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The National Voice of Clinical Social Work 

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  • 14 Dec 2020 9:50 PM | CSWA Administrator (Administrator)


    Since the Affordable Care Act went into effect in 2011, there have been new forms of treatment reviews through Medicare called Comparative Billing Reports (CBRs).  They are designed to identify which LCSWs are considered “outliers” in psychotherapy practice; psychologists and psychiatrists are also receiving CBRs for psychotherapy.  This paper is designed to explain how CBRs are developed, what areas are being used in preparing CBRs, and offer suggestions as to how LCSWs may want to respond to them. 

    There are several companies, called Health Information Handlers (HIHs), which create CBRs for the 14 Medicare Administrative Contractors (MACs) in the country, including CIOX, Ability Network, Chartfast, and others.  For more information see https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Information_for_Providers .

    As LCSWs know, psychotherapy treatment can take several months or even years of weekly psychotherapy sessions.  There can be great variation in the areas assessed by CBR companies.  These include 1) how frequently a patient is seen; 2) the average number of sessions for each beneficiary; and 3) how  long each session is/how much reimbursement has occurred.  For LCSWs, these areas are primarily determined by the diagnoses a patient has as found in the DSM-5, and the treatment methods the LCSW uses to treat these conditions.  For example, complex PTSD and complex grief can take longer to treat than adjustment disorders; cognitive behavioral therapy generally takes less time in treatment than psychodynamic psychotherapy. 

    To find information on the three areas noted above, the HIH preparing the CBRs reviews all psychotherapy provided by providers for a given MAC.  All LCSWs are compared to all other LCSWs providing psychotherapy. Any LCSW who is in the top 10% in at least two categories, who sees at least 10 Medicare beneficiaries for psychotherapy, is sent a CBR notifying the LCSW. Additional documentation may be required to explain the reasons for the high level of service and/or reimbursement.  

    There are numerous evidence-based psychotherapeutic methods which treat different kinds of mental health or substance use disorders.  It is safe to say that the majority of Medicare beneficiaries are senior citizens who qualify for Medicare based on age.  LCSWs who understand the senior population’s emotional difficulties are likely to specialize in this kind of psychotherapeutic work and see more Medicare beneficiaries. It would be a false dichotomy to see LCSWs who see a high number of Medicare beneficiaries as outliers; this is their area of expertise and practice. 

    Another difficulty for LCSWs in the development of the CBRs is the comparison of all mental health conditions to all other mental health conditions.  As noted above, there are numerous mental health diagnoses, some of which take longer to treat than others.  Diagnoses should be “apples to apples” if these comparisons are being made.

    Thus the LCSWs who are most likely to receive a CBR are those who see a large number of Medicare beneficiaries; who see these patients in long-term therapy; and who use 90837 more often than other CPT codes.  Long-term psychotherapy has been shown to have multiple benefits.   Some studies that have validated this point of view are:

    • Studies that support a ‘sleeper effect’ for long term psychodynamic therapy in which there continues to be a course of clinical improvement following termination of therapy (Abbass et al., 2006; Anderson & Lambert, 1995; de Maat et al., 2009; Leichsenring & Rabung, 2008; Leichsenring et al., 2004; Shedler, 2010).   
    • For patients with a broad range of physical illnesses, there is evidence that short term psychodynamic therapy decreases utilization of health care resources.  Abbass, Kesely, & Kroenke, (2009) did a meta-analysis of 23 studies involving 1,870 patients who suffered from a wide range of somatic conditions (e.g., dermatological, , neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, genitourinary, immunological) and found a reasonable effect size of .59 in diminishing the severity of their health disorders.  Shedler notes a similar robust finding stating “Among studies that reported data on health care utilization, 77.8% reported reductions in health care utilization that were due to psychodynamic therapy – a finding with potentially enormous implications for health care reform” (Shedler, 2010, p.101). 
    • With respect to more chronic mental health conditions, Leichsenring (2008) comments in this study that a considerable proportion of patients with chronic mental disorders or personality disorders do not benefit from short-term psychotherapy.  This meta-analysis showed that long-term psychodynamic psychotherapy (LTPP) was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning.  Furthermore, some cost-effectiveness studies suggest that LTPP may be a cost efficient treatment (Bateman, Fonagy, 2003; de Maat, Philipszoon, Schoevers, Deffer, de Jonghe, 2007).

