Health coaches help clients do what their doctors tell them. Most of them work with diet and exercise issues, although they can help with substance abuse or any other behavior the client wants to change. The discipline is growing fast. There are more than 120,000 coaches in the U.S today doing $7 billion in business.
Coaching is an emerging discipline without a state licensing board or universally accepted standards of practice and ethics. When lawyers help set up a coaching practice — trained as we are to minimize risk — we contractually supply those missing standards and clearly distinguish what a health coach will and will not do. Here are some pointers for creating a provider agreement.
1. Explaining the services
A coach is not a licensed professional but helps people follow their providers’ advice. As one case defines it, a health coach is a wellness guide and supportive mentor who does not administer medical care but helps clients implement their medical professionals’ advice by giving guidance on how to stay active, eat healthfully and control stress. The National Board for Health and Wellness Coaching (NBHWC), a national certifying board, says much the same thing. “As partners and facilitators, health and wellness coaches support their clients in achieving health goals and behavioral change based on their clients’ own goals and consistent with treatment plans as prescribed by individual clients’ professional health care providers.”
While the NBHWC provides a certification, and while the American Medical Association has created three Current Procedural Terminology (CPT) codes (potentially for billing insurance), anyone can hang out a shingle as a health coach, whether they have a certification or not. There are a huge number of training and certification programs, usually online. Some have the backing of a name university, some are approved by the NBHWC, some require some other health care license, some are quick and cheap, some are useless. The courses usually take between two to 12 months, but again, no certification is required to practice in this field.
2. Avoiding unlicensed practice
Coaches should not practice any discipline that requires a license. This means they should not diagnose diseases or give advice. They cannot hold themselves out as dieticians, nutritionists, psychologists, or practitioners of medicine. Our statutes define the practice of medicine as encouraging “the reliance of another person upon an individual’s knowledge or skill in the maintenance of human health by the prevention, alleviation, or cure of disease, and involving or reasonably thought to involve an assumption of responsibility for the other person’s physical or mental well-being: diagnosis, treatment….” The key words are diagnosis and treatment. Don’t do that. And remember that it is the patient who assumes responsibility for her own well-being. The coach merely supports her.
Often, clients will bring up psychological issues that may be at the root of an eating disorder. The coach can listen patiently but should refrain from speculating on whether there is any relationship between the trauma and the disorder and return as quickly as possible to the behavior the client wants to change. The coach focuses on what the patient is doing. A psychologist can focus on why they are doing it.
It may also be hard to avoid giving nutritional advice, particularly if the patient is on a fad diet the coach thinks may be harmful. A coach can express concerns about the patient’s health if she follows a particular regime, but it is always best to recommend speaking with a nutritionist or dietician.
Health coaches may already have licensure in another field like nursing. If that is the case, the provider contract should make it clear that this is a coaching relationship. The coach is merely helping the client implement the recommendations of her treatment team. The coach is not using her nursing skills in this relationship.
Consider drafting a disclaimer and release, in addition to the provider agreement, saying: (a) the coach is not licensed; (b) the client will rely solely on licensed professionals for advice; and (c) the client releases the coach from claims for malpractice or those concerning the rendition of medical services or advice.
3. Billing
The provider agreement needs to be very clear about what services will be provided and what they cost, and whether insurance is paying for them or not. Does the coach charge for phone calls? Travel time? Is an hour an hour? Are there charges for missed appointments? How much notice does either party have to provide to terminate the relationship? How are expenses reimbursed? Are there group sessions, and if so, what are the guidelines? Is there a charge for text or email support? The answers will be different depending on the services the coach provides.
4. Ethics
Coaches and clients need clear boundaries. Some health coaches will go out to meals with clients, accompany them to parties, or even go on trips. Many allow clients to text or email them outside of coaching sessions at any hour. Whether these practices are a good idea or not, they underscore the importance of boundaries. The NBHWC code of ethics hits the high points: record-keeping, confidentiality, professional conduct and conflicts of interest. But anyone who has represented a doctor or psychologist with a boundary violation knows the problems take root in the gray areas. While one can reference this one published code, it would be wise to look at the ethical rules for psychologists, doctors and other professionals and set clear limits that both the client and coach must follow. You should also be very clear about how each person can terminate the relationship, notice periods, and what steps the coach will take to avoid prejudice to the client.
A successful coaching business starts with a good provider agreement that sets clear expectations on both sides. Because there is no licensure for coaches, it is up to the attorney to look at analogous fields to define the relationship between coach and client in this developing field.
Joel Rosen is the founding partner of Rosen & Goyal PC. He represents doctors, dentists and other health care professionals.