Aliah Wright:
This is NASW Social Work Talks. I'm your host, Aliah Wright. Social workers are the largest group of mental health services providers in the United States. Many social workers who provide mental health services in private practice have experienced clawbacks, or when an insurance company requires a provider to return money they've been paid in the past. Clawbacks can occur months or even years after the service has been provided. These retroactive denials of health insurance claims make it difficult for social workers in private practice to know their true income and are leading some social workers to remove themselves from insurance panels, including state Medicaid programs. This in turn, hurts patients who need to use their insurance in order to afford mental health care. At least 24 states impose some limitations on the time an insurance company has to retroactively deny or adjust claims and to demand reimbursement from providers in Massachusetts. There are no time limitations on clawbacks, at least not yet. Today we're speaking about this topic with Rebekah Gewirtz, executive director of NASW Massachusetts Chapter.
Rebekah Gewirtz:
Welcome, Rebecca. Thank you very much for having me. So why are you interested in the issue of clawbacks? Clawbacks hurts social workers who are trying to help society's most vulnerable. This issue came to our attention a few years ago when we heard from clinicians and private practice in particular who were being audited and then clawed back for payments they had received from an insurance company. Perhaps one of the biggest problems has to do with the fact that this involves Mass Health patients or Medicaid patients, so some of society's most vulnerable patients are impacted in Massachusetts. We have an opioid crisis right now where there is lack of access to providers who specialize in substance use disorder and we know that this is a time where we need to make sure we're expanding access as opposed to limiting access. Clawbacks limit access. One example of a social worker member that contacted us about the problems he was experiencing with clawbacks, he was a, he is a social worker working in the city of Lynn, which is impacted significantly by the opioid crisis. He provides substance use disorder services. He made about $25,000 last year and he received a $3,000 clawback. He contacted us and told me that he really wasn't sure if he was going to be able to continue to practice. Wow. This is the kind of thing we need to avoid. We need to be making it possible for social workers to do the work they're trained to do in the community outside of the clinic, keeping people well. That is the role of social workers in a lot of cases. And when you have a practice that insurance companies can clawback payments that they already made to you any number of years back, they can look back and definitely that creates a lack of consistency. A lack of many social workers end up feeling that they can't trust that a payment is an actual payment. They can't count on their income. And I don't know of another profession where those are the sorts of, you know, and I'm speaking about behavioral health in general. So there are other practitioners besides social workers, but where this is where this is a reality, where you are paid, the service has been rendered. There's no question about medical necessity. And for any number of reasons an insurance company can just decide to clawback without explanation. This seems really, really unfair. So the therapist provided a service, insurance coverage was verified, and the therapist was paid only to be told after the fact that an error occurred. These are errors that are not the therapist's fault. So what's the Massachusetts chapter been doing about this? Well, we've taken this issue very seriously. We heard from our members through a listserv that we host, that there was a situation going on about a year and a half ago where one of the companies, one of the managed care companies that contracts with Mass Health a, was conducting an audit and, and was clawing back thousands and thousands of dollars from social workers. So we moved into action. We alerted our legislative allies that there were these clawbacks going on, that people didn't know why in many cases they were getting a clawback. They in a lot of cases, didn't have the resources to pay the claim back. They can't necessarily track down the person who paid the claim. And that's a lot of social workers wouldn't want to do that anyway. Um, a service was rendered, the insurance company paid the claim, and that's supposed to be the way it works. But it wasn't working that way. So again, we worked very hard. We were able to have some influence with Mass Health and they ultimately stopped this clawback, uh, situation. Can you explain to our listeners what Mass Health is? Yes. Mass Health is the state Medicaid program and various different states. It has different names and in Massachusetts, Mass Health equals Medicaid. So we were, we were thrilled to be able to tell our members when the audits were being stopped. And at the same time we knew that this was not a necessarily a permanent fix because it's still legal in Massachusetts for insurance companies to clawback payments going back any number of years. So we knew that we also needed to work on a parallel track of advancing legislation that would limit the insurance company's ability to to claw back payments after a certain period of time had elapsed. So the bill that we're working on would limit both Mass Health and commercial health insurance to a 12 month period for recovering payments to a behavioral health provider. And so the social workers and others for behavioral health services completed. It would also require the insurance companies provide a reason or rationale when they do clawback within that window of time. The way in which that helps is it provides some predictability. So social workers can know, okay, I've now passed this one year period and unless I've committed fraud, I should not expect a clawback and it would be illegal for an insurance company to claw back payment. Right now, like I said, you know, a little earlier, insurance companies can go back and definitely so they might decide later, well, we're going to start climbing back for some infraction that was in fine print in the manual three years ago and take back thousands and thousands of dollars that they didn't, you know, clawback at the time. Certainly are and that they paid out. These are claims that were paid out. We want that to stop. We need that to stop. We need consumers to be able to have access to behavioral health providers who accept insurance. And if insurance companies are going to employ practices like this where they can go back and definitely and take back money from, from providers, then providers aren't gonna want to accept insurance listeners. We'll be right back.