    CSWA hopes that this paper is helpful to LCSWs in understanding the CBR and responding to them.

    Laura Groshong, LICSW, Director, Policy and Practice

  • 16 Nov 2020 11:40 AM | CSWA Administrator (Administrator)

    The Aware Advocate: LCSW Reciprocity

    November 2020

    Laura Groshong, LICSW, CSWA Director Policy and Practice

    In these difficult COVID times, the issue of being able to practice across state lines has become increasingly important.  Most LCSWs* – not by choice – have become proficient in videoconferencing over the past eight months.  While this has presented challenges and frustrations, the upside is that we now have the technology skills to provide psychotherapy in this format. [See the three CSWA webinars in the Members Only section on the website to review these issues.] With these skills comes the ability to practice with patients who are not close enough to meet with us in the office.  Those LCSWs who have tried to make lemonade out of this development, i.e., expanding their practices online, have found that there are many barriers to practicing across state lines without a license.

    This issue of The Aware Advocate, CSWA’s occasional newsletter providing a deeper dive on current matters affecting clinical social work practice will explain the current state of affairs when it comes to practicing across state lines in the time of the pandemic.

    History of Reciprocity

    Clinical social work licensure laws are governed by the state social work board in that state (there are four states that have governance by a state agency).  These boards and agencies implement rules as to how the laws that created clinical social work licensure are implemented. Most states have rules that regulate which LCSWs may practice in each state.  The Association of Social Work Boards (ASWB) serves as the organization that develops the clinical social work examination and as a ‘home base’ for social work boards but does not have oversight over them.

    Until last March, most boards had some process for becoming licensed in a new state.  Almost no states allowed LCSWs to practice without acquiring a license in each state, except in emergency situations (for more information see my book, Clinical Social Work Practice and Regulation: An Overview, 2009.)  Some states allowed an LCSW to become licensed in another state if their license had the same or higher standards of licensure than the state in which they were licensed without going through the whole licensure process of gathering supervised experience hours; the ASWB clinical examination only needs to be taken once and is transferable to any state. Some states do require completing supervised clinical hours again, an onerous task for established clinicians. 

    * LCSWs is used to cover all clinical social work titles including LICSWs, LISWs, etc.

    The small group of LCSWs that have chosen to become licensed in more than one state have more options for the patients that they can treat. Being licensed as an LCSW in more than one state means higher costs for being licensed in more than one state, different continuing education standards, and more complicated relationships with third party payers.

    Current Clinical Social Work Policies on Reciprocity

    Many of the laws and rules governing clinical social work licensure reciprocity have changed since COVID-19 has impacted our ability to see patients in person, roughly since March, 2020 when the State of Emergency was declared nationally. Beginning with Maryland, whose Governor allowed any LCSW licensed in another state to see patients in Maryland through videoconferencing without becoming an LSCW-C in Maryland, many states have relaxed the rules in place for which LCSWs can provide treatment in their state.  See my article “Guide to Telemental Health Across State Lines” on 11-11-20 for more details on how to find out the current standards on reciprocity for LCSWs in each state. A good link for this information is  https://www.naswil.org/post/state-by-state-guide-to-the-rules-laws-about-telehealth-services-across-state-lines. It is crucial to check these standards in the state in which you are currently licensed and the state in which a patient resides.

    National Policies on Reciprocity

    Another outcome of the pandemic is the increased pressure for national reciprocity for LCSWs.  Psychologists have been working toward this goal with a group of states that accepts the license of a psychologist from a state which is affiliated with a group of states who agrees on licensure standards, called PSYPACT.  This is a much easier task for psychologists because all   psychologists licensed as psychologists have a doctorate before they become licensed and that process is standardized.  NOTE: psychologists who have a terminal Master’s degree cannot become licensed as a psychologist and generally become licensed counselors.

    The Master’s in Social Work is considered the terminal degree for clinical social workers, though there are several ways LCSWs continue to be trained for 2-3 years after receiving an MSW.  The laws and rules governing this training varies widely from state to state and each social work board has a vested interest in the standards that they have created.  Getting social work boards to agree on standards that would allow an LCSW to practice in another state is challenging.  Nonetheless, CSWA in collaboration with ASWB and NASW, is hoping to find a way to do so and have been working on this goal for the past 4-5 years.  There is a special urgency now because all the patients that we are seeing who we can now treat because of relaxed standards may be unable to continue their work with us, and have that work be covered by insurance,  when the State of Emergency ends.

