Ethics in Mental Health Practice- Double-booking and Overbooking

Ethics and Scheduling Psychotherapy Clients

There are many things to consider with regard to ethics and scheduling psychotherapy clients. Here are just a few areas for consideration:

Maintaining the privacy and confidentiality of those who seek to schedule appointments with you, including HIPAA and HIPAA HITECH considerations.
Fairness- Are you giving priority to certain clients over others with regard to scheduling (based on things such as fees, etc?
Are you scheduling appointments with clients that you are not equipped to see based on your areas of competency, hoping to “brush up” on that area of practice prior to your appointment?
Are you charging clients fees for missed appointments or assigning other consequences that they can’t anticipate?

What is Double-Booking?

Double-booking is when two or more clients/patients/people are scheduled to see a health provider at the same appointment time. Generally speaking, when we go to medical doctor’s appointments, it is common to wait long periods of time to see the doctor. The doctor might have several patients in separate individual rooms waiting to be seen (that is after time spent in the waiting room).

Double-booking is a frustrating practice that:

damages rapport with patients,
makes people reluctant to schedule appointments because they don’t have the availability to wait, and
allows doctors to bill insurance for many patients on the same day.

It seems we’ve all accepted double booking because there seems to be a doctor shortage and because doctors don’t give us a choice. Additionally, doctor visits tend to be short. It wouldn’t make sense for them to only schedule one client for a full hour or even half hour.

Double-Booking in Mental Health Practice

I recently learned of a scheduling strategy that involves double-booking psychotherapy clients on purpose. Thankfully, this is not a widespread practice among psychotherapists in private practice. Generally speaking, when people schedule an appointment with their therapist,they can expect to be seen at that time. It is a cornerstone of therapeutic relationships to “create space” and “hold space” for the work of therapy to happen.

People who have private insurance or who can pay for therapy out of pocket are unlikely to be subjected to intentional double-booking. When a therapist double-books they are generally mortified. It is typically an error that leads to profuse apologies, followed by trying to figure out who keeps the appointment.

Most pre-existing therapeutic relationships can withstand the error.

So Who Is Double-Booking?

Based on some recent exchanges with colleagues it is apparent that double-booking is occurring in some settings that serve people with limited resources. Double-booking seems to be connected to a “no show” – when someone does not show up for an appointment and they did not give notification that they would not attend.

The practice of double-booking seems to be that when one of these clients/patients/consumers “no shows”, then when they are ready to schedule again, they are offered half hour appointments instead of the previous 45, 50 or 60 minute appointment. Presumably, they are splitting the hour with another person (who also no showed). If that other person does not show up or cancels late, then the person who does arrive receives a full session. If both show up then they each get a 30 minute session.

Somehow these settings must maintain enough services provided to continue being funded and to bill 3rd party payers for services. Therefore, it is important to acknowledge –

high overhead and administrative costs,
the high rate of no shows, and
the inability to re-coup no show/late cancellation fees from these clients/patients/consumers.

It is also notable that those with fewer resources are subject in many ways to lesser treatment considerations than those of means. This might contribute to health disparities.

Scheduling in Private Practice

I think that one of the problems occurs when a person who has worked in a setting that practices double-booking moves in the direction of private practice without consultation, training and support. They may be unprepared for the differences between these two settings as they relate to a number of business practices including scheduling, billing and informed consent.

Double-booking in private practice rarely occurs because a person who engages in double-booking in private practice is working outside of the standard of care.

Overbooking

Double-booking is not to be confused with overbooking. Overbooking is when a provider schedules more clients in a given day/week/month than they would ideally need to see in order to maintain their practice. Each client is given their own unique appointment time. The purpose of scheduling 30 client hours in a week, when your goal is to see 25 clients in a week is to make sure that you hit that target number.

There is nothing wrong with overbooking. However, there may be times when all 30 of those clients show up and the therapeutic day gets very long and has fewer breaks than are ideal for the therapist. If this happens too often, the risk is burnout or negligence, which is very risky.

Keys to Ethical Scheduling & Maintenance of Therapeutic Relationships in Private Practice

Protect clients’ privacy and confidentiality.
Screen clients appropriately to make sure you are seeing those you can serve best.
Develop some rapport with clients, via phone if possible, during your screening process. This will better ensure their attendance to the first session.
Don’t over promise or over-simplify their problems and concerns. This can backfire and make you appear untrustworthy. It can also lead to people expecting fast results.
Treat all clients with respect.
If you mess up, apologize and do what you can to fix it…within reason. After all, therapists are human beings, not robots who never make a mistake.
When you haven’t seen a client in a while, make sure you have a process you engage in to determine if and how you should close the case file.
Lastly, if you have not received any hands-on training or experience in private practice but you have a right to practice in that setting…obtain consultation or join a group practice when getting started.

Don’t dive into an area of practice outside of what you are familiar with based on your previous experience. Don’t try to implement the same strategies and policies of any sort including billing, scheduling, marketing and relationship building. What works in one practice context does not necessarily transfer effectively to others.

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