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Aliah Wright:
And we're back. Rebekah, what can social workers expect if and when this bill passes?
Rebekah Gewirtz:
Well, social workers can expect more predictability. They can expect that when they, when they are paid for a claim that that payment will stand. There is going to be this period of time where the insurance companies can still look back. But it is, it is a limited period of time. It is not indefinitely. Now callbacks are happening all over the country. What can social workers in states without the time limitations on clawbacks do if they experience this? So the best thing is social work social worker can do is to contact their NSW chapter. The people in the chapter offices are incredibly knowledgeable about these issues. And what if one of our primary functions at sw is to advocate for our members and to make practice possible both for them in their practice and for clients and communities. So for consumers, we know that we both need a workplace and workplace rules that are reasonable and we need people to have especially vulnerable people, but people across the board to have access to this important care that they need. So I would say organize, I would say advocate, you know, with your, with your NASW chapter. And I would say try to get more information about what's in law now in your state. We know that at least 24 other states impose some limitations on the time within which an insurer can retroactively deny and or adjust claims and demand reimbursement from providers. So that's a lot of states. And why is it important for NSW chapters to advocate for an end to this practice? Because this is where our members want and need us to be. They need us to be an advocate for them. They need us to be organizing with them, lifting up their voices and making sure that decision makers, whether they be regulators, whether they be administration officials, whether they be legislators are taking social workers seriously and are addressing issues and needs as they arise. And we view that as really our primary purpose. Our primary purpose is to defend and advance social workers and the clients and communities that social workers are. So I think this is an issue that if it happens in other states, it's a, it's a great issue for, for chapters to work on. Certainly here in Massachusetts, we are getting very close to the, to getting this bill passed. And I think if it does get passed, it will be an enormous victory both for consumers to be able to have more access and for social workers to be able to practice. So do you think this is a winnable issue? And if so, why? I do think it's a winnable issue. I think it's from the conversations we've had with our legislative allies and friends in the State House, that people, legislators just feel like this is an unfair practice.
Rebekah Gewirtz:
There should be rules. It should be that if you, if you provide a service, you get paid for that service. It shouldn't be that sometime down the line years later, someone turns around and says, just kidding. You know, or we're taking that back from you, or you didn't follow this rule that you should have at the time, or you didn't know that this person you were seeing was actually insured by somebody else. So, uh, we're taking back. We don't think that's, that's fair. And legislators don't think that's fair. And that's why there are more than 40 cosponsors of the bill at this particular legislative session issue. Yeah, it's great. Um, this issue was included in a health care omnibus bill last year that didn't quite make it over the finish line and the waning days of the legislative session. But this year it's been moving much more quickly. In fact, it's advanced through two committees and I anticipate it may be taken up in the house in the Senate this calendar year for passage. That's phenomenal. So I feel really optimistic. Of course, I don't want to jinx it. You know, you know and legislation, you never can know definitively what's going to happen until it happens. But you know, you do your best to talk to the people who do know about these things and people in leadership and the lead sponsors and then sort of make determinations on what the likelihood is based on those conversations. Our lead sponsors on this bill are incredible. A representative Jim O'day is our lead in the house and he's a social worker from the central part of the state. He has been a fighter for social worker issues since he's been in office and we're so lucky to have him on the Senate. We've had two leads. We've had senators, Cindy Friedman, who is such a champion for issues of mental health and is so passionate about these issues and senator Michael Rodrigues, who's now the Senate chairman of the ways and means committee and he has long been an ally of ours on these issues and this issue in particular. So we're really lucky and fortunate and our lead sponsors and fortunate that they have all taken this as a, as a priority. Rebecca, what else should people know about this problem? Well, I guess I would say you don't have to suffer this problem. You know, that change is possible that we can see problems like this in, in practice and working with NASW and other advocates and other advocacy groups together. We can, we can change these things. I mean, seeing a Mass Health put a stop to the audit or to the clawbacks really earlier this past year was really, really incredible. You know, it was, it was such a wonderful statement that they made that we are going to support our providers, we're gonna support our practitioners and we're not gonna let this, these club acts continue on the absence of any firm understanding of why they're happening. And uh, just sort of, I guess I would say randomly because that's the way it has been. We can make change. I have seen it and I feel very optimistic that with the power of NASW, which has all these social workers join together and um, and cause you know, we can, uh, eradicate issues like this and make practice possible and access a true reality.
Aliah Wright:
Thank you, Rebecca.
Rebekah Gewirtz:
You're welcome. Thank you for having me on the show today and thank you listeners. We'll provide resources on this issue in our show notes and if you'd like to see episode, please be sure to leave us a review on iTunes.
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