    Summary

    For all the reasons noted above, there are problems for licensed clinical social workers in creating a way to use our licenses across state lines.   This may come about in time, but the nature of clinical social work licensing is state based and boards are reluctant to give up their right to create standards of practice for becoming licensed or for allowing reciprocity.  For now, the best way to practice across state lines through telemental health is to make sure you are in compliance with the rules of your own state and those of the patient’s location.  This is likely to change when the State of Emergency ends, likely within the next year.

    Let me know if you have any questions at lwgroshong@clinicalsocialworkassociation.org.


  • 11 Nov 2020 5:32 PM | CSWA Administrator (Administrator)


    I have been getting many questions about current rules for LCSWs practicing telemental health in states where they are not licensed.  This used to be much simpler than it is now; pre-COVID most states did not allow an LCSW who was not licensed in the same state as the patient to practice there.  These rules were determined by state Boards and there is no national policy at this time.  There are some bills in Congress that would supersede state laws and rules, if they passed, about the ability to practice across state lines.

    Since the pandemic began in earnest last March there have been many changes to state rules.  If you wish to practice across state lines, I recommend consulting the following up-to-date guide about this topic which has been developed by the University of Pennsylvania and University of Texas which covers all mental health disciplines: https://utexas.app.box.com/s/r797qp7woupga5x65yob0ki2u7mbd84y/file/647374529609 .  It is in Excel format and should be downloaded to read more easily. You should be aware of the rules in the state where your prospective client is a resident as well as knowing emergency services. Additionally, you should keep in mind that the telemental health coverage that currently exists will possibly be eliminated when the State of Emergency ends.  Having a plan for how to manage the treatment around this possibility is part of good clinical practice.

    Be sure you have changed your Informed Consent forms to include information about how to file complaints in your state and the state of the patient in addition to following the rules about practicing across state lines. This typically would include providing links to the social work Board of the state in which you are licensed and the social work Board where the patient is located.

    Let me know if you have any questions about practicing telemental health across state lines.

    Laura W. Groshong, LICSW, Director, Policy and Practice
    wgroshong@clinicalsocialworkassociation.org

  • 08 Oct 2020 12:56 PM | CSWA Administrator (Administrator)


    I’ve received several questions about the HHS extension of the State of Emergency which I will answer below:

    1. Does the HHS State of Emergency affect reimbursement for telemental health or audio only treatment? No, this only applies to the coverage in some form of telemental health and audio only therapy by Medicare and Medicaid, which is determined by CMS. Reimbursement rates are the same as for in-person sessions.

    2. Does the HHS State of Emergency extension affect coverage and reimbursement by commercial insurers?  The commercial insurers, e.g., Optum, Aetna, BlueCross/BlueShield, Cigna, etc., will develop their own policies about telemental health/audio only coverage.  Many have followed the direction that CMS takes so far.  Reimbursement is more varied.  Some states have required insurers that cover telemental health and audio only treatment to reimburse at the same level as in-person treatment.  Check with your Insurance Commissioner or Social Work Board.

    3. Does the HHS State of Emergency extension affect the ability to provide treatment across state lines without being licensed in the state of the client? The extension does not address the ability to treat clients in states where the LCSW is not licensed. Some states have allowed LCSWs to get a temporary license, some allow temporary reciprocity if an LCSW is licensed in another state. There are a couple bills in Congress that would make this national policy if they are passed. For now, it is the responsibility of the individual LCSW to find out what the policy about treating clients in states where they are not licensed in that state, as well as in the state where they ARE licensed.

    4. What will happen when the State of Emergency ends to coverage of telemental health and audio only treatment?  That is currently unknown but unless there is a permanent requirement that telemental health and audio only treatment be covered as in-person treatment is, it is likely that insurers will only cover in-person treatment.

    In short, coverage of telemental health and audio only treatment will now continue until January 21, 2021, for Medicare and Medicaid.  The reimbursement rates will remain the same for Medicare and Medicaid during this time.  Commercial insurers may follow this policy but are not required to.  The responsibility to find out what coverage is for commercial insurers is our responsibility as LCSWs to check.

