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Comments on the document “Clinical Social Workers in Private Practice: A Reference Manual”
Respectfully submitted by Kathy T Rider, LCSW, BCD, CGP, FAGPA Austin, Texas
Page 10 Section on “Education and Credentialing”
Please consider this language… “Earning the direct clinical hours required to become an LCSW in a given state”. Probably do not want to specify hours as these requirements vary from state to state.
Page 11/12 LCSW Section
In this section…Please consider these statements/language: Those who graduated with a clinical focus should meet the minimum requirement of two (2) years of supervised clinical experience.
Those who graduated with a nonclinical focus should take clinical courses that would be the equivalent of the clinical social work curriculum provided in an accredited MSW degree program.
All states have legal regulation for independent clinical practice, and practitioners must be licensed in this category to engage in the independent private practice of clinical social work.
Possessing the knowledge base and clinical skills to diagnose mental health conditions as specified in the International Classification of Diseases, 10 Revision, Clinical Modification (ICD-10-CM) (or later editions) and the Diagnostic Statistical Manual V (or later editions), and to provide psychotherapy using the accepted methods of practice agreed to by NASW, CSWA, and AGPA.
Page 12 Section on “Continuing Education”
All states have provisions for continuing education in their requirements for renewal of social work licenses.
Page 13 Section on “Business Planning”
Please consider including: One of the first business planning tasks is the structure and formation of your practice which includes the projection of income and overhead. A practitioner must plan for a monthly salary draw in addition to ongoing monthly expenses. There are initial startup costs which will not be ongoing monthly expenses, such as furniture and equipment, but still must be planned. Office expenses such as lease/rent, business cards, stationary with letterhead, janitorial services, cleaning supplies, office supplies (incl equipment…copier, fax and credit card machine, file cabinet), and printing of forms (incl intake, history, consent, releases and billing). Computer-related expenses such as a designated work
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computer, internet services, printer, and supplies for computer and printer. Note: some lease/rent agreements include janitorial services. Administrative services such as practice management, i.e., support staff, and billing services. Again, some lease/rent arrangements include a receptionist and/or a messaging center. Taxes such as estimated tax payments, income taxes, business and property taxes. With regard to Nonpayment of fees for services rendered, it is important to have written policies to be given to client at first appointment regarding fees for less than 24 hour cancellation notices and no-show appointments. This is a business so having a separate bank account and a dedicated business credit card will make it easier to track income and expenses for the purposes of income tax filing.
Page 17 Section on “Health Insurance Portability and Accountability Act”
Non-compliance with HIPAA can result in fines being levied.
Under the heading “Payment for Services”, please include
One of the considerations of forming and managing your private practice is the consideration of whether to accept third party reimbursements or to do fee for service only. Although there is federal legislation mandating parity with regard to behavioral health, there is not parity in third party reimbursement. Additionally, a practitioner must apply for and be accepted on an insurance panel. Many insurance panels are closed to the addition of new practitioners in a particular geographical area. Participation as a behavioral health provider in Medicare and/or Medicaid programs requires an application with a process which can take several months to be completed. Many practitioners only accept fee for service for a variety of reasons…confidentiality, in-network requirements of insurers, and low reimbursement rates. In these cases, the practitioners provide the needed documentation to the patient if the patient is filing their own medical health care insurance claim. Other practitioners choose to do a combination of approaches for payment of services rendered. One must be very clear with written policies on when medical health care insurance is accepted, when fee for service applies, and when pro-bono/sliding fee schedule is available with criteria clearly stated.
Page 18 Section on “Network Providers”
It is important to have a written policy outlining what the financial responsibilities are for the patient when their medical health care insurance does not make payments to the provider for the full amount of the billed services rendered. Some states have specific prohibitions against “balance billing” by the provider.
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Page 18 Section on “Out-of-Network Providers”
Some medical health care insurance plans do not provide reimbursement for “out of network” services. Either the provider or the patient must contact the insurer to see what the coverage is for a specific plan. It is not uncommon for an insurer to have multiple plans available with different coverages of services.
Page 19 Section on “Types of Insurers”
Sometimes the patient’s own employer has created their own self-insured medical health care system with eligibility criteria, coverage of services, rates of reimbursement, and paneled providers. These self-insured employer plans have their own rules and contracts. Generally, the panel of health care providers, including behavioral health providers, is small and specific as to specialty areas and geographic locations.
