Dear CSWA Members,
Given the chaos of the situation in Washington, DC, I wanted to let you know that CSWA is thinking of our many members who live in and around the area. It is very disturbing and frightening to watch from a distance; it would be exponentially worse to be in proximity to the destruction that has been inflicted on the heart of our democracy.
Please take care of yourselves. We hope this misery will come to a quick conclusion. On top of the pandemic, this traumatic situation will only escalate the anxiety and depression we are seeing in our practices. We must take care of ourselves so that we can take care of others. CSWA is here for you.
Kendra Roberson, LICSW, President Clinical Social Work Association kroberson@clinicalsocialworkassociation.org
Laura Groshong, LICSW, director, Policy and Practice Clinical Social Work Association lwgroshong@clinicalsocialworkassociation.org
Since The Aware Advocate article, Nine Months into the Pandemic: Practical Telemental Health for LCSWs, came out yesterday, I’ve received several questions about whether LCSWs are essential workers and when will they be eligible to get the COVID vaccines. I hope this will clarify this complicated situation.
The Centers for Disease Control and Prevention (CDC) has made recommendations about who should have access to the vaccines and in what order.
There are two Phases, but Phase 1 is divided into three parts when it comes to rolling out the vaccines:
These recommendations can be found at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html .
Note: LCSWs are considered essential workers but whether we fall in 1a, 1b, or 1c depends on where we work and the way that the state we live in is organizing the vaccinations. If we work in a hospital or skilled nursing facility it is pretty clear we would be in the 1a group. Those of us who are over 75 are clearly in the 1b group. But all the other factors that affect us make it impossible to say for sure when we you will get be eligible to be vaccinated.
I recommend that everyone google “COVID Vaccination in [your state/jurisdiction]” and find out which state agency is organizing the distribution and policies for how the vaccines will be available. It may also be prudent to contact your PCP and ask when they may be able to vaccinate you. As you know, some of the vaccines require special refrigeration and may not be storable in doctor’s offices.
Keep in mind vaccination alone may not necessarily make us immune to COVID, but it may certainly help. Keep following all guidelines for masking, staying 6 feet apart, washing hands, and not spending time in closed spaces with people you do not live with until CDC/HHS say it is safe to stop these practices. To those of you who have reservations about getting vaccinated, use your judgment and if you choose not to get the vaccine, keep following all the guidelines above.
We will get through this pandemic and are getting closer, even though we may be many months away. Happy new year to all.
Laura Groshong, LICSW, Director, Policy and Practice Clinical Social Work Association lwgroshong@clinicalsocialworkassociation.org
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:
CSWA hopes that this paper is helpful to LCSWs in understanding the CBR and responding to them.
Laura Groshong, LICSW, Director, Policy and Practice
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.
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
I’ve received several questions about the HHS extension of the State of Emergency which I will answer below:
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
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 PracticeClinical Social Work Association
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:
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
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
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
PO Box 105Granville, Ohio 43023
