Psychotherapy Practice Finance: Credit Card Worries?

October 1 2015 was an auspicious day for mental health professionals in private practice for two important reasons. As health care providers, we had to switch to ICD-10 for our diagnostic coding. And as small business owners, we got worried about whether we needed to change the way we processed our credit card payments. 

So what was so special about October 1, 2015 in the world of credit card processing?  That’s the day liability for transactions resulting from fraudulent EMV chip credit cards shifted from the bank issuing the credit card to the business owner running the transaction. In terms relevant to our profession, if a client payment using a fraudulent EMV chip card goes through AND we don’t have an EMV Chip Reader terminal to run the sale, the bank will charge back the cost of the service and we will be stuck unpaid. The good news is, no additional penalties or fees are incurred beyond the charge back. It’s also good to know that nothing has changed for transactions using cards without the EMV chip. So, if your usual method of processing credit cards is using a magnetic swiper (either a free standing terminal or one attached to your computer or smartphone), hand entry from a client’s form authorizing repeated automatic card payments, or client entry using a payment portal web site AND the client uses a fraudulent magnetic strip card, the bank will still be the liable party. The bank also still incurs the liability if we run the card in a way that wouldn’t customarily use an EMV Chip Reader, such a remote entry when the customer and card are not physically present while the transaction is being run.

So what’s the big deal and why all the fuss? Well, apparently just under half of all the world’s credit card fraud occurs here in the USA, even though only one quarter of all credit card transactions occur within our borders. A key reason for these disheartening statistics is that America’s love affair with cheap and easy to use magnetic strip credit cards has lingered way past its prime. Magnetic strip cards are simply too easy to counterfeit. EMV (which stands for Eurocard/Mastercard/Visa) technology has been in use in other parts of the world for years. The inclusion of an electronic chip embedded within the credit card makes it significantly more difficult to create usable counterfeit cards. It is currently estimated that here in the US, only one third of all transactions are processed using chip enabled cards, but that number is expected to rise rapidly. All chip-enabled cards will still have a magnetic strip and will work in magnetic strip readers, but the liability for fraudulent transactions processed in this way has shifted from the bank to the merchant. For the time being, there are no plans to charge merchants differential rates for running EMV chip-enabled cards vs. magnetic strip only cards.

Switching to a new card reader that will do magnetic strip cards, EMV cards and NFC (Near Field Communication) devices such as Apple Pay will eventually be a worthy endeavor and is likely to incur only minimal costs and inconvenience. Given (1) the volume of business we private practitioners generally do, (2) the fact that we hand-enter many transactions based on credit card information we keep on file, and (3) the ongoing professional relationship we have with most of our clients, our actual risk of getting stuck because someone paid us with a fraudulent chip card AND we didn’t have a chip reader is, in fact, pretty low.

I use Transfirst for running my credit card sales and when I called to ask, they freely advised me that they consider my current risk extremely low. Their advice was to plan to get a chip reader at some point but not to worry about it for now. They don’t currently have a chip or NFC based system to use with the iPhone/iPad but they anticipate having something on offer in the near future. I haven’t yet done any diligent research on the new “Chip and Dip and NFC” card reader systems but it seems like options are still pretty limited. I did review Squares’ site and if you use a Square reader plugged into your phone or an iPad to process your credit cards, you can purchase one from them $49. Free-standing machines seem to be running in the $200-$300 range. Remember, if you purchase a free-standing machine, you need to check with your credit card processor first to make sure it will work with their system. I couldn’t find any good peripherals currently available that connect directly to a computer via USB cable. It seems like you will need to hold tight for the time being if you routinely run your transactions through a swiper peripheral connected via USB cable to the computer running your practice management system, as I currently do. Again, check with your credit card processor before buying anything to make sure it will work with their system.

I am all in favor of easy to use, inexpensive systems that reduce fraud. Whether we eat the cost or the bank eats the cost, it is still theft and it is wrong. Updating our equipment as more affordable user-friendly options come available is something we can do to help curb the use of fraudulent cards here in the US. When I have some good affordable options to choose from, I will definitely get an EMV/NFC card reading system. For now, I will stick with what I’ve got, and cross this off my “Things to Worry about List.”

