10 Reminders for Therapists About Fees
Ann Tran-Lien, JD
Therapists often have questions regarding fees, such as whether fees can be
raised and how to collect unpaid balances from clients. The following reminders
are intended to help therapists exercise care in managing fee policies to comply
with legal and ethical standards and to minimize the possibility of fee-related
1 Prior to rendering services, provide clients with disclosures regarding
fees for services as required by law and ethical standards.
The BBS requires therapists to disclose to a client or prospective client,
prior to the commencement of treatment, the fee to be charged for the professional
services, or the basis upon which that fee will be computed.1 Furthermore,
Section 9.3 of the CAMFT Code of Ethics states, “Marriage and Family
Therapists disclose, in advance, their fees and the basis upon which they are
computed, including, but not limited to, charges for canceled or missed appointments
and any interest to be charged on unpaid balances, at the beginning of treatment
and give reasonable notice of any changes in fees or other charges.”
Although not legally required, it is recommended that fee disclosures be written.
Your policies regarding fees may be presented in your Disclosure of Services
Statement, Informed Consent Form or a separate fee agreement, which the client
acknowledges and signs. The disclosure should include your usual and customary
fee; how fees may be raised; information regarding insurance billing; policies
on fees for cancellation and missed sessions; and acceptable forms of payment.
This ensures clients are fully aware of your fees and any policies concerning
Be clear about your fee-related policies. If you provide the disclosures in
writing, make sure you take the time to discuss each policy with the client,
especially policies regarding charges for missed and canceled sessions. If
you fail to disclose such policies to your client at the outset of treatment,
it is recommended that you not charge your client for a missed or canceled
Think of your practice and the needs of your clients. If there are items that
need to be billed outside of therapy sessions, you should consider including
those items and the associated fees in the client’s fee agreement. If
you intend to charge a client any professional service not fully described
in your fee agreement, such as writing a report or appearing at a deposition,
you should discuss with your client in advance and ensure the client agrees
to the fee before the client is charged for the service. It is prudent to document
this discussion and the actions taken.
2 Make sure advertisements that include your fees are in compliance with California
Any advertisement for professional services that includes your fees must be
exact, without the use of words or phrases, including, but not limited to, “as
low as,” “and up,” “lowest prices,” or other
similar words or phrases. The law states that price advertising must not be
fraudulent, deceitful, or misleading, including statements or advertisements
of discounts or premiums, or any statements of a similar nature. The fee for
each service must also be clearly identifiable.2 Advertisements include, but
are not limited to, websites, flyers, signs, social media profiles, brochures.3
3 It is important to communicate your policies and procedures regarding insurance
reimbursements with clients prior to rendering services.
Many therapists are contracted providers for insurance plans. Those who are
not contracted providers typically produce a “superbill” so the
client can seek reimbursement from the insurance plan directly.4 Your policies
regarding insurance billing should be clearly stated in your fee agreement,
Informed Consent Form, or Disclosure of Services Statement. If you are a contracted
provider, your written fee policy may include information about your contracted
fee schedule; your billing procedures; and the client’s co-payment, if
any. If you are not a contracted provider, your fee agreement may state your
policies regarding insurance billing and payment, such as, who is responsible
for verifying eligibility and benefits; when payment is collected; and when
and how superbills are offered. The fee agreement may also specify that the
client is responsible for paying for the service rendered, regardless of whether
or not the insurance plan actually reimburses.
A common issue regarding insurance reimbursements is whether Registered Interns
can bill for insurance when working under supervision of a licensed professional.
California’s Freedom of Choice laws do not mandate that services of Registered
Interns be reimbursed, so it is unlikely insurance companies will reimburse
for services rendered by Interns.5 If requested, the Intern may submit claims
on behalf of clients or provide a claim form to clients to seek reimbursements
for services rendered by the Intern. According to Section 9.6 of the CAMFT
Code of Ethics, therapists “represent facts regarding services rendered
and payment for services fully and truthfully to third-party payers and others.” Therefore,
if a claim form is submitted, it should clearly indicate the Intern as the
provider of services and both the supervisor and the Intern should sign the
claim form. A cover letter may also be attached to the claim form pointing
out that the services were provided by the Intern who is registered and under
It is important for clients to be informed that his or her insurance plan
may not provide reimbursement for the treatment provided by the Intern. It
is best practice to disclose this information in detail to the client at the
outset of treatment and to present it in the Disclosure of Services Statement,
Informed Consent Form or in a separate fee agreement. Clients may not be aware
of this fact and it is the Intern and employer or supervisor’s responsibility
to articulate this information to clients.
