, or employees (section 13.4(2)).

The Standards of Professional Conduct, 2017 state that:

11.1 Fees and Billing Arrangements
Members must reach an agreement with an individual, group or organization concerning the psychological services to be provided, the fees to be charged and the billing arrangements prior to providing psychological services. Any changes in the services to be provided must be agreed to by the client before service is delivered or fees are changed. Fees must be based on amount of time spent and complexity of the services
rendered.

Practical Application: Fees for services should be determined on a consistent basis, regardless of the payer. A member may, however, offer pro bono services or apply a sliding scale to ensure access to services and affordability.

While this Standard is most often thought of in the context of initiating services with a new client, it also can be read to apply with respect to the ongoing provision of services. That is, “providing psychological services” could be read to mean each instance of providing a psychological service. It would be inappropriate for a client to learn that their fees had been increased when they receive a bill for a service that had already occurred. Increased fees may be an important consideration for clients in the ongoing informed consent to service process and some clients may need to reconsider whether they are able, or prepared, to continue at the new proposed rate.

There is no specific period of notice for a fee change set out in any Regulations or in the Standards as this is a matter of professional judgment. Adequate notice of the change however, is important and there may be clients who experience a fee increase as akin to indirect termination of therapy.

In cases where the client may not agree to an increased fee, and a member is not prepared to continue to provide services at the existing rate, guidance regarding the termination of services can be found in section 8 of O.Reg. 80.1/93: Professional Misconduct. This section of the Regulation states that termination of service that is needed is an act of professional misconduct unless:

i. the client requests the discontinuation,
ii. the client withdraws from the service,
iii. reasonable efforts are made to arrange alternative services,
iv. the client is given a reasonable opportunity to arrange alternative services, or
v. continuing to provide the services would place the member at serious personal risk.

Although there are informal ‘rules of thumb’ with respect to ‘winding down of therapy’, often based upon the length of time a person has been receiving treatment, the College does not set any particulars in this regard. If the client requires additional services but can not or will not pay the increased rate, it would be reasonable and appropriate to work with them for a time period that, in the member’s professional judgment, is sufficient to arrange for a transfer of care to another service provider and  avoid any harm due to a disruption of treatment.

A:  The Information and Privacy Commissioner of Ontario (IPC) recently addressed this issue in PHIPA DECISION 133, October 2020.

The Decision sets out the statutory limits to what one may charge, as follows:

[12]  Under PHIPA, custodians have the discretion to charge a fee for providing an individual with access to their own personal health information. Sections 54 (10) and (11) state:

Fee for access

54 (10) A health information custodian that makes a record of personal health information or a part of it available to an individual under this Part or provides a copy of it to an individual under clause (1) (a) may charge the individual a fee for that purpose if the custodian first gives the individual an estimate of the fee.

Amount of fee

(11) The amount of the fee shall not exceed the prescribed amount or the amount of reasonable cost recovery, if no amount is prescribed.

The legislation does not prescribe an amount for “reasonable cost recovery”. In providing Reasons in Decision 33, the Adjudicator for the IPC states, previous IPC orders and PHIPA Decision 17 conclude that the 2006 fee scheme set out in the proposed regulation to PHIPA provides the best framework for determining the amount of “reasonable cost recovery” under section 54(11) of PHIPA.

The Decision provides a detailed analysis of the particular case and anyone facing this sort of issue is advised to read the entire Decision. For ease of reference, here is an excerpt from the Reasons that the Adjudicator gave for a finding that the health professional’s charges were excessive:

[44]  In PHIPA Decision 111, I determined that not every type of record containing personal health information subject to PHIPA requires the same amount of time for review. … records with standard, predictable content require only a straightforward review with minimal time needed to determine whether they contain information to which access may be refused. For these types of records, I determined a review time of five seconds per page was appropriate. I found that other records, which by their nature, have the potential to contain information to which access may be refused, require a more detailed and lengthy review. For these types of records, I determined a review time of two minutes per page was appropriate… I have no evidence before me to suggest that any of the records at issue have the potential to contain personal health information that may required a more detailed and lengthy review…

[46]  As a result, and in the absence of evidence to the contrary, in my view it is reasonable to conclude that the 27 pages of responsive records would require only a straightforward review at five seconds per page. Accordingly, I find that a reasonable amount of time for the custodian to review 27 pages of records containing the complainant’s own personal health information is encompassed in the first 15 minutes of review that are accounted for in the set fee of $30 per request. Given the nature and number of responsive records, I find that when the 2006 fee framework is applied, the custodian is not permitted to charge review fees in excess of what is accounted for in the set fee of $30. I accept that, in the circumstances, this amounts to “reasonable cost recovery” as required by section 54(11) of PHIPA.

While this reasoning is not enshrined in legislation or in formal guidelines, the precedent set by this, and previous Decisions should be considered by members when they set fees for the copying of records.