    Let me know if you have any other questions about the State of Emergency extension at lwgroshong@clinicalsocialworkassociation.org

    Laura W. Groshong, LICSW, Director, Policy and Practice

  • 12 Aug 2020 11:52 AM | CSWA Administrator (Administrator)

    There have been several opportunities for LCSWs who are Medicare, Medicaid or CHIP providers to access additional funds if our income has been affected by COVID-19.  Through the Coronavirus Aid, Relief, and Economic Security (CARES-donation) Act and the Paycheck Protection Program and Health Care Enhancement Act (PPPCHE-loan), and the Provider Relief Fund (PRF-donation), the federal government has allocated $175 billion in payments to be distributed through HHS (administered by Optum).

    Yesterday the fourth option was announced, the Provider Relief Fund Phase 2, which includes funding for LCSWs, and is detailed below. This is called the Phase 2 General Distribution funding.  This is a way to make up lost income, not a loan. To apply for these funds go to https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/for-providers/index.html#key-facts-providersand complete the 6-step application process.

    To date only a fraction of the $175 billion in funds has been claimed.  Therefore, CMS is extending access to these funds, which was supposed to end on August 9 for all behavioral health providers and other health care providers, including for LCSWs, until August 28, 2020. The funds distributed will be up to 2% of all income fromMedicare, Medicaid or CHIP in tax years 2017, 2018, or 2019 (not all three, just the highest one). 

    HHS will host a webinar on Thursday, August 13, at 3PM EDT. Register here  to learn more about the application process, which is somewhat cumbersome.

    You need to be able to document lost income due to COVID-19 and provide the income that you received from Medicare, Medicaid or CHIP per your tax returns for one of three previous years to 2020.

    I hope this will be somewhat helpful to members who work in these areas and help give some relief for those who have seen a decline in revenue during these difficult times.

    Laura Groshong, LICSW, Director, Policy and Practice
    Clinical Social Work Association

  • 07 Jul 2020 11:25 PM | CSWA Administrator (Administrator)


    I have heard from many members about letters that they have received from a number of insurers in what is being called a “treatment review”.  You will recall that these reviews were part of the process that was put in place when the Affordable Care Act went into effect in 2010.  The basis for these reviews was left up to the judgment of the insurers.  These reviews generally occur every two years.

    The last time this came up was in 2018 when Global Tech mailed out 10,000 letters to Medicare LCSWs,  questioning their practice based on three areas: how often a patient was seen; how long a patient was seen; and whether the 90837 CPT code was used regularly.  We are being compared to all other LCSWs in the insurance plan and identified as being ‘outliers’ in one or more of these areas.  As with the last round of reviews, this process is flawed as it does not take into account the conditions being treated.

    The current letters are being sent by a number of private insurers including Anthem, Carefirst, and OPTUM (UBH).  Some of the companies are separate entities, such as CIOX like Global Tech.  Some are directly from the insurer.  It is necessary to comply with these reviews to avoid being penalized. 

    If you have received one of these letters and would like some citations to support  length and frequency of treatment, here are some examples:

    • Studies that support a ‘sleeper effect’ for long term psychodynamic therapy in which there continues to be a course of clinical improvement following termination of therapy (Abbass et al., 2006; Anderson & Lambert, 1995; de Maat et al., 2009; Leichsenring & Rabung, 2008; Leichsenring et al., 2004; Shedler, 2010).   
    • For patients with a broad range of physical illnesses, there is evidence that short term psychodynamic therapy decreases utilization of health care resources.  Abbass, Kesely, & Kroenke, (2009) did a meta-analysis of 23 studies involving 1,870 patients who suffered from a wide range of somatic conditions (e.g., dermatological, , neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, genitourinary, immunological) and found a reasonable effect size of .59 in diminishing the severity of their health disorders.  Shedler notes a similar robust finding stating “Among studies that reported data on health care utilization, 77.8% reported reductions in health care utilization that were due to psychodynamic therapy – a finding with potentially enormous implications for health care reform” (Shedler, 2010, p.101).
    • With respect to more chronic mental health conditions, Leichsenring (2008) comments in this study that a considerable proportion of patients with chronic mental disorders or personality disorders do not benefit from short-term psychotherapy.  This meta-analysis showed that LTPP was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning.  Furthermore, some cost-effectiveness studies suggest that LTPP may be a cost efficient treatment (Bateman, Fonagy, 2003; de Maat, Philipszoon, Schoevers, Deffer, de Jonghe, 2007).