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Fixing What's Broken: What to do About Mental Health Care in America

Tonight’s episode of CBS “60 Minutes” really touched a nerve for me. It discussed how broken our mental health system is through the lens of one family’s tragedy. Virginia State Senator Creigh Deeds told CBS’ “60 Minutes” news program about the loss of his son Gus, who had been diagnosed with Bipolar Disorder.  Last November, the Deeds family had tried to find inpatient mental health care for their son Gus, but no beds were available. Gus went home with his family. He subsequently attacked his father, inflicting multiple stab wounds, before shooting and killing himself.

Senator Deeds spoke with “60 Minutes” since it was “the biggest megaphone I could think of to talk about the system’s failings.” He has declared it is his mission to protect other families from the horrible misfortune he has experienced. As a state senator he is committed to changing Virginia’s mental health laws to keep anything like this from happening again.

I wish it didn’t take a personal catastrophe of this magnitude to enlighten government officials about the need for change. I wish it didn’t take Mr. Deed’s attack and disfigurement and the suicide of his son to raise awareness. The fact that it usually takes something this extreme to bring the need for change to the forefront is just more compelling evidence as to how broken the system really is.

I started graduate school in 1981 as a National Institute of Mental Health (NIMH) fellow. The NIMH fellowship program was set up as part of Lyndon Johnson’s great society, which recognized that good mental health care was an integral part of a successful, productive, enlightened country. After Reagan took the presidency, he redlined the NIMH fellowship program out of the federal budget. The loss of my fellowship created a challenge for me as to how I was going to pay for my graduate education. Instead, I worked as a research assistant on a federally funded grant that paid my tuition and provided a stipend. I was fortunate. Many others weren’t able to find an alternative and had to give up their dreams of helping others as mental health professionals.

Throughout my early career, I watched as the residential treatment system was dismantled. I don’t remember many homeless people as a child but the homeless have been a fixture in my adult life, mostly because there were no longer residential treatment programs or institutions to house and care for them. I’m not implying the old institutional system was perfect. But needy, fragile, patients were turned out into the streets, with nothing in place to fill the resource gap.

During my years as a clinical psychologist, I’ve been frustrated by the increasing fragmentation of care and the lack of emergency and support services. I’ve watched care plans dictated by limitations imposed by insurance coverage rather than patient’s treatment needs. I’ve seen the number of psychiatrists dwindle. Most psychiatric medications are now handled by internists, family practitioners and pediatricians, who are already overburdened and freely profess to a lack of confident expertise in managing psychiatric medications.

The multiple failures of our current  mental health care system isn’t news to me or anyone else interacting with the system as a health care professional, patient or family member. A crisis of this severity, breadth and magnitude can only be solved by government mandates and intervention. Insurance companies won't freely provide the coverage needed for adequate services and hardly any one can afford the level of care needed for serious mental illness without being incredibly wealthy. This moment has been inevitable ever since Ronald Reagan started dismantling the system during my first year in graduate school. Nothing has ever trickled down to restore it. It is so heartbreaking to bear witness at the front lines.

Instead of shaking our heads in helpless frustration we need to ask, “What can be done?” We can legislate the availability of more affordable long-term residential treatment resources funded by insurance, government programs or grants. Lawmakers need to step up and push for programs that will once again fund training for psychiatrists and other mental health professionals, particularly those who can provide services in rural, impoverished or blighted areas, We must have enforceable mandates for true parity of insurance coverage for mental health. Emotional and physical health are so intertwined, there should be no question that the standards of coverage should be the same. We used to have government programs to fund residential and outpatient treatment and scholarships and grants to fund education and training for mental health professionals. It wasn't a perfect system but it was vastly better than what we have now. So far, no for-profit model has worked effectively for mental health services except for those who cater to patients with sufficient wealth to pay for care or who have exceptionally good health insurance that has far-better-than-average mental health coverage. 

