Ethical Practice Under Pressure: Navigating Insurance, Financial, and Systemic Challenges

Sponsored by the Western Oregon Mental Health Alliance (WOMHA), an Approved Credentialing Body for the Oregon Board of Licensed Social Workers. All proceeds go toward funding the legislative advocacy work of the Oregon Independent Mental Health Professionals (OIMHP).

This training features Susan Frager, MSW, founder of PsychBilling Coach and former owner of Psych Administrative Partners. A clinically trained social worker who began her career providing direct mental health services before working inside managed care, Susan brings a rare perspective from both sides of the insurance system. For more than 25 years, she has helped mental health professionals navigate billing, reimbursement, contracting, Medicare, audits, appeals, and the financial realities of insurance-based practice.

Training Description:

Mental health clinicians routinely face ethical dilemmas that cannot be resolved by simply knowing the rules. Insurance requirements, reimbursement pressures, contractual obligations, audits and clawbacks, changing healthcare systems, and the financial realities of running a practice can place clinicians in situations where professional values, clinical judgment, client needs, and business sustainability appear to conflict.

This training examines these real-world dilemmas through the lens of moral injury and the tension between individual and systemic responsibility. Through practical examples and discussion, participants will explore how systemic pressures can influence clinical decision-making, documentation, billing, access to care, and the therapeutic relationship—and consider how to distinguish individual ethical responsibility from problems created by flawed or inequitable systems.

Topics will include ethical dilemmas involving the use of 90837 and insurer profiling or downcoding; audits and clawbacks; financial practice management; working with insurance-based platforms; insurance contracts and provider manuals; and Medicare Advantage and Medicare opt-out decisions. Participants will examine situations in which there may be no perfect solution and develop strategies for making thoughtful, informed decisions while balancing obligations to clients, payers, their practices, and themselves.

Objectives:

➢ Define moral injury and relate it to ethical dilemmas and clinician emotional responses arising from insurance involvement in client care.

➢ Identify systemic health insurance issues that create or contribute to ethical conflicts in clinical practice.
a. State how these systemic issues foster moral injury and ethical dilemmas in clinical practice.
b. Gain an understanding of why these systems exist and are reinforced by the current healthcare structures we work under.

➢ Apply ethical decision-making, advocacy, appeal, and compliance-based strategies to navigate insurer-imposed pressures while balancing client interests and practice sustainability.

Presenter Bio:

Susan Frager, MSW, earned her Master of Social Work from Washington University in St. Louis in 1991 with the goal of becoming a private-practice therapist. Her early career included work in substance use treatment, with individuals with serious mental illness in forensic settings, with children in state custody, and as an employee-assistance counselor. After experiencing firsthand the clinical and financial pressures faced by mental health professionals, Susan moved into managed care, where she became fascinated by the ways insurance systems intersect with—and sometimes conflict with—the realities of clinical practice.

Susan left managed care in 1998 and founded Psych Administrative Partners, a billing and revenue cycle management company she operated through 2024. During that time, she billed for clinicians in at least 22 states and developed subspecialties in geriatric and Medicare billing, psychiatry, and neuropsychological testing. Her book, Managing Managed Care: Secrets from a Former Case Manager, was published by Wiley in 2000.

Susan has presented for organizations including the American Psychological Association, NASW, the New York State Psychological Association, the Missouri Society for Clinical Social Work, and the California Association of Marriage & Family Therapy, as well as for SimplePractice and ICANotes. She also served on the Commercial Payer Relations Committee of the Healthcare Business Management Association (HBMA) and was certified in Compliance by HBMA.

In 2022, Susan founded PsychBilling Coach in response to the rapidly changing landscape of mental health billing, telehealth, technology, and the growth of vertically integrated insurance and mental health platforms. Today, she provides consultation and training to clinicians and practice owners and intervenes in complex claim denials, appeals, audits, reimbursement disputes, credentialing, and other insurance-related challenges.

Susan’s combination of clinical training, experience inside managed care, and decades spent working directly with mental health practices gives her a distinctive perspective on the ethical dilemmas clinicians face when client needs, clinical judgment, insurance requirements, and the financial sustainability of practice collide.