July 21, 2020

CSWA is pleased to see that the Office for Civil Rights has issued guidance on compliance with civil rights laws during the COVID-19 pandemic. The health disparities between Black, Indigenous, and People of Color (BIPOC) citizens and white citizens has been a major concern of CSWA. We hope this guidance will improve the underlying problems that are barriers to mental health care for BIPOC citizens. The lack of attention to LGBTQ citizens in this guidance is a glaring omission which we hope will be corrected in future guidance.

To read the whole OCR Bulletin, please visit: Title VI Bulletin - PDF

===================================================================================

OCR Issues Guidance on Civil Rights Protections Prohibiting Race, Color, and National Origin Discrimination During COVID-19

Yesterday, the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) issued guidance to ensure that recipients of federal financial assistance understand that they must comply with applicable federal civil rights laws and regulations that prohibit discrimination on the basis of race, color, and national origin in HHS-funded programs during COVID-19. This Bulletin focuses on recipients' compliance with Title VI of the Civil Rights Act of 1964 (Title VI).

To help ensure Title VI compliance during the COVID-19 public health emergency, recipients of federal financial assistance, including state and local agencies, hospitals, and other health care providers, should:

OCR is responsible for enforcing Title VI's prohibitions against race, color, and national origin discrimination. As part of the federal response to this public health emergency, OCR will continue to work in close coordination with our HHS partners and recipients to remove discriminatory barriers which impede equal access to quality health care, recognizing the high priority of COVID-19 testing and treatment.

Roger Severino, OCR Director, stated, "HHS is committed to helping populations hardest hit by COVID-19, including African-American, Native American, and Hispanic communities." Severino concluded, "This guidance reminds providers that unlawful racial discrimination in healthcare will not be tolerated, especially during a pandemic."

"Minorities have long experienced disparities related to the medical and social determinants of health – all of the things that contribute to your health and wellbeing. The COVID-19 pandemic has magnified those disparities, but it has also given us the opportunity to acknowledge their existence and impact, and deepen our resolve to address them," said Vice Admiral Jerome M. Adams, Surgeon General, MD, MPH. "This timely guidance reinforces that goal and I look forward to working across HHS and with our states and communities to ensure it is implemented."

July 7, 2020

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, CSWA Director of Policy and Practice

June 24, 2020

A hearing for about 20 mental health bills in the House of Representatives Energy and Commerce Committee was scheduled yesterday on June 30. Unfortunately, the bill that CSWA has been sponsoring for about 7 years in various forms, H.R. 1533, has not been included in the bills to be heard. This is the bill that would increase Medicare reimbursement to LCSWs and allow us to again work independently in skilled nursing facilities.

We need an all-out effort to get the bill included. Please send the following message to your representative, ESPECIALLY if they are on the E&C Committee. To check whether you representative is on the Committee, go to https://energycommerce.house.gov/about-ec/membership. Feel free to send messages to other members of the Committee as well.

Dear Rep. ___________,

I am a constituent and a member of the Clinical Social Work Association.

Please consider adding HR 1533 to the agenda for the Energy and Commerce Hearing on June 30. This bill, Improving Access to Mental Health Act, would greatly improve the access of Medicare beneficiaries to mental health services provided by clinical social workers. As the largest group of mental health providers in the country, clinical social workers are currently a key part of the treatment of behavioral disorders in Medicare and across the country.

I notice that HR 945, which addresses mental health counselors and marriage and family therapists, is included in this hearing, a sister bill to HR 1533. The goals of these bills are similar, to allow Master’s level mental health clinicians to provide independent services in skilled nursing facilities and give beneficiaries much needed access to mental health services. Currently, HR 945 does not include clinical social workers. It would make sense to include all Master’s level mental health providers at this hearing.

Thank you for your attention to HR 1533.

Sincerely,

[your name, license, email]

CSWA appreciates your help and continued partnership. As always please let me know when you have sent your messages.

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

June 23, 2020

On June 16, President Trump issued an Executive Order, “Safe Policing for Safe Communities”, to begin to law enforcement reform. While it is not as strong as CSWA would wish, it is a start. In the spirit of collaboration on this crucial topic, CSWA has written a response to the Order.

To ensure clinical social work ideas get included in the discussion we hope the Order will generate, please send the attached document to all your members of Congress, and state legislators with the following message:

“I am a member of the Clinical Social Work Association (CSWA) and a constituent. The President’s recent Executive Order, “Safe Policing for Safe Communities”, is of great interest to us, as clinical social workers. We offer some suggestions about how to implement the goals of the Order, which we have been working on for decades. Please let me know if there is any way we can help further this discussion.”

Click here to find emails for members of Congress.

As always, let me know when you have contacted your legislators.

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

June 22, 2020

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, CSWA President, brown@clinicalsocialworkassociation.org 

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

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

June 15, 2020

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

The Supreme Court issued a wonderful decision today, BOSTOCK v. CLAYTON COUNTY, GEORGIA, today that guarantees LGBTQ citizens to have the right to work regardless of their sexual orientation or gender. This decision holds that an employer who fires an individual merely for being gay or transgender violates Title VII. CSWA is in complete support of equal rights for LGBTQ people and we are delighted at this decision. It is notable that the majority decision was issued by Justice Neil Gorsuch, who was widely seen as having conservative views that might have made him unlikely to lead this decision. To read the complete decision go to https://www.supremecourt.gov/opinions/19pdf/17-1618_hfci.pdf.

In an incredible and terrible coincidence, HHS issued a rule last Friday that undoes an Obama-administration policy that had redefined “sex” to include “gender identity” and “termination of pregnancy” for purposes of nondiscrimination under the Affordable Care Act.

Section 1557 of Obamacare prohibited discrimination on the basis of race, color, national origin, sex, age, or disability in health-related programs or activities. Near the end of President Obama’s second term, his HHS Department released a regulation redefining “sex” for the purposes of Section 1557 to include “gender identity” and “termination of pregnancy.” As a result of the rule that HHS released, that regulation has been reversed and “sex” once again refers only to biological sex. This entire new rule may be found at https://www.hhs.gov/about/news/2020/06/12/hhs-finalizes-rule-section-1557-protecting-civil-rights-healthcare.html. This rule will almost certainly be challenged, especially in light of the Supreme Court decision today.

Finally to end on a more positive note, please read the CSWA statement on “Stopping Aggression in our Communities” by CSWA President Britni Brown. CSWA will be doing many webinars and statements to address the ways that black lives are demeaned, attacked, and harmed.

Another article that calls attention to these issues by Linda Michaels, PhD, Co-Chair of the Psychotherapy Advocacy Network (PsiAN) is ”@Whatsinahashtag@We’reallinthistogether?” which can be found at https://medium.com/@psian/whats-in-a-hashtag-we-reallinthistogether-7928adf5d756?sk=9276106ac0a81675e27e67f54751a8f8 It succinctly and heartbreakingly illustrates the ways that black Chicagoans have had decades of inferior public services, culminating in a much higher incidence of death among black citizens.

Stay safe and well in these perilous times.

June 2, 2020

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

May 24, 2020

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.

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