Please note: This information is not to be construed as
legal advice. It is being posted with links to additional information, and
further research may be required. [ It is current as of 4/14/20.] * UPDATED
ON 4/30/20.* Changes to the law
as a result of the Covid-19 crisis can happen at any time, as Executive Orders
issued by the Federal or State governments have been frequent since the
national State of Emergency has been declared. If you are aware of any
new/different information, please contact judy.gallant@verizon.net. We will do our best to keep this
information updated, but cannot guarantee it is up-to-date at any given time.
We work closely with The
Clinical Social Work Association, with frequent exchanges of practice-relevant
information during this National Crisis. CSWA is also maintaining a helpful
Toolkit (available to all) on their website.
For more detailed Medicare
information, see pages 4-5 of this document.
ALL LOCAL JURISDICTIONS (MD, VA & DC) ARE INDICATING THAT IT
IS OK FOR TELETHERAPY TO OCCUR ACROSS STATE LINES FOR CONTINUITY OF
CARE WITH CURRENT CLIENTS DURING THE DECLARED STATE OF EMERGENCY
DUE TO THE COVID-19 VIRUS. In Maryland, there is an explicit order from our
governor, with our licensing board interpreting how they are proceeding. In DC,
explicit guidance has also been developed: if you are practicing from another
jurisdiction in DC, there is no problem with providing continuity of care with
clients with whom you have a prior relationship; establishing a new
relationship gets complicated. In Virginia, the regulatory requirements have nowbeen
waived.
The Board of Social Work Examiners (website: https://health.maryland.gov/bswe/Pages/default.aspx)
is asking clinicians to submit an application in order to provide
ongoing therapy through teletherapy, to already established client(s). It
is free to apply, and it is reportedly not too onerous. Contact person to
obtain an application: gloria.hammel@maryland.gov
For DC: Waiver of Licensure Requirements for Healthcare
Providers 20-03-13, and Guidance On Use of
Telehealth in the District of Columbia 3-12-2020. We have just heard
from a member that after writing to the DC Board to ask about establishing
relationships via videoconferencing with new clients, she was given permission
to do so prior to her DC license being processed. We would recommend that you check directly with
the DC Board if you would like to do this.
Pursuant
to Governor Northam’s Executive Order No. 57 (effective April 17,
2020), a
clinical social worker with an active license issued by another state may be
issued an accelerated temporary license by endorsement as a health care
practitioner of the same type for which such license is issued in another state
upon submission of an application and information requested by the applicable
licensing board and the board's verification that the applicant's license
issued by another state is active in good standing and there are no current
reports in the United States Department of Health and Human Services National
Practitioner Data Bank. Such temporary license shall expire ninety (90) days
after the state of emergency ends. During such time the practitioner must seek
a full Virginia license or transition patients to Virginia-licensed
practitioners.
Health care practitioners with an active license issued by another
state may provide continuity of care to their current patients who are Virginia
residents through telehealth services. However, if they want to acquire new patients, they must
apply for full licensure in Virginia or an Accelerated Temporary License as
indicated above.
· For any state where your client is located
during sessions, make sure that you check with the Board that governs social
work practice in that state to see if you need to apply for a waiver, pay a
fee, etc.
At this writing, audio only
telephone appointments are not reimbursable by insurance companies, except by
Medicare. And an executive order
signed by Gov Hogan approves reimbursement of telehealth sessions provided by
telephone for health care providers who participate with Maryland Medicaid only…OR providers who are
enrolled with MD Behavioral Health Administration programs. (This
is also true for those participating in SAMHSA grant programs.).
PAYMENT,
BILLING, CODING, CPT MODIFICATIONS
Most commercial insurance plans will reimburse
for telemental health therapy through video platforms, but the details depend on the specific plan.
Patients should be asked to confirm with their insurance that reimbursement
will be provided, and whether they are restricted to receiving it on a specific
platform like Teladoc. BlueCross BlueShield and Aetna have lifted requirements
that providers use Teladoc for telehealth sessions during the National
Emergency, and will reimburse for sessions on HIPAA compliant platforms. See
links below for coding modifiers to use for those insurances. Other insurances
seem to be accepting a 95 modifier for the CPT code and 02 as the place of
service. Medicare is asking 11 to be used at the place of service with the 95
modifier.
