December 30, 2020

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, CSWA Director of Policy and Practice

December 14, 2020

The 6.9% Medicare cuts are still planned for 2021 in spite of the major efforts of CSWA and many other mental health groups. Fortunately, there are two bills which would put off this cut for two years. Time is short to get S. 5007 and H.R. 8702, “Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020”, passed. Send messages to your members of Congress.

Both bills would institute additional payments, separate from the physician fee schedule, to essentially establish 2020 Medicare reimbursement rates as the floor for payments in both 2021 and 2022.

Go to https://www.congress.gov/contact-us immediately to ask your Senators to cosponsor S.5007 and your Representative to cosponsor H.R.8702 to protect Medicare payment rates for services provided by LCSWs and other healthcare providers.

Below is a template for your use:

“I am a member of the Clinical Social Work Association and a constituent. Please pass H.R. 7802/S. 5007 to allow LCSWs to continue working as Medicare providers. The proposed cut of 6.9% will make it very hard for me to afford to continue as a Medicare provider. In these perilous times, the need for mental health services has grown exponentially. Please allow the 250,000 LCSWs in the country to be able to provide the help that is so sorely needed.”

As always, let me know when your messages have been sent.

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

December 14, 2020

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, CSWA Director of Policy and Practice

December 4, 2020

There are now 25 new ICD-10 codes for substance use disorders (SUD) which all LCSWs who work with patients diagnosed with these disorders should know.

They are:

Be sure to use these codes in addition to the mental health disorder codes that we commonly use for anxiety, depression and other conditions.

HEADS UP for the Physician Fee Schedule! We have been waiting for this rule since last summer. It should be coming out any day now. I plan to answer any questions you have about it at the online Town Hall next Thursday, December 10, 2020, at 5 pm EST. Register at the CSWA website. Hope to see you then.

November 15, 2020

By Laura Groshong, LICSW, CSWA Director of 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.

November 11, 2020

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, CSWA Director of Policy and Practice

November 3, 2020

I am delighted to inform you that the Federal Court which made the ruling in Wit v. United Behavioral Health in March of 2019 has issued further remedies for the implementation of this ruling today. This ruling was consolidated with Alexander et al. v. United Behavioral Health, another case which found UBH in violation of mental health parity laws nationally and in California. The court explained in the 99-page document the need for the following steps:

1. a 10-year injunction requiring UBH to exclusively apply medical necessity criteria developed by non-profit clinical specialty associations;

2. appointment of a special master;

3. training of UBH in the proper use of court-ordered medical necessity criteria; and

4. reprocessing of nearly 67,000 mental health and substance use disorder benefit claims denied during the class period.

The remedies only apply to self-insured plans that fall under the Employee Retirement Income Security Act of 1974 (ERISA). It does not apply to government employees or commercial insurance plans.

Nonetheless, this implementation of the Wit ruling is as a major success for fully implementing mental health parity for the 50,000 ERISA enrollees in California and serves as a guide for laws in other states which have not fully implemented mental health parity laws.

October 28, 2020

CSWA is happy to report that the Texas State Board of Social Work Examiners has voted today to overturn the rule change that was enacted last week to allow LCSWs to refuse to see clients on the basis of disability, sexual orientation or gender identity. For a more complete report go to the Texas Tribune article at https://www.texastribune.org/2020/10/27/texas-social-workers-lgbtq-disabilities-discrimination/.

Many thanks go to CSWA Board member Kathy Rider, LCSW, a longtime advocate for clinical social work in Texas who was a major contributor to the effort to overturn the unethical rule.

October 25, 2020

You may have been hearing about a new rule that is called “Open Notes” which begins on November 2, 2020. It allows patients to have extended access to their Medical Record.

While it is technically true that patients have increased access to their electronic clinical records as of November 2, it should not be much of a change for the way we as LCSWs practice with one exception (see below). Open Notes was part of the Interoperability section of the CURES Act last spring which says:

Blease C, Walker J, DesRoches CM, et al. Annals of Internal Medicine. October 13, 2020. doi: 10.7326/M20-5370

On 2 November 2020, new federal rules will implement the bipartisan 21st Century Cures Act that, in part, “. . . promotes patient access to their electronic health information, supports provider needs, advances innovation, and addresses industry-wide information blocking practices.” The rules forbid health care organizations, information technology vendors, and others from restricting patients’ access to their electronic health care data, or “information blocking.” Although the Health Insurance Portability and Accountability Act gave patients the legal right to review their medical records, the new ruling goes further by giving them the right to access their electronic health records rapidly and conveniently via secure online portals. Providers must share not only test results, medication lists, and referral information but also the notes written by clinicians. Over the past decade, this practice innovation—known as “open notes”— has spread widely, and today more than 50 million patients in the United States are offered access to their clinical notes." https://www.opennotes.org/research/new-u-s-law-mandates-access-to-clinical-notes-implications-for-patients-and-clinicians/

I believe that Open Notes is primarily for other kinds of medical services, not psychotherapy. The only exception may be if we are not making notes in the interoperable medical record. There may come a time when other providers or patients complain about it and we will need to make “open notes” in an interoperable record, but that is not the case now unless you are paneled in a plan that requires you make notes in an interoperable record.

Remember that Psychotherapy Notes can be a separate file from the Medical Record which is for our use only, most commonly what we call process recordings, and are not shared with anyone else. There is certain information which cannot be kept out of the Medical Record by being put in Psychotherapy Notes; see the CSWA website for more information.

We know that it is a clinical issue if the patient wants to see what we have written about them and it happens fairly rarely. We also know that it is a best practice whether we are keeping notes for our own Medical Record or an interoperable one, to keep notes brief and connected to the treatment goals established for a given patient. If we stick to these practices, Open Notes should not pose a problem for clinical social workers.

Please let me know if you have any questions.

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

October 23, 2020

CSWA is concerned about a change in the Texas State Board of Social Work Examiners’ rules which allows LCSWs to refuse to provide services to clients on the basis of disability, sexual orientation or gender identity. This change was made to make non-discrimination rules consistent with existing Texas statutes. Governor Greg Abbott proposed the change to LCSW rules. See the article on this issue in the Texas Tribune at https://www.texastribune.org/2020/10/14/texas-social-workers-rule-discrimination-lgbt-disabilities/#:~:text=New%20Texas%20rule%20lets%20social,conform%20with%20existing%20state%20law.

This change is completely at odds with the ethics and values of clinical social work. This kind of attack on our profession should be fought as strongly as possible whenever it occurs. The fact that the Texas State Board of Social Work Examiners and the Texas Behavioral Health Executive Council, which oversees behavioral health boards, accepted the proposed rule without objection (on advice of counsel) is even more concerning than the fact that it was proposed in the first place.

CSWA will be filing a complaint with the Texas Social Work Board and the Governor’s office as well as signing on to a Declaration from the Hogg Foundation for Mental Health, an organization that opposes discrimination in all forms. To see the Declaration go to https://hogg.utexas.edu/who-we-are/racism-declaration?utm_content=82b8b13291ac3a2233b0e8193b1bb908&utm_campaign=Healthy%20Mind%20Project%20RFP&utm_source=Robly.com&utm_medium=email.

If this can happen in Texas, it can happen anywhere so we wanted to make all members aware of this situation. CSWA encourages all members to oppose any laws and rules that threaten our values and the rights of all clients to our services.