Are psychoanalytic billing practices ethical?

The changing climate of "health care reform" and increased third-party intrusion into psychotherapy are raising challenges over the ethics of traditional psychoanalytic practices such as billing for missed sessions. The practice of billing for missed sessions is an integral part of some analytic psychotherapies and forms the basis of the field of operation of many therapies. When used in this way, the billing practices are unique in medicine in that only these therapies use billing as a part of treatment. This practice is used for a variety of practical reasons but especially to emphasize to patients that the therapy occurs in their internal lives and addresses the symbols they use in organizing their world view. The symbolic use of a time commitment and the obligation to pay for that commitment are necessary so as not to present the patient with a contaminated field of operation. In this way the practice is similar to many other areas of medicine, such as surgeries that are viewed as global procedures whose billing allows for time that is not actually spent in contact with patients. This paper discusses the clinical rationale for the ability to bill for missed sessions and its ethics in terms of the newer language of utilization review. By laying down the principle of billing as a practice parameter for an open-ended bundled service that is billed globally the author translates the practice into more modern utilization-review terminology.