Psychoanalysis is a unitary therapeutic procedure (CPT: 90845) consisting of a number of repetitive technical entities conducted from beginning to end over a course of many psychoanalytic sessions (Gray and Cummings, 1995). The establishment of the frame and therapeutic alliance of the analysis involves an agreement between analyst and analysand regarding the scheduling of times they will meet for psychoanalytic sessions, the setting of the fee and the manner and scheduling of payment of the fee. Data such as the actual number of total sessions over the course of psychoanalysis, the amount of the fee, and the schedule of fee payment and collection are not standardized technical features of analysis; however the methods by which these matters are agreed upon and managed between analyst and patient are integral to the treatment itself.
It is the general practice of many psychoanalysts to keep some record of their analysand's appointments and payment of fees. There is no established format. Each analyst chooses to keep such information by his or her own method. When psychoanalysts and patients conduct treatment under systems which provide for third party reimbursement for treatment, it has been common in the past that some additional information is appended to appointment records or insurance billing and claims records such as diagnostic codes, procedure codes for treatment, billing information to the third party, etc.
These appointment and fee payment records have been considered to be an official part of a patient's medical chart whenever charts are officially peer reviewed, audited by licensing boards and various other authorized agencies, or requested voluntarily or by subpoena in courts of law.
In recent years, government and private third party insurance programs have asserted that a patient's right to protection of the confidentiality of their medical records is abrogated by the patient's decision to file a claim for government or private insurance subsidy reimbursement for the services in question (Ault, 1995). The patient waives rights of confidentiality of these records by signing a release at the time of claims filing. Release forms supplied by insurance programs are often too vaguely written to give patients a clear understanding of the rights being waived and the possible consequences for psychoanalytic treatment .
Government and private insurance programs have been requesting that more information be recorded in patients' charts and be available for third party review and audit upon request. In regard to appointment records, we understand that some third-parties request a session by session indication of a patient's lateness to appointments and missed sessions. The stated purpose for requesting such information is to allow the outside party to monitor and avoid paying for missed appointment time. Documentation might be requested for each session to specify if the patient was on time or late, how many minutes late, and to confirm that the patient attended or failed to attend the session altogether. The requirement to document this information tends to violate the principles developed in our practice guideline, Charting Psychoanalysis . Since psychoanalysis is a unitary therapeutic procedure, lateness and missed sessions are not isolated matters which can be regarded as separate from the treatment process. Instead, lateness and missed sessions have important meaning and usefulness within the context of the treatment process and the therapeutic alliance. Matters of lateness and missed sessions are integral to psychoanalytic treatment which is essentially confidential and private. The practice of documenting such matters imposes an attendance surveillance function upon the analyst which compromises the analyst's technical role in the therapeutic alliance with the patient.
The usual and customary practice to refrain from documenting each discrete incident in a patient's chart tends to place the psychoanalyst in conflict whenever outside parties assert an interest in such matters, particularly in the case where there is consideration of third party subsidy for the patient's treatment. The concerns of these outside parties have legitimacy in extra analytic terms. In such circumstances, the psychoanalyst and patient may need to consider the advisability of establishing treatment under such conditions, especially if reasonable arrangements for analyst and patient to agree on a payment method for missed sessions are so intruded upon that an arrangement which can reasonably support psychoanalytic treatment cannot be made. If treatment were to proceed without a mutually satisfactory agreement, this can effect the psychoanalytic treatment process to the core and can diminish or destroy reasonable opportunity for psychoanalysis to be therapeutic in relieving suffering, resolving internal conflict, and ameliorating character pathology to provide for continued emotional growth.
We recommend that psychoanalysts who choose to keep appointment records such as those described above assume that such records are part of the official medical chart of the patient and are discoverable in a variety of legal ways. Information contained in such records should be confined to simple billing information and items such as dates of appointments for service, charges, amounts received and balances owed. Factors which are integral to analytic treatment such as documentation of lateness to sessions and missed sessions are not recommended to be included in appointment records because these matters are customarily contained within the body of confidential material of the analysis.
It is recommended that when psychoanalysts keep appointment records in conjunction with billing records involving third parties, that such records be created with the understanding that confidentiality for the information contained in such records often has been waived in exchange for consideration of treatment subsidy by the third party. For this reason, such records should not contain unnecessary information, particularly information which is integral to the analytic process, such as documentation of lateness or missed sessions.
In the interest of avoiding allegations of insurance fraud, it is recommended that mutually agreeable arrangement and understanding regarding financial responsibility for missed sessions be clarified at the outset of treatment with the patient and with any third party that is expected to contribute to payment for missed sessions. The activity of clarifying such matters with the third party is usually performed by the patient to avoid unnecessary interaction between the analyst and the third party.
When a third party insists that lateness to sessions be documented for the purpose of denying financial support for minutes of treatment missed, it is an indication that a viable psychoanalytic treatment cannot be established and sustained in conjunction with that third party.
This practice guideline was prepared by the Subcommittee on Interacting with Third Parties of the Committee on Peer Review of the American Psychoanalytic Association: Robert R. Cummings, M.D., and Sheila Hafter Gray, M.D. (co-chairs), Joanne Marie Greer, Ph.D., Leon Hoffman, M.D., Roberta K. Jaeger, M.D., Mark Leffert, M.D., Frederic J. Levine, Ph.D., and Richard West, L.C.S.W. It was written for the subcommittee by Robert R. Cummings.
The American Psychoanalytic Association does not intend this practice guideline to state or serve as a standard of practice for mental health care. It is intended as a guideline only. The ultimate judgment regarding a particular clinical decision or method of intervention or overall treatment plan will be made by the practitioner on the basis of the clinical data presented by the patient and the diagnostic and treatment options available in the particular clinical setting. This practice guideline was approved by the Executive Council of the American Psychoanalytic Association on May 2, 1996.