Clinical Social Work: Reimbursement

The National Uniform Claim Committee (NUCC) was created in 1995 to develop a standardized data set for use by the non-institutional health care community to transmit claim and encounter information to and from third-party payers. The committee recently announced revisions to the CMS-1500 form which is used by clinical social workers and other health care providers to submit claims for reimbursement of services. The Centers for Medicare and Medicaid Services (CMS) and the Office of Management and Budget (OMB) have approved the revised CMS-1500 paper claim form, OMB-0938-1197 FORM 1500 (02-12). These numbers are located at the bottom right hand corner of the revised form.

The American Taxpayer Relief Act of 2012 was signed by President Obama on January 2, 2013.  This new law averted a payment reduction of 26.5 percent in 2013 for clinical social workers and other health care professionals who are Medicare providers.  Under the Sustainable Growth Rate (SGR), the law provides a zero percent increase for Medicare providers through December 31, 2013.  The law also provides Congress with additional time to fix the SGR which is an annual growth rate that controls growth in Medicare expenditures for provider services.

On behalf of NASW members, the Association engages in a multitude of advocacy efforts to improve social work practice. The Center for Workforce Studies & Social Work Practice receives numerous calls from social workers identifying areas of concerns in clinical practice. In response to these issues, NASW provided the advocacy and resources described below.

In 2009, NASW received telephone calls from members who expressed concerns that Medicare would not reimburse them for mental health services provided to Medicare beneficiaries when home health services were initiated before or during treatment. To determine how widespread the problem of non-payment was, NASW developed a practice alert, Advocating for Change in Home Health Care, (Coleman, 2009), and requested clinical social workers to contact the Association at psyhomecare@naswdc.org if they had encountered reimbursement problems when providing mental health services to Medicare beneficiaries who were actively receiving home health care services under Medicare. The responses were mixed with some clinical social workers reporting Medicare payment denials and others reporting no problems.

Clinical social workers who are Medicare providers frequently encounter claim denials due to unreported changes in their solo or group practice. Clinical social workers are responsible for reporting changes to their Medicare Administrative Contractor (MAC) as soon as possible or within 30 days of the change. Reporting changes immediately ensures timely and proper processing of claims and prevents rejections.

Beginning July 1, 2008, clinical social workers who are Medicare providers received an increase in reimbursement. This increase is the result of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), enacted on July 15, 2008 (also known as HR 6331, public law number 110­-275).