4 Familiarize yourself with the antitrust laws so you do not inadvertently
violate them by discussing fees with other independently practicing therapists.
The Sherman Act and the Cartwright Act are federal and state antitrust laws
that prohibit two or more otherwise independent actors engaging in concerted
activity to restrain trade or competition. What do antitrust laws have to do
with therapists and fees? First, concerted activity occurs when there is an
agreement between independently practicing therapists. Second, courts have
concluded fixing fees is a restraint of trade. Hence, independently practicing
therapists who agree to set certain fees for their professional services would
be violating antitrust laws. The agreement does not have to be formal or
in writing. An understanding between two or more therapists that leads to parallel
conduct can be sufficient to raise antitrust concerns.
The following are examples of an agreement or understanding between therapists
that would generally constitute fee-fixing that may trigger antitrust scrutiny:
Four independently practicing therapists have an understanding with one another
to charge the same fees for psychotherapy sessions. A written agreement does
not exist, but the therapists have informal discussions concerning fees every
six months, and all therapists charge the same fees.
Two separate therapy professional corporations agree to have matching sliding
fee scales for their psychotherapy services.
A group of independently practicing therapists agrees with one another to
raise their fees by ten percent.
Concerted activity does not occur when joint conduct is taken by therapists
who are owners or employees of a completely integrated therapy business entity,
such as a professional corporation. Therapists in such business entities are
not independently practicing and do not have independent competing business
activities, hence, their practices are integrated into the business entity.
In other words, if you co-own a therapy professional corporation with another
therapist, you and your partner can discuss and agree on the corporation’s
The key is to exercise independent judgment when making decisions about fees.
It is important for therapists to take steps to avoid even the appearance of
collusion with another therapist, as what may appear as harmless discussions
regarding fees can lead to allegations of antitrust violations. You may scan
the advertisements of other therapy practices, as well as public surveys regarding
other therapists’ fees to determine your fee structure, but fee setting
decisions must be made individually and not in concert with other therapists.6
5 It is unlawful to require a client who uses a credit card to pay a surcharge.
Under California law, retailers and service providers, including health care
providers, cannot impose a surcharge on a cardholder who elects to use a
credit card to pay for products or services.7 Therefore, therapists may not
require clients to pay an additional fee when they are paying with a credit
card. The law does allow for the retailer or service provider to offer a
discount for the purpose of inducing payment by cash or check. Nevertheless,
therapists should determine whether it would be ethical or clinically appropriate
to offer a discount to clients for this purpose.
6 Consider the legal and ethical implications when faced with a request from
a client to barter for therapy services.
While bartering services is not prohibited by law or ethical standards, it
is not generally encouraged. You should exercise good judgment when faced with
a situation in which clients are requesting to barter for therapy services.
According to Section 9.5 of the CAMFT Code of Ethics, “Marriage and Family
Therapists ordinarily refrain from accepting goods, services, or other non-monetary
remuneration from patients in return for professional services. Such arrangements
often create conflicts and may lead to exploitation or distortion of the professional
relationship.” Consider the difference between allowing a client to pay
for a session hour with gardening work and allowing a client to pay for a session
with bags of vegetables equal to the therapist’s hourly rate. Also consider
whether the barter could potentially lead to exploitation of the client or
impairment of the therapist’s judgment. Seeking clinical and legal consultations
in these situations is highly advisable.
7 Avoid accepting fees or paying for the referral of professional clients.
It is unlawful and unethical for therapists to offer or accept payment for
referrals, whether in the form of money or otherwise.8 A conflict of interest
or exploitation of this nature could harm a client.
A therapist who terminates his or her employment relationship may find his
or her former employer demanding a certain percentage of fees for services
provided to clients who continue with the therapist in his or her new practice.