    Data on why it is necessary to use 90837 instead of 90834 is harder to come by, since there is only one minute difference between them.

    While it is possible that there may be some audits after the treatment review, this affected a small number of LCSWs in 2018.  The treatment review itself is not an audit.

    This process is a frustrating and anxiety-producing one, especially with the difficulties most of us have had moving to telemental health and dealing with the pandemic.  CSWA continues to work with CMS to accept the variations in practice without requiring these reviews.  It may require Congressional action as the ACA was approved by Congress.

    Let us know if you have any other questions about this process.  Stay safe and healthy.

    Laura Groshong, LICSW, Director, Policy and Practice
    lwgroshong@clinicalsocialworkassociation.org


    Clinical Social Work Association
    The National Voice of Clinical Social Work

    Strengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY

  • 22 Jun 2020 11:40 AM | CSWA Administrator (Administrator)

    The Clinical Social Work Association offers the following comments on the President’s recently signed Executive Order.

    The overall intent of the Executive Order is to develop a federal approach to eliminate misuse of authority by police, as printed in Section 1: “Unfortunately, there have been instances in which some officers have misused their authority, challenging the trust of the American people, with tragic consequences for individual victims, their communities, and our Nation.”   CSWA supports the attempt to resolve the pervasive problem of overuse of force but notes that the Executive Order neither acknowledges the systemic racism that leads to the misuse of authority, nor does it provide a plan of action for enforcing needed change. To be clear, CSWA sees the Executive Order as a work in progress, and, as such, finds two of its main goals worthy of serious consideration.

    Section 3 of the Executive Order focuses on information sharing: “The Attorney General shall create a database to coordinate the sharing of information between and among Federal, State, local, tribal, and territorial law enforcement agencies concerning instances of excessive use of force related to law enforcement matters, accounting for applicable privacy and due process rights”.  Such a database would potentially provide critical information for targeting problems to be addressed at the local level through required regular public reports.   

    Section 4 would take steps to provide additional mental health and social services to citizens who have mental health and social needs that the police are currently encounter:  “Since the mid-twentieth century, America has witnessed a reduction in targeted mental health treatment…As a society, we must take steps to safely and humanely care for those who suffer from mental illness and substance abuse in a manner that addresses such individuals’ needs and the needs of their communities.”  As clinical social workers, we applaud promotion at the federal level of the use of appropriate mental health and social services as the primary response to individuals who suffer from impaired mental health, addiction, and homelessness. At this time, law enforcement does not offer expert training in mental health treatment or in providing complex social services. Because the police have been increasingly asked to respond to these cases, the result is uncounted wrongful incarcerations and deaths, as noted in the Executive Order. 

    CSWA supports the concept of clinical social workers and law enforcement officers working as “co-responders” to address emotional distress and work to prevent wrongful deaths and incarceration. Indeed, at the local level, clinical social workers speak of successful examples of such partnerships: in protective services; on domestic violence calls; on Mental Health Crisis Teams; in prison settings; and more.  Such a pairing tempers the law officer’s militarized tactics, and, as one clinical social worker said, is what “brings a thoughtful calm to the crisis situation.”

    A major barrier to the approach promulgated in the Executive Order is the exponential growth of funding for law enforcement, with emphasis on “warrior” attitudes and militarization, while at the same time there has been a concomitant defunding of mental health treatment and social services.  Little discussion of common interests and how to work together has taken place. We strongly believe that any integration of the services provided by law enforcement and clinical social work will need mutual oversight by both Department of Justice and Department of Health and Human Services, with more balanced funding, mutually determined by these agencies.

    Having a more nuanced view of what behavior constitutes real danger and what behavior is an expression of unmet social needs has not been part of the law enforcement mindset, and CSWA would like to have an in-depth national discussion about how to facilitate this change.  Clinical social workers can offer expertise in helping create the changes that will help minimize over-zealous law enforcement by using our knowledge of deescalating potentially dangerous situations through access to mental health and social service care.  We welcome a forum for creating true integration of what law enforcement and clinical social work can provide.


