Clinical Social Work: Reimbursement

Effective January 1, 2005 , clinical social workers who are Medicare providers may receive a pay increase of no less than 1.5 percent according to the Medicare Prescription Drug, Improvement and Modernization Act. Pay increases may vary in different areas due to geographic adjustments that reflect differences in the costs to provide services. Clinical social workers in rural areas and Health Professional Shortage Areas may receive higher pay increases.

Clinical social workers in private practice are licensed, independent, clinical practitioners who bill third party payers for clinical services provided when diagnosing and treating mental illness and other behavioral disturbances. The largest providers of mental health services in the nation, clinical social workers file health claims through Medicare, managed care companies, and other insurance carriers. For example, in 2002 alone, more than 3,529,000 claims were filed by clinical social workers through Medicare.

Clinical social workers and other health care professionals who are Medicare providers can expect to receive an average of more than 1.5 percent pay increase for the calendar year 2004, effective January 1. Clinical social workers in some rural areas may see an additional increase in payments as a result of the Medicare Prescription Drug, Improvement, and Modernization Act (DIMA), which requires the Centers for Medicare and Medicaid Services (CMS) to change how it adjusts payments to recognize area cost differences.

Oxford Health Plan, one of the largest mental health insurers in the northeast region, recently conducted an audit of clinical social workers, psychiatrists, and psychologists and requested repayments from providers for lack of adequate documentation of therapy sessions. The records included in the audit were retroactive to 1997 and were reported by Oxford as not having enough evidence to support the cost of treatment.

NASW is currently  receiving telephone calls from members regarding Medicare changes in reimbursement  for  clinical social workers who file claims for services provided in skilled nursing facilities (SNFs). Members are reporting that Medicare carriers are: (1) denying claims submitted for services provided in  SNFs; and (2) requesting refunds of  claim payments previously made for  services provided in SNFs under Medicare Part A.

The Department of Health and Human Services (DHHS) recently released a Program Memorandum to Medicare Carriers to inform the provider community about Medicare payment of Part B mental health services. The memorandum identified the requirements and qualifications of professionals who may be considered mental health providers, including clinical social workers, qualified physicians, clinical psychologists, nurse practitioners, clinical nurse specialists, and physician assistants. Highlights of this memorandum, as it relates to clinical social workers in private practice, are summarized in this practice update.