Additionally, CareFirst is amending its Medical
Policy on a temporary basis to pay a $20.00 flat fee for phone consultations of
10-15 minutes provided by behavioral health providers in CareFirst’s network. “Psychiatrists
and Nurse Practitioners should use CPT 99441. Psychologists, Licensed
Certified Social Workers and Licensed Professional Counselors should
use code 98966. We selected these codes, as check-ins for
all phone visits, regardless of the amount of time. This is in effect through
April 17, 2020. At the end of the 30 days
CareFirst will re-evaluate whether the policy
should be extended for a longer period.” As I understand this, the 98966 code
can be used for a phone consultation - not a phone call to deal with scheduling
issues, but a consultation where a clinical issue is addressed.
HIPAA
PLATFORMS FOR TELEMENTAL HEALTH THERAPY
HIPAA regulations are relaxed. As a result of the COVID-19 national emergency
declaration, the Office of Civil Rights (OCR), Department of Health and Human
Services (DHHS), has affirmed that it will “exercise
its enforcement discretion and will not impose penalties for noncompliance with
the regulatory requirements under the HIPAA Rules against covered health care
providers in connection with the good faith provision of telehealth during the
COVID-19 nationwide public health emergency.” See https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.
Although penalties
are being waived, we should always strive to maintain client confidentiality to
the best of our capacity. Currently, we are aware of three platforms - doxy.me,
VSee, and Zoom - that each offer a Business Associates Agreement (BAA) to users
as well as offering encryption to make the platforms more secure. Zoom’s
platform offering those services is quite costly, but Zoom also offers free and
less expensive platforms that do not have the same level of security. Doxy.me
and VSee have free platforms that offer security, but which may not be systems
that are as smooth to view as paying for additional speed within their
platforms. There are likely others which are not included here.
A major issue to
note: although the OCR notification allows non-HIPAA-compliant platforms, it
does not allow “public-facing” platforms. Facebook Live, Twitch, TikTok, and
similar video communication applications are public-facing, and they should notbe used in the provision of telehealth by covered
health care providers.
We have found sample
consent forms on other websites to be inadequate, lacking a place to record contact
information for a local hospital or Crisis Center Hotline. Having a personal
emergency contact is not enough, as
you may be the person who needs to make contact for emergency services to be
delivered during a teletherapy session.
ONLINE PAYMENT FOR PSYCHOTHERAPY
Paypal and Venmo are
not generally seen as secure even in privacy mode.
Zelle is a
bank-to-bank transfer, and requires the client’s bank to use this system, as
well as your bank. You need only give your client a cell phone number or email
address, no information about bank accounts is exchanged with your client.
Ivy Pay is a system
is exclusively for therapists’ use. There is a 2.75% fee. You charge the
client’s debit, credit, HSA or FSA card on file. It is HIPAA compliant.
Square is a secure
platform that permits you to accept credit card payments. Fees are 2.75% per
swipe or 3.75% plus 15 cents for manually entered transactions.
A credit card can be
kept on file and billed directly. Credit card fees vary.
Bills may be sent
via mail and clients may pay by check.
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 for Medicare claims. During the Public
Health Emergency, the CPT telehealth modifier, modifier 95, should be applied
to claim lines that describe services furnished via telehealth.
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.
New information and news releases can be found
at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
SOME
CLINICAL ISSUES TO CONSIDER
Numerous clinical issues have emerged regarding the way we
practice psychotherapy via telehealth. This list is by no means exhaustive, but
it can be useful in thinking through ways to understand the impact these issues
may have on our patients and ourselves and help us think about what we can
anticipate and discuss with clients. We can reach out to our fellow therapists
as part of our own support and taking care of ourselves. For our clients, it may
all be worthy of exploration and is “grist for the mill.”
