As solo practitioners, we commonly face situations in which
we walk a fine line with ethics, or perhaps even in which we have crossed into
unethical business practices. When red flags pop up, we need to step back,
analyze the situation and think, "Is this good business practice?" or "Is what
I'm doing ethical?" Speech-language pathologist Lisa Milliken, in her video
seminar "Ethics, Compliance and Consequences," is very clear: "Be true to
yourself, your client and code of ethics."
Those new to private practice often call on more experienced
practitioners for advice. All of us—new and veteran clinicians—can turn to
ASHA's Code of Ethics to guide us in our
decision-making. In these real-world scenarios, what would you do?
SCENARIO: Your private practice has more empty slots than
you'd like. A potential client wants to come to you for treatment, but you
haven't had experience with this type of client, the client's disorder or the
treatment technique the condition requires. This client will bring in
much-needed revenue from the evaluation and treatment. Is it OK to schedule the
client and the figure it out as you go along?
Our code of ethics clearly states we should "provide all
services competently" (Principle I, Rule A) and "shall not misrepresent
competence, education, training, experience" (Principle III, Rule A). These
rules lead us to the obligation to refer to another practitioner "when
appropriate, to ensure that high-quality service is provided" (Principle I,
Rule B). Many other rules discuss competence, training and experience—such as
engaging in "only those aspects of the professions that are within … level of
education, training and experience" (Principle II, Rule B) and engaging in
"lifelong learning to maintain and enhance professional competence and
performance" (Principle II, Rule C).
SCENARIO: Your client's insurance covers therapy services,
but reimbursement for the procedural code that corresponds to the client's
disorder is substantially less than your hourly rate. Your practice is "in
network" and must accept the contracted rate. But, if you use different
procedural and diagnostic codes, reimbursement is higher. Should you bill the
other codes, collect higher fees, and keep this client?
One area in which we should never get "creative" is billing.
Our code is very clear, stating that clinicians "shall not misrepresent
services rendered" (Principle I, Rule O); "shall not defraud or engage in any
scheme to defraud in connection with obtaining payment, reimbursement"
(Principle III, Rule E); and "shall not engage in dishonesty, fraud, deceit, or
misrepresentation" (Principle IV, Rule C). ASHA's Health Care Economics
Committee has noted that some professionals are serving prison terms for fraud.
SCENARIO: The client's insurance reimbursement is much less
than your hourly rate. You're "in network" and have agreed to the insurance
company's reimbursement rate. So, to make up the difference in the hourly rate,
you could bill the client, correct?
If you sign a contract to accept an insurance company's
reimbursement, you may not collect anything from the patient other than the
copayment. Ethically (and legally) this practice constitutes fraud. If you
aren't willing to accept the contract rate, complete the paperwork to change
your provider status to out-of-network provider.
SCENARIO: You accepted a client and now regret it for many
reasons—the client makes inappropriate demands, constantly reschedules and
cancels often. You've made up your mind—you will tell the client you can no
longer work together and that today's session will be the client's last.
It is unethical to terminate a client without "providing
reasonable notice" (Principle I, Rule R). If you want to end treatment, inform
the client of the end date for services—giving "reasonable notice"—and provide
names of other facilities for treatment. Follow through with records transfer,
and make sure to document the transition to protect yourself against a claim of
SCENARIO: You have several employees in your private
practice, whom you equip with the most recent editions of assessments and
plenty of equipment to use in evaluations and treatment. After a staff member
leaves to work elsewhere or to open a practice, you look for—but can't locate—a
particular assessment tool or treatment aid that costs several hundred dollars.
You can't be sure when it disappeared, but no one knows where it is.
Theft of equipment, protocols, tools and other materials is
a real concern in private practice. Employees should understand that they
should not "engage in dishonesty, fraud, deceit, or misrepresentation"
(Principle IV, Rule C). Without proof, however, employers have little recourse.
To protect yourself, you might want to develop a sign-out system for equipment
and materials, and address the issue of theft in your employee handbook.
Business owners and employees in any work environment will
face ethical issues. But just as we spend a great deal of effort maintaining a
profitable business, we need to be vigilant about maintaining an ethical
practice as well.