    Contact:

    Britni Brown, LCSW, President
    brown@clinicalsocialworkassociation.org

    Laura Groshong, LICSW, Director of Policy and Practice
    wgroshong@clinicalsocialworkassociation.org

    Margot Aronson, LICSW, Deputy Director of Policy and Practice
    maronson@clinicalsocialworkassociation.org

  • 02 Jun 2020 5:50 PM | CSWA Administrator (Administrator)

    The Clinical Social Work Association (CSWA) stands with the thousands of protesters throughout the country who are advocating for justice in the deaths of Ahmaud Arbery, Breonna Taylor, George Floyd and many others. We also condemn the militarized police tactics being used against protesters and the aggressive police practices used against Black and Brown people throughout the country every day.

    Systematic injustices have broken our society, and our communities and clients are hurting. It is imperative that our members are supporting their clients and communities through this time of pain and protest. We are encouraging all of our members to 1) stay informed of current events, 2) read and research to ensure they understand the micro- and macroaggressions their clients face daily, and 3) continue to create environments where clients feel safe in expressing themselves and getting the support they need.

    As clinical social workers, we have always advocated against injustices. This is the very nature of our work, and it requires we address both blatant and subtle racial hostilities, anti-blackness, demeaning attitudes towards people of color, and the White supremacist attitudes that our culture and society have tolerated for far too long. In support of this work, CSWA will share resources and information and offer support in a way to help our members support their clients and combat racial aggressions in their communities. We will continue to support you as you support your communities and clients.

    Britni Brown, CSWA President

  • 24 May 2020 12:28 PM | CSWA Administrator (Administrator)

    Dear CSWA Members,

    I have been getting many requests from members for how to safely consider returning to their offices. I will be doing two webinars on this topic on June 11 and 13 (details to follow). But before we start thinking about the understandable wish to get back to our offices, I would like to offer some thoughts about what losing the ability to work there has meant for me.

    We tell our patients, rightly, that the office is the safest place there is to look at what has caused the hurt/troubled/traumatized feelings they have. We see ourselves as the owner of this safe space and feel safe there ourselves. Pre-COVID, if my patient or I was sick, it was not the potentially life-threatening issue that it is now.  Also pre-COVID, on the rare occasions that a patient or I was sick, I assessed how much of a risk there is for both of us if one of us gets a cold or the flu from the other.  I had never thought that one or both of us might be putting our lives at risk by being in the same room. 

    Now I have those thoughts.  Much as I want to return to my office, it feels like there might be a serious physical risk to one or both of us (or all patients I see).  This feels like a dangerous situation.  I don't know how to be sure that my office is a physically safe space at this point, It doesn't feel like keeping a 6-foot distance, having the right air treatment machines, wearing masks, or all the other adjustments that many are considering will bring back the precious emotional and physical safety that we have lost until we acknowledge that loss.

    Painful as it is to lose this safe space for me and my patients, it is a reality. I have been trying to explore this in myself and with my patients. Patients have made many comments about the room I am using at home when we meet online, how it isn’t like the office we used to share and what it means to them. This often leads to some feeling of loss.

    To be sure, some CSWA members are more sanguine about working by telephone or videoconferencing. Some had already been working in these ways and did not feel the shift to videoconferencing solely was that different.  I support those of you who are doing well in this way of working and hope you understand that not everyone has the level of comfort with it that you do.

    I will be offering members the multitude of issues to be considered when returning to our physical offices in the aforementioned webinars next month. In the meantime, please consider how much we have already lost.  Let’s honestly look at how much we feel that we and our patients have to protect ourselves from each other in the office. In my view, we have to achieve that before we can actually reclaim making our offices a safe space again. Hopefully the loss of our offices won't be going on too much longer, but I am trying to accept the pain that losing it has already caused.

    Hope you are all weathering this difficult time as well as possible.


  • 12 May 2020 4:40 PM | CSWA Administrator (Administrator)

    by: Laura Groshong, LICSW, CSWA Director of Policy and Practice

    May 12, 2020

    Just as we are settling in with videoconferencing and (thank you, CMS!) audio psychotherapy, the possibility that we will no longer be forced to maintain the distancing that led to these forms of practice is beginning to emerge in some states . What we can expect in the near to later future is at best likely to vary from state to state and region to region. The range of options for how psychotherapy is conducted is likely be forever changed, as well as the reimbursement that goes with the different options.

    LCSWs are flexible and we can process and make choices about all the new information we are getting that affect our practices. We can integrate the changes that we need to make to our well-honed skills to protect ourselves and our patients. Here are the issues (not exhaustive) that seem most important to consider at this point in time, whether you are planning to hunker down with your computer screen for a while, itching to get back to seeing patients in your office, or both.

    Dealing with Insurance Issues in the Here and Now

    I think it is safe to say that, while LCSWs used to feel frustrated by low reimbursement rates, lack of coverage for more than once a week treatment, and treatment reviews for psychotherapy that lasted more than a year, we now have a whole new set of frustrations.

    Among these new frustrations are the variability of private and public insurance policies: first they agree to cover the co-pays, then they don’t; first they will pay the same amount for distance therapy as in-person therapy, then they won’t; first they ask us to use a certain POS code and modifier, then change them without notice while denying claims; and more. Spending hours tracking down provider liaisons about why our claim was denied, or paid at a lower rate, is painful and even scary. One remedy is to engage our patients in the process of finding out what their current co-pay coverage is. Another recommendation is to keep a list of POS and modifier guidance as it comes out, by insurer, and keep it updated. If you find inconsistencies, let your insurance commissioner and attorney general know. This is the best way to get action on insurers’ failure to pay us what they have agreed to when we have complied with stated policies.

    Telemental Health Changes and Challenges

    I have heard from clinical social workers from all over the country in the past 4 months: the vast majority tell me that they have moved from doing in-person psychotherapy to doing psychotherapy through videoconferencing and telephonic means. Most LCSWs struggled at first with the loss of the in-person office setting and the intimacy that usually goes with it. Staring at a screen for 5-8 hours a day is tiring as we try to maintain the level of empathic attunement that is optimal with what can feel like less emotional information coming through the screen for both patients and therapists. The good news is that the process becomes more ego-syntonic over time and many LCSWs report that they have adjusted to videoconferencing after about two months. Many have gotten training in telemental health (see CSWA website for training by Marlene Maheu of TBHI at www.clinicalsocialworkassociation.org in the Members Only section).

    LCSWs have put in the time to explore the best videoconferencing platforms which have good connectivity, reasonable pricing, and adequate confidentiality. Similarly, many LCSWs want to find a different payment system since checks or cash can’t translate well to distance treatment; again, much information on the CSWA website home page – click the red bar.

    Others wonder if they can wait the possible 3 months, 6 months, 12 months, or two years, all of which have been suggested as the amount of time it will be take to be safe from COVID-19, to return to office practice. Safety will be based on having ‘herd immunity’, e.g., most people have had it and are immune, or a vaccine has been found; most epidemiologists see this as a 12-18 month process at best. The lack of knowledge about how to plan our lives is anxiety provoking as is the thought that it could be 2-3 years before we can safely return to doing in-person psychotherapy.

    CMS has given LCSWs the options to use videoconferencing and audio only psychotherapy to be covered at the same level as office psychotherapy, after much prodding by CSWA and other mental health associations. CSWA is looking at the widespread discrepancy that still exists among private insurers and ERISA plans in covering videoconferencing and audio psychotherapy at all; which insurers and ERISA plans are covering co-pays; and which insurers and ERISA plans will pay for videoconferencing/audio therapy at the same rate as in-person therapy.

    What will our practices look like in another 8 weeks, in 6 months, in a year, or maybe three years from now? We have no idea. Different states are following different trajectories based on the way COVID-19 is impacting the people who live there. Some states are coping both with “Hot Spots” and with areas which are lowering the curve and returning to an acceptable level of infection (less than 1:1 increases). The devastating impact of the 15% unemployment rate, higher in some states, affects many of our patients. Fortunately, the Affordable Care Act is still in place so that patients can find insurance if they need it when they lose their jobs.

    So far, our state and local governments have been trying to create guidelines that will protect as many people as possible, mainly through physical distancing, hand washing, wiping down all high touch surface, and masks. While this is the legal “frame”, all LCSWs still have to determine what we think is safe in doing our work in the present and moving forward.

