clinical social work association

Informed Consent Forms

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.

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.

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, Director, Policy and Practice

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, Director, Policy and Practice

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:

• CDC Foundation is an independent nonprofit created by Congress to mobilize philanthropic and private-sector resources to support the Centers for Disease Control and Prevention’s critical health protection work.(https://www.cdcfoundation.org/) 
• Feeding America is a nationwide network of more than 200 food banks that feed more than 46 million people through food pantries, soup kitchens, shelters, and other community-based agencies.(https://secure.feedingamerica.org/site/Donation2?df_id=28150&mfc_pref=T&28150.donation=form1&s_src=Y20XP1B1Y&s_subsrc=c&s_keyword=feeding%20america%20donations&&gclid=CjwKCAjw-YT1BRAFEiwAd2WRtrjw_E_IYRzcDsp7_2McRYNkC8ldKLgm15WD4vlzlHIUzz11LnU6AhoCipgQAvD_BwE)
• Meals on Wheels supports individuals who are elderly, disabled, chronically ill and home-bound by delivering nutritious meals, reducing hunger, improving health and promoting independence.(https://ams.mealsonwheelsamerica.org/eweb/DynamicPage.aspx?WebCode=globaldonate&site=mowa&CampCode=AnnualCampaign&AplCode=AnnCampWeb&_ga=2.86054296.1679140158.1542118140-1937589897.1533304096)
• The National Domestic Works Alliance has set up a fund to provide immediate financial support for domestic workers, and enable them to stay home and healthy — protecting themselves, their families and their communities while slowing the spread of the Coronavirus.(https://www.domesticworkers.org/)
• One Fair Wage Emergency Coronavirus Tipped and Service Worker Support Fund provides cash assistance to restaurant workers, car service drivers, delivery workers, personal service workers and more who need the money they aren’t getting to survive.(https://ofwemergencyfund.org/)

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, Director, Policy and Practice

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, Director, Policy and Practice

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, Director, Policy and Practice

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, Director, Policy and Practice

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.