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Is it not possible for the client to know the encryption key and you to not have it, requiring the client to unlock the file if there is to be a session or something?
Do you mean for their medical records? Like I would write their medical records into an encrypted file that they hold the key for?
This is an interesting idea but it would be reliant on the client self funding services. I also don’t know if it would be legal because I am not a lawyer and generally the government wants access to your data
The other aspect that I absolutely glossed over here which was probably a bad idea is that payers retain the right to your records for auditing purposes to ensure their funds are not being wasted (which is a whole textbook of issues).
The vast majority of time this transmits data that is typical for medical services and is somewhat minimal - time and date of service, CPT code(s) (aka what kind of service was rendered, diagnosis code(s) relevant to service, who the service was for, charge rate for the service (how much money I bill). The stuff you see on an explanation of benefits. Insurers don’t typically see actual progress notes.
However, they reserve the right to do so in a few instances: if you file a grievance against the clinician, if they feel the clinician is doing something wrong, or if they simply decide to do a random audit (this is astoundingly rare with commercial insurers but happens much more routinely with government funded plans like Medicare and Medicaid).
In the first instance it’s generally a good thing; the insurer is acting as an advocate for you because the clinician did you harm in some way. In this instance the insurer is actually one of the best people you can have on your team. They don’t actually care about you but they are aligned with your mission; if they can prove clinician malfeasance they can usually recoup tens of thousands of dollars of insurance payments going back years.
The second two are where things are muddier. When that insurance ceo got got a light was shone upon the ugliness of these systems for a brief moment but now no one cares again. Audits are increasingly being triggered by automation: if you are an outlier in terms of utilization then you run the risk of getting your therapist’s practice raided by Optum. Insurance regulations are contractual, not legal, and are often conflicting and obscenely complex. They are written in such a way that it is essentially guaranteed that if complex cases are audited they will find issue with dozens of notes. And the law is on the side of the insurance: they can go back years and rescind payments
So what can end up happening is that you come to therapy from a hospitalization. You aren’t doing well. You see me twice a week because of this for 4 months. You do better. We see each other for another 6 months weekly. You regress, and we go back to twice weekly for 4.5 months. You have optum insurance (a subsidiary of United, but they aren’t the only ones who do this), and their internal systems flag you for high utilization of services
They contact me and tell me that is anomalous and as a result they will be doing an audit of records. They don’t just audit you though, they audit anyone I work with who has optum for the last 3 years. Any note that has even a minor issue: did I not make use of an intervention clear enough? Did I forget to change the session times to actual times from the default 5-6pm? Did we have a session where you were doing poorly and it was more just me listening to you vent and process? All those are retroactively rejected. Now my practice suddenly owes optum thousands of dollars, sometimes tens of thousands. I’ve had colleagues with group practices where this ends up being a 20-30k bill due in 15 days or their contract is voided and all their optum clients are fucked.
The problem is self funding services is a mixed bag. With overheads even as a telehealth only practice the minimum I can charge for a livable wage of about 50-60k a year is a sliding scale of $45-60 and frankly that only works because I have about 50% of a caseload that’s commercial insurance clients that pay double that. Even with that 45-60 is a huge ask for a weekly or biweekly service, 90-240 a month is a tremendous expense for most people. Therapy should cost nothing, or maybe like $10 a session at most, but if I charge that I will starve. I don’t know a resolution here.