Seeing each other’s home environment
In a virtual session, we are
"seeing" clients in different places – we see them in their houses
and they see you in yours. How do we feel about the loss of privacy we usually
have with our clients? How do they feel about our having this visual window
into their world? We and our clients can make some choices about what we want each
other to see, with the option of exploring related therapeutic issues.
Boundaries
What is the background view our
clients see behind us on-line? What pictures or pets might they see, what noises
might they hear, what is the potential for interruptions from family members? How
might those things make your clients feel? How would you feel about them seeing
those things?
Try to protect the space you use at
home from interruptions by posting a sign on the door – “In session. DO NOT
ENTER” – and informing family beforehand that you will not be available during
this time, and ask clients to do the same.
Feelings and concrete issues patients might have about receiving
telemental health therapy
Which of our clients might not want
to receive psychotherapy in this format? Reasons could include feeling disconnected
from the therapist with the computer screen between them, discomfort with the
technology, lack of access to the technology, lack of private or safe space in
their home, etc.
We can appreciate that for some
clients this platform feels comfortable and works well. Might this impact what
format they want to continue receiving therapy with after the national
emergency is over?
Feelings some therapists might have about providing videoconferencing
Do we want to, or are we
comfortable with using this format to provide psychotherapy? It can be
important to notice: do we feel less engaged, or have more difficulty with
“screen silence” than we would with silence in a room both you and your client
are present in?
Distractions
Are we, or our clients, distracted by
things the other person cannot see, such as email, texts, etc? How easy is it
for any of us to lose our focus in this environment?
Contribution of the electronic platform to our therapeutic work
What nuances in the clinical
encounter might we be missing, i.e.: the shift in affect that you feel when you
are sitting with someone? The electronic platform, with delays and pauses, lack
of synchronicity with visual and audio signals, presents general challenges of
the medium.
Does the medium impact client
response; ie: might time delays impact your client’s reactions by them becoming
more passive, for example?
Does the screen permit some clients
to express themselves more freely than in-person work does? What dynamics are
at work that we can help the client look at to increase their understanding of
the difference?
What impact does the medium have on
us? How does the screen impact our sense of engagement? Increased tiredness due
to constantly having someone “in your face” hour after hour?
Technological problems
When the technology for
videoconferencing breaks down, patients may experience anxiety about the abrupt
interruptions and this should be anticipated in discussion at the beginning of
telemental health therapy. A plan for reconnecting with the patient should be
agreed upon in advance, should the connection be lost.
Diagnostic criteria
What risks might there be to seeing
people with specific diagnoses via telemental health therapy? Some diagnostic
criteria can make videoconferencing or telephone sessions problematic or
potentially dangerous. We need to assess the level of suicidal or homicidal
thoughts a client has and whether we can manage them successfully without being
in the same room with them. Having clear boundaries in the informed consent
about when the client may be referred to a different level of care is a prudent
part of videoconferencing.
Uncertainty
The questions around how long the
pandemic and physical distancing will last creates anxiety for clients and
therapists alike. In particular, we all feel uneasy about the length of time we
will be unable to meet in person with our clients. Exploring this topic with
patients, and understanding for ourselves how difficult we find this, can be
helpful.
Support
The GWSCSW list serve has provided both an
exhaustive and exhausting series of announcements, updates, and helpful
commentary from our members. Some
members are offering webinars and/or discussion groups, some paid, some
free. We are our own wonderful resource!
CSWA is offering CE webinars on telemedicine,
ethics, and more, free to members (and free for newly joining members), as well
as “Get Together” sessions to provide support and connection.
This is a time to reach out to one another,
explore feelings, renew or develop new collegial friendships as we navigate
this new world together….
This
looks like a wonderful resource, which we learned of through CSWA’s
collaboration with the Mental Health Liason Group. Scroll about a quarter of
the way down the page and click on Mental Health Providers. https://psychhub.com/covid-19/
Many thanks to Margot Aronson, Laura Groshong and Melissa Grady for their assistance in the development and editing of this document.
www.gwscsw.org
PO Box 711 | Garrisonville, VA 22463 | 202-478-7638 | admin@gwscsw.org
