May 12, 2020

By Laura Groshong, LICSW, CSWA Director of Policy and Practice

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:

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.

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.

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.

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. 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 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.

DO NOT see patients who:

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.

April 30, 2020

I am pleased to confirm that LCSWs can now be reimbursed by Medicare for audio only psychotherapy sessions. More details can be found at https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf.

The CPT codes are the same as the ones that we use for in-person and videoconferencing sessions, e.g., 98034, 98037, 90791, etc. Any telephonic session that you have conducted since March 1 can be submitted for reimbursement.

The POS code should continue to be 11 as is has been for the past three weeks. The modifier is 95.

This is the decision that CMS has made for Medicare coverage. As we know, private insurers often follow the lead of Medicare policy, so there is a chance that we will see more coverage of audio only sessions by private insurers. Do not take it for granted though, that this is the case. Continue to check the plan that each patient has if you wish to conduct treatment in an audio only format.

This also will not automatically apply to ERISA, or self-insured, plans. We are continuing to pursue audio only coverage for those plans as well.

This is a big win for LCSWs and you all helped! When we work together through CSWA, as well as with NASW and the American Psychological Association, we can accomplish great things.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

April 29, 2020

Many CSWA Members have wondered about the risks and benefits of applying for the second round of relief funds from the CARES Act General Allocation Fund. Some of the guidance on applying for these funds is as ambiguous as the explanation for the first round of relief funds, but I will give you my understanding of what it means.

First, tomorrow is the last day for accepting or rejecting the first round of funds, which did not require an application, as the second round does. The first round of funding went to any LCSW who saw Medicare patients in 2019. There is some confusion about what accepting these funds, either through active attestation or no response, will mean. But anyone who does not actively reject the funds by tomorrow will be seen as eligible for the second round of funding.

To be considered for these new General Allocation funds, information on filing the application can be found at https://chameleoncloud.io/review/2977-5ea0af98f0fd0/prod. A couple of changes are 1) you must file your 2019 tax return, and 2) you must estimate your lost income for March and April of 2020. These funds will be available until they are exhausted and will go out as claims are validated.

There is no guarantee that you will receive these funds, or a formula for how they will be distributed. The main thing to remember is that if you want to be considered for receiving them, apply sooner rather than later. Giving our tax returns to HHS is a calculated risk. If the information is accurate, there should be low risk; if not, there could be an audit of your tax return. Estimating lost income may be difficult and could lead to problems if it is found to be overestimated. But for some LCSWs, it may be worth the risks of applying for these funds because of the need for more income at this perilous time.

Remember - this is a separate source of funding from the Payroll Payment Protection (PPP) funds, which LCSWs are also eligible for. PPP allows businesses to borrow 2.5 times our average monthly “payroll costs”, a bit of a misnomer, because when you look at the actual definition payroll costs include self-employment income, e.g. net income reported on Schedule C. This program applies to anyone with self-employment income and is a loan which must be repaid.

I hope this helps you make the decision that is right for you about applying for these funds. Let me know if you have any other questions.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

April 23, 2020

I hope you are all making the adjustments that most LCSWs have made to preserve the safety and health of ourselves and our patients.

In addition, there are many people struggling to meet basic needs and solve the ways to prevent COVID-19. Here are a few that could use your help in doing their good work:

Helping others is a big part of our clinical social work values. I hope everyone can find a way to chip in for those who are in need.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

April 18, 2020

There are several concerns about the potential risks of accepting the funds which many members have received as compensation for the potential loss of income due to COVID-19. There is no clear guidance on the meaning of the Relief Fund Payment Terms and Conditions, some of which are ambiguous, but the risk which accepting the funds causes seems less problematic than so have suggested. This is not legal advice, but my best guess about what the likely outcome of accepting the reimbursement will be and factors you may want to consider in making your decision.

Purpose of Funds – This statement in the Relief Fund Terms and Conditions is unclear when applied to psychotherapy: “The Recipient certifies that the Payment will only be used to prevent, prepare for, and respond to coronavirus, and shall reimburse the Recipient only for health care related expenses or lost revenues that are attributable to coronavirus.” This can be interpreted in the broadest of terms, i.e., that there is anxiety and depression about the pandemic which almost all patient face even if that is not their primary reason for treatment, or in a narrower way, that the presenting problem is specifically emotional distress about being ill with COVID-19, having family members with COVID-19, or fears about this happening. We must use our judgment about which way to interpret this section.

Meaning of UHC Involvement in Payments – this may be unusual in the way we are generally paid but this public/private partnership should not have any impact on our status as out-of-network providers, if we are. UHC is a pass through in this case, writing checks for HHS; Medicare does not accept out-of-network clinicians so there is no possibility of that option being limited for beneficiaries.

Out-of-Pocket Payments – finding LCSWs to provide services is challenging even without the additional burden of the emotional stress that has been created by the pandemic. Accepting the reimbursement requires us to agree that we have not charged anyone our out-of-network rates if we saw them outside of Medicare and that we will not do so going forward.