Such contractual provisions may be deemed unenforceable and in violation of
the law. Therefore, you should consider seeking legal consultation if you are
faced with a similar situation.
8 Take into account certain legal and ethical issues when pursuing collection
against a client.
Occasionally, a client, for one reason or another, fails to pay the agreed
upon fees for therapy services. As a service provider, you are able to collect
unpaid balances from clients, if done so in a diligent manner. You should consider
the following if you desire to collect from a client: Which collection route
do you want to take? What is the possibility of a client retaliating by filing
a claim or complaint against you? Is it worth pursuing the debt?
Section 9.4 of the CAMFT Code of Ethics, provides that “Marriage and
Family Therapists give reasonable notice to patients with unpaid balances of
their intent to sue or to refer for collection. Whenever legal action is taken,
therapists will avoid disclosure of clinical information. Whenever unpaid balances
are referred to collection agencies, therapists will exercise care in selecting
collection agencies and will avoid disclosure of clinical information.” It
is generally recommended that you attempt to settle the matter with the client
before taking legal action. Consider contacting the client to discuss feasible
financial arrangements that work for both you and the client.
If all attempts fail, the remedies available to a therapist when collecting
debt include referring the claim to a collections agency; taking the client
to small claims court; or agreeing to mediation. It is important that you provide
the client with reasonable notice of your intent to take legal action. For
instance, if you choose to forward your client’s claim to a collections
agency, you should send a certified letter to the client informing the client
of the client’s outstanding balance and the deadline in which your client
has to either contact you to discuss financial arrangements or to send payment,
and if the client fails to respond, that the client’s claim will be forwarded
If you want the least time-consuming route and limited involvement on your
part, referring the claim to a collection agency may be the route to take.
After providing specific information, the collection agency will essentially
pursue the debt for you. However, be aware that most collection agencies take
approximately 40 percent or more of the collected fees. Make sure the collection
agency you choose are familiar with their obligations regarding confidentiality
under HIPAA and the Fair Debt Collection Practices Act.
You also have the option to pursue the collection in small claims court. In
California, you may file a claim in small claims court if the amount in dispute
does not exceed $10,000. Corporations and other entities cannot file a claim
for more than $5,000. You will need to file forms with the court, pay a nominal
fee, and have someone properly serve the individual you are suing. You can
also subpoena any witnesses who can attest on your case. On the date of the
hearing, you should bring documentation to substantiate your claim. Although
an attorney may help you prepare your case, you must represent yourself at
Another option is mediation. Mediation allows you and the client to work out
a resolution together and attempt to resolve the dispute amicably. It would
usually involve a mediator who will meet with you and the client in a neutral
location to facilitate discussion and reach a mutual agreement.
Before pursuing collection, you may want to consider if it is worthwhile to
collect. Some therapists have chosen to forego pursuing collection because
of the possibility of the client filing a lawsuit or complaint against the
therapist as a retaliatory measure.
Also, note that the law and ethical standards do not allow therapists to withhold
a client’s records or information solely because the therapist has not
been paid for prior professional services.9
9 Consider the legal and ethical issues regarding raising your fees for current
Therapists may desire, from time to time, to raise their fees for current clients
who are continuing in therapy. According to Section 9.3 of the CAMFT Code of
Ethics, therapists are to give reasonable notice of any changes in fees or
other charges. Therefore, if you choose to raise fees for continuing clients,
you can do so if reasonable notice is given. Nevertheless, it is recommended
that clients be informed of your policy about raising fees in writing, at the
outset of treatment. This can reduce the likelihood of clients feeling exploited
when they are given notice that fees will be increased. This language can be
inserted in your fee agreement, Disclosure of Services Statement, or Informed
Consent Form. If you anticipate raising your fee in a particular manner, e.g.,
fees will be raised on January 1 every year at five percent, you may want to
consider including the following information: the possibility that the fee
may be raised; the percentage the fee may be increased by; how often the increase
may occur; and how much notice clients will be given.