Let’s fix what’s broken before more high profile tragedies occur. The consciousness raised by the horrors we’ve already witnessed, as well as what we’ve learned about the day-to-day heartbreak of families and patients currently struggling with mental illness, should be sufficiently motivating for us all.

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Yes, There's an App for That: Useful Apps for Psychologists and other Mental Health Practitioners

If you've been wondering if there are any good apps available for use by mental health professionals, I have good news for you.  Here is a list of some top rated free smart device apps used by psychologists and other behavioral health care professionals. The choices come from recommendations made by psychologists on the APA Division 42 (Psychologists in Independent Practice) Listserv. I’ve downloaded and tested all of these app so I know they do what they promise and are easy to use. All of the apps on the list are available free from Apple’s App store and iTunes for use on iPhones, iPads and iPod touch. Some of them are available for other devices as well:

3D brain is a really elegant app that lets you navigate a three-dimensional graphic of the brain on your device. It can be very helpful for refreshing your knowledge of neuroanatomy as well as serving as a useful reference tool for helping patients and their families understand and visualize the brain structures impacted by neuropsychological trauma and injury. FREE 

Co-Occurring Conditions Toolkit is a resource published by the National Center for Telehealth and Technology to help clinicians identity common co-morbid conditions in mild TBI patients. FREE

PAR Assessment Toolkit is a utility produced by the psychological test publisher PAR as a handy reference for psychologists and other mental health practitioners who administer standardized tests. Features include a graphic of the normal curve with conversions, a stopwatch function, age calculator and compliance calculator. FREE 

Psych Drugs provides a comprehensive reference for reputable information about the major classes of psychotropic drugs including SSRIs, anitpsychotics, mood stabilizers, and ADHD, insomnia and anti-anxiety medications. It includes generic and brand names, class, indications, dosages, half-life and side effects.  FREE

PFA Mobile is a Psychological First Aid Tutorial developed by the University of Minnesota School of Public Health to provide a convenient resource for first responders and mental health professionals providing assistance following a traumatic event, natural disaster, emergency or crisis. FREE

Medscape from WebMD is a popular and well-respected medical resource app used by millions of health care professionals.  It provides comprehensive reference data about prescription drugs, diseases, conditions, procedures, medical terms and medical calculators (like BMI). An added feature is daily updates about medical news and critical alerts. It also allows searchable access to Medscape News and MEDLINE databases. FREE

ICD 10 Lite 2013 gives you convenient free access to the complete ICD 10 right on your iPad or iPhone. FREE

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Psychotherapy and Electronic Health Records (EHR) Q & A

EHR Q&A: Answers to Mental Health Practitioner’s Most Frequently Asked Questions

By Jill Squyres, PhD

Lately, there’s been a lot of buzz about electronic health records.  Here are answers to some of the most frequently asked questions about EHRs as they relate to mental health practice.

What’s the difference between an EHR and an EMR? What does this have to do with PII and PHI?

The digital age in health care requires us to keep track of a veritable alphabet soup of acronyms!  While the terms EHR and EMR are often used interchangeably, by the most stringent definition, EHR (Electronic Health Record) refers to all of a person’s health information maintained in an electronic format.  EMR (Electronic Medical Record) generally refers to a patient’s chart maintained by a health care practitioner or organization.  An electronic document that includes data entered by a health care provider as well as information added by the patient would be an EHR by this definition.  Many people are starting to use the term EMR to refer to both as a convenience because when typing in Microsoft Word, the spell check function automatically changes EHR to HER!  PII stands for personally identifiable information and PHI is protected health information, both of which are included in the EMR.  HIPAA guidelines require us to take careful security measures to protect PII and PHI.

Do mental health care practitioners have to use an EMR?

Currently, counselors and psychotherapists are not required to use EMRs.  However there are many benefits to an EMR that may outweigh any drawbacks.  Physicians currently have guidelines requiring them to adopt EMRs.    

I’ve heard the government will pay you a lot of money if you start using an EMR.  Is this true? 