    Types of Psychotherapy Delivery

    There are many questions to be answered by LCSWs as individuals to decide how we decide to practice from month to month and year to year as the pandemic runs its course. The answers may change depending on where we live, state restrictions, our own comfort with telemental health or audio therapy, coverage of these delivery systems and much more. Here is a list of considerations for making these decisions:

    1. Comfort with Telemental Health – the surprise for many LCSWs is that telemental health is much more successful than they thought it would be. Some patients prefer it to in-person treatment, as do some therapists. Deciding whether you want to continue providing psychotherapy through telemental health is a decision that each LCSW will make as an individual.
    2. Regulations by State – many state insurance commissioners and governors have required private insurers to cover telemental health and even audio therapy. It is unclear what will happen if and when COVID-19 is controlled by herd immunity or a vaccine. These solutions are likely to take 12-18 months. The longer that alternatives to in-person therapy continue, the more likely it is that they will be to covered when in-person therapy again becomes a viable option. Until then, following the restrictions of our states is a necessary part of how we practice, i.e., sheltering in place, even if we think we are safe to see patients in-person.
    3. Regulations from Medicare – CMS has been a leader in covering telemental health and audio therapy. The same conditions apply to the continuation of these delivery systems as in the states. Whether we want to use these options will be a personal decision for each LCSW when it is safe to return to in-person therapy. Hopefully, CMS will collect data on the qualitative differences between in-person, videoconferencing, and audio psychotherapy and realize that there is a strong basis for continuing all three options.
    4. Intersection of Diagnoses and Psychotherapy Delivery – there may be a difference in the success of psychotherapy delivery depending on the presenting problems, diagnoses, treatment method used, and length of treatment. There will be much more research into these topics. Each LCSW should consider the intersection of these items when deciding whether to see someone in-person, audio therapy or through videoconferencing.

    Confidentiality Issues

    CSWA has had several articles about the potential confidentiality problems with using telemental health (see https://www.clinicalsocialworkassociation.org/sys/website/?pageId=18219 for complete list). The use of video platforms that are not HIPAA compliant has been relaxed but this should be taken with a grain of salt; state laws may still be more stringent than Federal laws and therefore apply.

    Another confidentiality concern comes into play if and when we are see patients in-person. If, in spite of our best efforts to maintain a COVID-19-free office environment we discover that a patient has been infected, we will need to do contact tracing and notify every other patient who has been in our office within 14 days. Confidentiality is affected by COVID-19 in ways that are not usually a concern in the consultation room.

    Safety of In-Person Psychotherapy

    There has been increasing discussion about returning to in-person psychotherapy as some states begin to relax sheltering-in-place regulations. Many LCSWs understandably miss seeing patients in-person and are anxious to return to the office. Here are some safety issues to consider in making this decision. It goes without saying that LCSWs should comply with any state or federal laws about sheltering-in-place.

    • Office sanitization of doorknobs, chairs, tables or any other surface between each patient
    • WHO safe distance of 2 meters/6 feet
    • Negative pressure ventilation (if possible)
    • Antiviral cleaning of any areas touched by patient in waiting room or restroom
    • Virus air filtration (if possible)
    • Office ventilation (if possible)
    • Screen for any flu or cold symptoms
    • Removal of porous objects such as stuffed animals, pillow, blankets
    • No waiting area/limited waiting area
    • Hand washing before entering
    • 80% alcohol sanitizer in dispenser in office
    • Patient and therapist wear face masks
    • Self-quarantine if exposed to patient with COVID-10
    • Notify any other patient who has been seen the same day that a patient with COVID-19 has

    DO NOT see patients who:

    • Have returned from international travel or from hotspots within the U.S. within the last 14 days
    • Have a fever of 100.4°F or greater (consider taking temperature of patients)
    • Have a cough, difficulty breathing, sore throat, or loss of taste or smell
    • Had contact with a person known to be infected with COVID-19 within the previous 14 days
    • Have compromised immune systems and/or present with chronic disease
    • Refuse to abide by social distancing

    Clinical Implications of Changes to In-Person Practice

    While the changes we make to our practices, in-person or distance practice, are based on the real dangers we face, LCSWs need to be aware of the emotional meaning to our patients of such changes. Seeing patients while the LCSW and the patient are wearing masks may have a chilling effect on the office being a safe environment. Use of hand sanitizer and all the other preventive measures may similarly feel like an intrusion into the safety of the therapy setting. Nonetheless. to keep ourselves and our patients safe, we may decide to continue conducting distance therapy, no matter how frustrating it may be. The feelings that patients have about the changes that we make will be ‘grist for the mill’ as always. Of course, we must strive to process our own feelings about the pandemic enough to be able to somewhat objectively help our patients process theirs.

    In short, use your own judgment about what form of psychotherapy feels safe for you and your patients. Keep letting insurers know that they need to be consistent and cover videoconferencing and audio therapy. And most of all - stay tuned.

PO Box 10
Garrisonville, Virginia  22463

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