EAP services are provided by the employers to their employees and dependents at no cost to the employee. Sometimes EAP services are provided onsite with a contracted provider. Other times, EAP providers are contracted to deliver services at the provider’s offices. Typically, EAP services are time limited as to duration and number of sessions covered before the employee must utilize their medical health care insurance. EAPs will have specific provisions as to whether the employee can continue with the EAP contracted provider for long term outpatient services covered by the employee’s medical health care insurance after the EAP sessions have been fully utilized.
Page 20 Section on “Independent Clinical Private Practice Settings”
A clinical social worker licensed in their state to practice independently has decisions to be made in setting up their own private practice. There are basically three structures for one’s practice:
1) Solo practitioner in one’s own office space who is responsible for their own practice, lease agreements, support staff and collection of fees for services rendered.
2) Solo practitioner who is responsible for their own practice while sharing office space and overhead expenses with one or more behavioral health care providers. This may or may not include sharing on-call or emergency coverage outside of regular office hours. There is no sharing of fees collected for services rendered.
3) Solo practitioner who is responsible for their own practice while participating in a group practice setting wherein in addition to sharing office space and overhead, there is a sharing of fees collected for services rendered by all members of the group practice. This may include sharing on-call or emergency coverage. This structure will need to be reviewed by an attorney for income tax implications.
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The most common structure is the solo practitioner sharing office space and overhead expenses while maintaining full responsibility for their clinical practice. There is no fee sharing between practitioners.
Some clinical social workers choose to set up their practices within their own home. One would want to consult with a CPA and an attorney regarding tax and liability implications.
Overall consideration: With the pandemic, one might consider a section on telehealth services and the accompanying provisions for the safe and ethical delivery of clinical services.
Page 46 Section on “Informed Consent”
When a parent requests services for a minor, it is important to have copies of the documentation related to parental custody and the authority to request behavioral health services. When possible, both parents, regardless of the custody issues, should be interviewed by the practitioner to do a complete assessment of the minor child. Releases need to be obtained from both parents for contact with significant others in the child’s life, such as school personnel, caretakers, and other family members, with knowledge of the child’s behavior and interactions with others.
Page 57 Section on “Privileged Communication”
In most states, when a patient files a complaint to the state regulatory body, it is understood that the patient has waived the privilege and confidential information may be shared to the appropriate body.
Page 58 Section on “Subpoenas”
A subpoena is a legal document. A subpoena issued by a court of law with jurisdiction in the matter at hand must be responded to by the practitioner. However, a subpoena issued by an attorney at law may or may not require a response by the practitioner. It is recommended that the practitioner consult with their patient before any disclosure of information, including acknowledging receipt of the subpoena. If the patient and the clinician mutually agree to release information, then a release of information for the party issuing the subpoena must be executed prior to any release of information in response to the subpoena.
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Page 59 Paragraph on “Copays and Deductibles”
The amount of the deductible applied for any given billing depends on the allowable fee determined by the insurer.
Page 62 Section on “Denials and Appeals”
Before any formal appeal is begun, please consider that denials frequently occur because the claim landed on a clerk’s desk who did not process the claim properly. It is also possible that you transposed the information resulting in the computer rejecting the claim. Always call and ask for the reason for the denial regardless of what is stated on the rejected claim. It is best to have your copy of the claim filed in front of you and to approach the interaction as one attempting to correct a mistake and have the claim re-processed. This is particularly true if previous claims for the same patient with the same CPT code have been approved and paid. If it is the insurer’s error, many times the clerk will re-process the claim immediately and/or allow you to fax the corrected claim form into their offices. Sometimes, the insurer has changed the way the form is to be filled out after notification. For example, requiring that whenever a year is indicated on the CMS 1500 form, it must be entered consistently either in a two digit format or a four digit format...otherwise the claim gets rejected.
Page 64 Section on “Record Keeping”
Medicare patients’ records are required to be kept for ten (10) years after the last date of service before being shredded.
State regulatory bodies will have in their Rules specific timelines for keeping of patients’ records. In general, records of persons who were minors at the time of service must be maintained until seven (7) years passed their eighteen birthday.
Page 75 Section on “Emergency and Disaster Planning”
Considering the experience of the 2020 COVID-19 pandemic and its impact for 2021, one might want to consider maintaining financial reserves for a minimum of nine (9) months to eighteen (18) months to cover unanticipated costs and changes in income.
Page 77 Section on “Professional Will”
Many state NASW chapters and state clinical societies have developed a professional will template in consultation with a health care attorney in their state. One would want to check with your chapter and/or society about available resources.
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