10 Be aware of the fees you may charge when dealing with a subpoena or request
Under California law, you may charge certain fees for responding to a subpoena
or request for records. When you are responding to a subpoena, the party requesting
your records or testimony is responsible for reimbursing you for copying costs
or your time.10 If you have been served with a deposition subpoena for just
the production of business records, you should receive a $15 witness fee for
allowing a copying service to come to your office to make copies. If you make
copies yourself, you are allowed to charge the following: $0.10 per page of
your clinical file; reasonable clerical costs incurred in locating and making
the records available to be billed at a maximum of $24 per hour, computed on
the basis of $6 per quarter hour; and actual postal charges.11
If you are called to testify at a deposition or a court hearing, you will
be called as either a percipient witness or a treating-expert witness. A percipient
witness provides testimony based on what they perceived with their senses.
You are also considered a percipient witness if you are called to simply read
your clinical notes. If you are called to give opinion testimony regarding
a client you are treating or have treated, including opinion or factual testimony
regarding the past or present diagnosis or prognosis made by you or the reasons
for a particular treatment decision made by you, you are considered a treating-expert
witness.12 It is important for you to know the role you will play because of
the difference in remuneration. A percipient witness is reimbursed $35 per
day plus travel expenses. An expert witness is reimbursed at his or her reasonable
and customary hourly fee or a daily fee if you are called to be present or
to testify all day.13 Consider providing the requesting party your fee statement
and make sure you are paid in advance of your testimony.
For appearances at criminal trials, including juvenile dependency hearings,
you may receive witness’ fees at the court’s discretion. The court
may direct the county auditor to pay you $12 a day of actual attendance.14
If you receive a request for copies of records by a client or a client’s
representative, you may charge reasonable fees for copying the clinical file
not to exceed $0.25 per page and any additional reasonable clerical costs incurred
in making the records available.15 If you provide a treatment summary in lieu
of the clinical file, you may charge no more than a reasonable fee based on
actual time and cost for the preparation of the summary.16
Therapists who typically work with clients involved in legal matters (e.g.
court-appointed therapists) should consider including language in their Informed
Consent Form, Disclosure of Services Statement or a separate fee agreement
that discusses the therapists’ policies and fees for any reports and/or
summaries to the court. This will help reduce the possibility of clients feeling
displeased and exploited when the therapist provides a fee statement for the
court report or summary.
It is essential that therapists communicate with clients their fee and payment
policies at the outset of treatment. Maintaining clear written policies about
fees and payment will help therapists avoid potential fee-related disputes
that could harm the therapeutic relationship, disrupt treatment and lead to
complaints and lawsuits.
Ann Tran-Lien, JD, is a staff attorney for CAMFT. Ann is available to answer
member calls regarding legal, ethical, and licensure issues.
1 Cal. Bus. & Prof. Code §4982(n)
2 Cal. Bus. & Prof. Code §651(c)
3 For further reading on advertising for LMFTs, Interns and Trainees, see “Ten
Advertising Mistakes Made by Therapists”, Ann Tran-Lien, JD, Staff Attorney,
The Therapist (Mar/Apr 2012)
4 A sample “Superbill” can be found on the CAMFT website at www.camft.org,
under Legal Forms in the Resource Center.
5 Cal. Health & Safety Code § 1373; Cal. Ins. Code §§10176,
10176.7, 10177, 10177.8
6 For further reading on antitrust laws and how they affect LMFTs, see “Avoiding
Antitrust Problems in Practice”, Ann Tran-Lien, JD, Staff Attorney, The
Therapist (Sept/Oct 2012)
7 Cal. Civ. Code §1748.1(a)
8 Cal. Bus. & Prof. Code §4982(o); CAMFT Code of Ethics, Part I, §9.1
9 Cal. Health & Safety Code §123110(g); CAMFT Code of Ethics, Part
10 Cal. Evid. Code §1563(b)
11 Cal. Evid. Code §1563(b)(1)
12 Cal. Code Civ. Proc. §2034.430(b)(2)
13 Cal. Code Civ. Proc. §2034.430(b)
14 Cal. Penal Code §1329(a)
15 Cal. Health & Safety Code §123110(b)
16 Cal. Health & Safety Code §123130(f)