Medicare and Medicaid have initiated an EHR (this is the term these programs use) adoption program that offers substantial cash incentives for meaningful use of electronic health records.  Detailed meaningful use criteria have been developed by Medicare and Medicaid.  At the present time, none of these criteria pertain to mental health practitioners so we are not eligible for these incentive payments.  However, mental health professional organizations, such as the American Psychological Association, are lobbying government agencies to have mental health care criteria included in the next stage of meaningful use incentives.

What are the benefits of using an EMR?

EMRs can make managing client documentation much easier and more convenient.  Most EMRs also include an entire suite of practice management tools including a scheduling calendar, billing module, and online insurance claim filing in addition to the standard chart.  Progress note templates and intake, assessment, and treatment planning forms are often included as well.  Of course, all documentation kept online saves paper, filing space and shredding costs.  Records requests can often be accommodated by faxing the documents directly from your practice computer, saving on mailing costs, paper and postage.  EMR developers are now adding integrated video conferencing modules to their software to make initiating online sessions a point and click option.  Online EMR’s offer the added convenience of being able to access your client’s chart and contact data from any device anywhere with internet access. 

If I use an EMR does it have to be online?

There are several different types of EMR software.  One type is stand-alone software that you load on to one personal computer.  This software does not require an internet connection and all of your data is stored on the single computer it’s loaded on.  Of course, frequent back-ups to a hard drive, data CD and / or a thumb drive will be necessary if you are using this type of system to protect against loss of all of your patient data.  From a HIPAA compliance standpoint, this type of system is the most secure, although a stand-alone computer can still be stolen or accessed by unauthorized personnel resulting in a data breach.  The risk of losing all of your data in a disaster or computer crash is an important consideration from a risk management stand-point as well.  While there are security issues to consider with web-based systems or online back-up, it is not acceptable professionally to lose all of your clients’ mental health care information because your computer died or you experienced a natural disaster or fire.

How do online EMRs work?

Online EMRs are generally accessed over the internet through a secure browser window.  Most will work with any browser software although some programs will only work on PCs, not Macs.  Traditionally, EMR software has not worked on tablets, PDAs or smartphones, however, many vendors are adding apps, which can be purchased for an additional charge, for convenient access on mobile devices. Large medical practices and hospitals often purchase software that is loaded onto a dedicated server which may be physically located on their premises but this is not an affordable option for private practitioners or small group practices.  This set-up allows for an online record that is only accessible to devices on the facility’s private network.

Can I be sure my online EMR is HIPAA compliant?

The developer of your software should provide documentation of their security measures and compliance with HIPAA standards.  Any browser window accessing an online EMR should have an address beginning with https: instead of the usual http.  Your EMR software vendor should also require you to sign a business contract attesting to their security measures for HIPAA compliance.

What about all of my paper notes?

Of course, you can keep all of your paper notes filed the same way you have traditionally kept them and start keeping records electronically from the date you implement your EMR.  Many clinicians purchase a scanner and scan in old records so the paper copies can be disposed of.  Most EMR software allows for easy uploading of paper documents.  Some clinicians even continue to write their notes on paper and then scan them into the client’s EMR when they close out the appointment.

I’m already spending a lot on running my practice.  Is it expensive to adopt and EMR?

There’s a lot of competition in the mental health electronic record market, which helps keep costs down.  For the most part, you will pay more for extra features like patient portals, billing features like automatic credit card payments and insurance filing, templates and state of the art interfaces.  The cost for most software is charged as a monthly fee although some companies charge an additional fee to get your account and data set up.  This set up fee can also include transferring data from old software to your new EMR, which may look expensive but can cost much less than paying someone hourly for data entry to get you up to speed.  The typical monthly cost ranges from $60 - $150 per month depending on what features and technical and administrative support you want from your software provider.  There are also free options, which are not specifically designed for mental health providers but can be easily adapted to our needs.

drjsquyres@mac.com

www.drjillsquyrespsychologist.com

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Text copyright 2012 by Jill Squyres, PhD.  All Rights Reserved