Consequences of Attestation – there may be some auditing of how the funds are used but it seems unlikely that the amount of money being distributed to LCSWs will be targeted. Signing the attestation that you have received the funds and intend to use them to treat Medicare beneficiaries with COVID-19 mental health problems seems like it is likely, to one degree or another. It is probably less risky if you affirmatively accept or reject the funds that you have received, after weighing all the factors involved.

Keeping the funds may be appealing and well-earned, but some members have decided to reject them because of the involvement with UHC, the ambiguity about whether the work we are doing meets the criteria for accepting the funds, and the possibility of being audited is not worth the risk. Each of us will need to come to our own conclusions about this difficult decision.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

April 18, 2020

Many members have begun to get Medicare ‘reimbursements’ as a result of the CARES Act. This has caused some confusion which I will try to clear up here.

1. Funding Source - These funds come from the from the $34 billion provided in the Coronavirus Aid, Relief, and Economic Security (CARES) Act through DHHS. The CARES Act appropriation is a payment that does not need to be repaid.

2. Amounts Reimbursed - The amounts are based on the treatment that an LCSW provided to Medicare patients on a fee-for-service basis in 2019; this does not apply to Medicare Advantage patients. The amount is based on the LCSW’s share of total Medicare FFS reimbursements in 2019. Total FFS payments were approximately $484 billion in 2019.

3. Reason for Reimbursement – Though these funds are primarily for services provided connected to COVID-19 issues, it applies to other mental health problems as well. It goes without saying that there is widespread anxiety and depression as a result of the pandemic which affects almost everyone in the country.

4. United Health Care Role - The reimbursements are distributed by HHS through United Health Care in a public/private partnership. Most reimbursements are under $2000, many under $500 from what I have heard.

5. Attestation - You can either ‘attest’ that you accept the funds directly at https://covid19.linkhealth.com/ or do nothing which will be seen as an affirmative attestation in 30 days from distribution. There is no penalty if an affirmative attestation is not made.

For more information go to https://www.cms.gov/newsroom/press-releases/cms-approves-approximately-34-billion-providers-acceleratedadvance-payment-program-medicare, hhs.gov/providerrelief or call the CARES Provider Relief line at (866) 569-3522.

There is another program which provides loans to LCSWs and other health care providers who need financial assistance as a result of the COVID-19 crisis. The CMS Accelerated and Advance Payment Program has delivered billions of dollars to healthcare providers, including some LCSWs. These accelerated and advance payments are loans that providers must start paying back within 120 days and complete paying back by 210 days. For more information on applying for these loans, go to https://www.cms.gov/newsroom/press-releases/cms-approves-approximately-34-billion-providers-acceleratedadvance-payment-program-medicare.

I hope this is helpful. Let me know if you have any further questions.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

April 16, 2020

Many clinical social workers have noticed the way that our current shift to working through telemental health platforms has affected the treatment relationship and our own view of our work. This summary of the discussions that we have had in the CSWA "Open Webinars" may help us think through these changes. The summary can be found at CSWA - Clinical Issues in Virtual Therapy - 4-16-20.docx.

Another "Open Webinar" will be held this Sunday at 2 pm ET/11 am PT. This is an excellent way to connect with colleagues and navigate the brave new world (for some) of telemental health. All CSWA members can register at https://www.clinicalsocialworkassociation.org/event-3814579. Hope to see you then.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

April 8, 2020

Below is a summary of most of the changes LCSWs have faced in the past few weeks as we have moved to telemental health psychotherapy at CSWA - Summary of COVID Changes for LCSWs - 4-8-20.pdf.

Please let me know if you have questions that are not addressed or corrections to the material presented.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

April 8, 2020

Below is an update on issues related to the changes to LCSW practice since we started using telemental health practice.

I can't stress enough how important it is to let your members of Congress know about the harm being caused by the lack of access to patients who do not have computers or smart phones. The only way to conduct treatment with them, primarily Medicare beneficiaries, at this time is through telephonic sessions. HHS has the ability to allow expanded coverage of telephonic sessions under the CARES Act. We need to keep up the pressure that Sec. Azar make this change. See the suggested language below to send messages to him and members of Congress.

I thought you might like to see the letter sent by CSWA to Sec. Azar and CMS Administrator Verma which can be found at CSWA - Letter on Audio Only Coverage - 4-7-20.docx.

As for those members who have had questions about small business loans for self-employed business owners, the programs that were set up under CARES are swamped. If you have applied, do not expect a response for about a month. Priority is being given to large corporations. I will provide more information on this topic as I have it.

Let me know if you have any other questions in these difficult times. Keep your patients and yourselves healthy, rested and safe.

“I am a constituent and a member of the Clinical Social Work Association. I have patients who are unable to meet with me in person for psychotherapy because of the COVID-19 crisis and do not have access to a smart phone or computer. The Centers for Medicare and Medicaid Services have not expanded coverage of psychotherapy to telephonic sessions, only videoconferencing; however, the only way I can provide services to these beneficiaries is by telephone.

