Online Therapy Part II

So it has been 4 weeks or so since I became active with the online therapy company.

Here’s the breakdown: The first two asked to be transferred within 2 weeks. One transferred and I think the other ended up cancelling. Not a good fit. The first one gave me a “bad” review however, when I talked to the quality assurance therapist, she saw how engaging this client would have been difficult no matter what (and she was demanding that I respond 7 days a week) and gave me some good hints about her process. The second one, I think got offended because I didn’t receive her message after a week and I was sending her notes about getting her engaged in treatment. She didn’t respond to asking about working with me despite my error. This month, one client decided she really didn’t like texting, and because it’s a slower process than traditional therapy. So... a rough start.

But even in traditional therapy, a therapist has to take time to get to know people otherwise how can we really be helpful? One of the hints is that after 2 more weeks, you ask about how the client likes the platform? Then you ask about your work together. You propose this structure during the introductory 10 minute free video chat. Seems to help set a pace for clients. Will do.

So now I have about 5-6 clients, most of whom are new but engaged in the process. I can pick up a max of 4 new clients per week. I have done some brief video chats with them, which I offer in the second week. Some like that, some don’t. But they all say they like seeing my face so they know who they’re texting – they see my photo on the profile page but I don’t see theirs. I more easily match stories to faces so it helps me keep track a lot. I have a client in the UK, which is really interesting, and the others are in Colorado, near and far. Picking up clients is a bit like bidding on a cow at the State Fair – you have to be scanning the “online office” when they post new clients to be matched. You have to check for your state and then reply quickly if it’s someone you want to work with. I have found that Fridays are good days but it means connecting over the weekend a bit so they don’t get discouraged. For just one person here and there I can manage that. It feels a little trollish to be doing that, vs going out with the kids or friends…

I tell people I respond at noon(ish) and 8:30(ish). We have to check twice a day. Some people write more than others, obviously. One person asked me to write even if she didn’t, just to let her know I was there and thinking of her. Sometimes I find myself still out running errands or at lunch at noon so there’s a little issue with time management here and there. And my younger daughter is staying up a little later so I switched from 9 to 8:30 to get a jump on tucking in time. She’s ten but she still likes me to stay with her until she falls asleep. I both love and loathe it… On Fridays I respond around 5PM while I am at Taekwondo with my aforementioned child. That way everyone’s weekend can begin…

So this has been a private practice supplement and also a JOB as a practitioner. Very interesting as an experiment in a new treatment modality and a social movement. I honestly wish I had heard of it 2-3 years ago, I could have used the side income, the experience. But here I am… Jumping in with both feet. In October I begin a “Business School Bootcamp for Therapists” program to help me revv up my practice and give me some skills to be successful. I can’t afford not to be, and I really like being my own boss. I will likely write about my upcoming experience and new insights into this whole thing. 

To Join or not to join?

If you are a therapist, you are providing a medical service. Mental Health care is a part of being healthy and having someone to guide you is just as important as having a doctor to give you a check up – check your vitals, run some blood work, treat an illness. So therapists are professionals who have the ability to be paid by health insurance. Now… there are hundreds if not thousands of companies – more so now than ever – that offer insurance and pay providers in their networks.

I started off working a full time job while seeing clients through 2 EAP providers - that’s Employee Assistance Programs. They don’t pay well but the client work is interesting. The credentialing was pretty easy as well. Clients usually self refer and have a limited number of sessions that the company pays for. Beyond that I offer a reduced rate for them to continue for the same number of sessions they got through their benefits.

How can any one therapist get credentialed with all of these companies? Recently, I joined Cigna, and it was a fairly painless experience. They were efficient about sending documents back and forth, my recruiter communicated with me often, when everything was done they credentialed me in 3 weeks, when they had up to 90 days. I have been told by another Cigna provider that they pay timely and have been good to work with. Their rates are similar to what I have seen, mostly Medicaid rates but clients usually have a co-pay. Medicaid credentialing, here in Colorado anyway, has been a completely different sort of animal.

One therapist in a cohort group I’m in on Facebook said she contracted out her credentialing to someone who does it for a living – a medical biller or something. I had no idea people did that although it makes sense because doctors who open a practice have to accept a lot of insurances and they have even more documents to provide. Do they have time for that? I don’t think so. My mother has offered to help me do billing and what not and I could add her to my profiles as an office person, but I would prefer to pay her and I can’t right now and I don’t think I really want to join more insurance panels. I can take any client with PPO benefits – meaning they can see someone out of network. They pay me then submit the bill to their insurance to be reimbursed. The last person who asked me about that discovered she had to meet a huge deductible before she would be reimbursed anything. I tried to sign up with her insurance but they are not accepting new providers in my county unless I can prescribe and/or speak a language not usual for the area, like Farsi or Somali.

Getting back to Medicaid. In Colorado, the State was divided into regions a few years ago and companies bid on regions. I live in Adams County – which is covered by BHI. I want to work with kids from Denver (foster care) and Morgan Counties, these are covered by ABC. A friend of mine said to apply at Colorado Access. They had no application – they said send us an email. They emailed back: we don’t need anyone right now. I thought, that can’t be true! I went on the State Medicaid site, was able to apply and be approved as of June 1. However, if you’re not part of one of the managed care entities, you will bill and not get paid. Sadly, I am not going to get paid for a few clients, but I am okay with that now. They needed the help, they got better and I am not going to take any more until I can get paid.

I finally reached someone about my questions with BHI and she was great at explaining all of this to me.  I sent in my documents, waited, and then was told that I passed round one and in a months she and the team would start round 2. I had to send her more documents, that I really could have sent her with the first round had she asked. I am very close to being done, I have clients in a rural county Human Service Agency waiting for me to start. That was the reason I got ABC coverage in the first place, otherwise I would have been declined (there is a need for therapists in the rural areas). There has been so much outrageous duplication and waste in these processes. Being a Black Belt in LEAN/Continuous Process Improvement, I have truly struggled to be patient with the inefficiencies.

CAQH is a national clearinghouse for billing. Cigna required me to join so they can pay me and credential me through this company, however Medicaid wanted my number as well. There are a few more similar companies, depending on which insurance panel you are on. Again, duplication. Now Colorado has a ballot initiative this fall for a single payer system. I can really see the benefit to this but man if I have to scrap everything I have done to date just to join that one I might lose my ever loving mind.

In the meantime, I do a few other things – I do paintingparties, I sell my art as much as I can, I have done a training on Primary Perpetration Prevention for foster parents through Foster Source, a new support agency a neighbor of mine started this year. I saved up before I quit so I could have flexibility and a nice summer with my kids. I signed up (aka invested) for a Business School Bootcamp for therapists because I need to know MORE of how to make this work. Marketing, networking, getting referrals, it’s all part of this thing we do and it is an entrepreneurial business. It is not a passive activity. While I want to help people of lower income and who have struggled more to get ahead, I deserve to make a decent living doing it. So do you!

Secondary Traumatic Stress

Today is September 11 and I am a New Yorker. I anticipate this day, I usually take the day off work but this year it falls on a Sunday. I asked my FB friends to be "mindful" about which images they post today, although TIME, Reuters and Huffington Post aren't friends of mine and they went ahead and re-posted all kinds of horrors.
When I first moved to Colorado, people talked about 9/11 very differently. They remember the Football game from the night before. They remember watching it on TV. New Yorkers remember the weather - the soft cool morning with clear skies and bright sun, They remember the sounds - metal screaming against metal, bodies hitting the pavement, the sirens, the alarms. They remember the smells - smoke, and later, the smell of the burning people. The only planes in the sky were fighter jets, everyone had to walk home. Everyone had to account for their friends and relatives.
September 11 was 15 years ago. But for so many, it's not just one day a year. I hope it's not everyday anymore, but it could be. I was a newlywed. My husband had gone downtown for a meeting. We both worked for Catholic Charities as therapists. That night we were asked to volunteer downtown, helping people de-escalate. There was NO de-escalating anyone. They were looking for their fiances, spouses, posting photos, checking the hospital rosters the volunteers were holding. My spouse went, but I stayed home, too afraid to go near the site. All day we were told anything could happen any time, and I lived by a major bridge - I was not allowed to go under it on my way to the hospital to give blood. I was given an appointment to come another day. There were no patients who needed it today.
Our agency negotiated a contract with the City to administrate funds for families and people who lost their jobs because downtown was shut down. We were also sent to various sites to provide counseling and provided onsite counseling in the offices.  I remember one woman who worked for American Express housed in the WTC. She walked all the way from one end of the island to the other to get home, the long way. She often sat in my office struggling to stay in the present. Other times her eyes were shut and she was back downtown running for her life. I would keep talking to her to help hold her mind in that office with me, safe and quiet. I felt like I failed her. We had no idea what we were doing. We were struggling as much as anyone else. Two years later, the agency gave us a therapist of our own to do some de-briefing groups. It seemed like an after thought by then.
Today I tried anything to avoid seeing images, to think about my life that day. Since then. I get angry at people for being so flipping patriotic when they were somewhere else, watching TV, watching football. As a social worker, a clinician, I hear un-believeable stories of victimization and survival. People who have been raped, stabbed, shot, slashed, relatives of the murdered, and my own first hand experiences of work in the ER with people who are fighting to live, or dead, and being prepped for organ donation, or being re-opened in the ICU because the ORs were booked. Or the rubble and the smell and the zombie like people milling around you.
But I can't stand people making a trauma their own when it was not.  You're a firefighter? That's great, I know you have trauma. But you're a firefighter in Boonie, IA and 9/11 was not your trauma. I have to deal with that, I hold my tongue a lot. First responders died in greater numbers than any other group, they ran to the danger. They worked in the middle of the danger. The Twin Towers have been targeted since the moment they went up and were a firetrap by design. They face outrageous risk of post traumatic stress disorder and secondary trauma - car accidents, and fires. The things they've had to see that can never be un-seen.
Those images replay in the mind, anytime you smell something burning outside on the wind. When a plane seems just a little too low over your neighborhood. Be kind to each other. You haven't walked in their shoes. And you haven't walked in mine.