Some enlightened insurers like Cigna and Aetna have already allowed some temporary coverage of telephonic psychotherapy sessions. Some states such as Texas, and Ohio have also required temporary coverage of telephonic psychotherapy sessions by private insurers.

Please tell CMS [and/or private insurers for state legislators and Insurance Commissioners] to approve coverage of telephonic psychotherapy sessions, sorely needed in these fraught times, for Medicare beneficiaries [and other enrollees privately insured] who may be isolated, emotionally fragile, and in need of mental health services."

You can find contact information for members of Congress at https://www.house.gov/representatives and https://www.senate.gov/general/contact_information/senators_cfm.cfm. You can find email addresses for your state legislators and Insurance Commissioners by going to your state websites.

April 3, 2020

Below is an update on several issues related to our transition to telemental health services.

1. Zoom – There have been concerns raised about the security of the Zoom platform and Zoom is taking steps to address these issues. A more secure system will be in place by April 5 for the ZoomPro and other platforms Zoom offers. Here is a summary of what will be happening:

Zoom

We’re always striving to deliver you a secure virtual meeting environment. Starting April 5th, we’ve chosen to enable passwords on your meetings and turn on Waiting Rooms by default as additional security enhancements to protect your privacy.

Meeting Passwords Enabled “On”

Going forward, your previously scheduled meetings (including those scheduled via your Personal Meeting ID) will have passwords enabled. If your attendees are joining via a meeting link, there will be no change to their joining experience. For attendees who join meetings by manually entering a Meeting ID, they will need to enter a password to access the meeting.

For attendees joining manually, we highly recommend re-sharing the updated meeting invitation before your workweek begins. Here’s how you can do that:

Log in to your account, visit your Meetings tab, select your upcoming meeting by name, and copy the new meeting invitation to share with your attendees. For step-by-step instructions, please watch this 2-minute video or read this FAQ.

For meetings scheduled moving forward, the meeting password can be found in the invitation. For instant meetings, the password will be displayed in the Zoom client. The password can also be found in the meeting join URL.

Virtual Waiting Room Turned on by Default

Going forward, the virtual waiting room feature will be automatically turned on by default. The Waiting Room is just like it sounds: It’s a virtual staging area that prevents people from joining a meeting until the host is ready.

How do I admit participants into my meeting?

It’s simple. As the host, once you’ve joined, you’ll begin to see the number of participants in your waiting room within the Manage Participants icon. Select Manage Participants to view the full list of participants , then, you’ll have the option to admit individually by selecting the blue Admit button or all at once with the Admit All option on the top right-hand side of your screen. 

Check out these resources to learn How to Manage Your Waiting Room and Secure Your Meetings with Virtual Waiting Rooms (links no longer available).
Please reach out to our Support Team if you have any questions at support@zoom.us.Medicare Issue

Medicare has made several changes in the past few days, revising some previous guidance. Below are some of the most important changes. To see the latest guidance, go to https://www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient.

2. Medicare Coding – the Medicare coding for psychotherapy continues to be in flux. Here is Guidance which came out today saying we should now use the POS we would have used had the service been provided in person, e.g., “11” for in-office psychotherapy, and the modifier “95”:

Billing for Professional Telehealth Distant Site Services During the Public Health Emergency — Revised (4/3/20)

This corrects a prior message that appeared in our March 31, 2020 Special Edition.

Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. When billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with:

As a reminder, CMS is not requiring the CR modifier on telehealth services. However, consistent with current rules for telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims:

There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.

3. Medicare Reimbursement – this is the area that has seen the most confusion; previous guidance had stated that reimbursement would be the same for telemental health as in-person treatment. So far, there have been payments made for telemental health that are 7-8% lower than previous reimbursement, some that have remained the same This seems to vary by region. Contact your MAC to discuss if you have received a payment that is not consistent with previous reimbursement.

4. Medicare Provider Enrollment - CMS is making it easier for providers to enroll in Medicare. Local private practice clinicians and their trained staff may be available for temporary employment since nonessential planned medical and surgical services are postponed during the pandemic.

5. Telephonic Coverage – this is the area that has caused the most confusion based on the March 30 guidance: “Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. During the public health emergencies, individuals can use interactive apps with audio and video capabilities to visit with their clinician for an even broader range of services. Providers also can evaluate beneficiaries who have audio phones only.” The problem with this statement for LCSWs is that there is only one service that is expanded for psychotherapy, e.g., the E/M 10 minute evaluation, NOT psychotherapy sessions. CSWA is still working hard to get coverage of telephonic sessions by Medicare. At present, they are not covered. Continue to let your members of Congress know that this is a problem as noted below.

CSWA will continue to provide information on regulatory changes to members that affect LCSW practices which will likely be continuing for the next month.

Please let me know if you have any other questions.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice