Update on Reimbursement for Clinical Social Work Services Provided to Residents in Skilled Nursing Facilities

The implementation of the new Medicare regulations issued by HCFA on April 23, 1998 that ended separate Part B payment for clinical social work services to inpatients of Medicare participating skilled nursing facilities was delayed until June 22, 2000. We are awaiting the publication of the Proposed Rule 1088P, which will determine if and when the regulations will go into effect.

The issue is the definition of a clinical social worker and whether clinical social work services are a condition for participation for a Medicare skilled nursing facility. We have argued that those social work services that are conditions for participation include discharge planning, general casework services, case consultation, arranging for follow up care, psychosocial assessment and treatment planning, linkage with other professional and community services, and supportive counseling. They do not include the formal diagnosis and treatment of mental or emotional disorders carried out by a clinical social worker.

To date no ruling has been made. NASW will advise you as soon as it is published in the Federal Register.

Meanwhile, regardless of the rule, we must continue to lobby for the Medicare Social Work Equity Act (MSWEA). This will exclude clinical social worker services from coverage under the Medicare skilled nursing facility prospective payment system and consolidated payment. This will allow clinical social workers who are providing diagnosis and therapy to residents of skilled nursing facilities to bill Medicare directly for these services as do psychologists and psychiatrists.

We ask you to contact your Members of Congress and ask them to sign on to the MSWEA (HR 655, S 847). Please, timing is very important; it would be great to have lots of calls about this legislation made prior to the HCFA rule. If you need further information, please call me, Pat Gorman, at 1-800-638-8799 Extension 336. Thanks.

Protecting and reinstating the ability of social workers to bill Medicare directly for Part A and Part B patients in skilled nursing facilities (SNFs) will continue to be a major legislative initiative for NASW and CSWF in the 106^th Congress. Legislation was introduced late in the 105^th Congress that would have changed a provision in the Balanced Budget Act of 1997 that negatively affected social workers. Early in the 106^th Congress, Medicare Social Work Equity Act of 1999 (MSWEA) was introduced in the House. A similar bill was introduced in the Senate. These bills address three issues of concern to social workers practicing in skilled nursing facilities.

1. Prospective Payment System (PPS) – Beginning in January 1999 social workers can no longer bill Medicare for services provided to patients in skilled nursing facilities under a Part A stay. Clinical social workers can continue to bill Medicare for Part B patients, but only until Consolidated Billing (CB) is implemented (see #2). Under PPS, skilled nursing facilities receive a lump sum payment for patients, which includes clinical social work services. Chances are good that SNFs will not contract with clinical social workers to provide services since the daily PPS amount is too low to cover ancillary services. Because psychologists and psychiatrists are not subject to PPS, they can continue seeing Part A patients and then bill Medicare directly. MSWEA will address this by excluding clinical social work services from PPS.
2. Consolidated Billing (CB) – Under CB, clinical social workers will have to submit bills to the SNF which will then bill Medicare. Implementation of this regulatory policy has been delayed until HCFA can correct the Y2K problem. MSWEA will address this problem, by excluding clinical social workers from CB, just as clinical psychologists and psychiatrists are excluded.
3. Billing Authority for Clinical Social Workers – Because of the confusion between clinical social work and social services, many believe that the social services provided "in-house" at the SNF is the same as the service provided by clinical social workers who are providing mental health diagnosis and treatment to residents. In order to eliminate the confusion, the provision in the current law that has led HCFA to interpret social services and clinical social worker services as the same service, will be deleted.

For more information of this effort, please contact Pat Gorman 1800-638-8799 x336

Five Reasons to Support the Medicare Social Work Equity Act

1. Mental Health Services were never intended to be bundled with other services in order to control costs. CSWs were inadvertently included in PPS and Consolidated Billing. A technical correction is necessary to fix the problem.
2. Access to mental health services is critical to nursing home residents who often experience depression and adjustment difficulties.
3. If Clinical Social Workers (CSWs) are discontinued from Medicare reimbursement for mental health services in skilled nursing facilities, nursing home residents in rural and underserved areas will suffer. CSWs are often the only mental health professionals available in these areas.
4. As CSWs are excluded from this area of practice, more expensive providers will fill the void in non-rural areas. For example, CSWs charge 25% less than Clinical Psychologists do.
5. In 1998 CSWs billed less than $4 million for these services.

Pat Gorman, LCSW
Congressional Lobbyist
Professional Development and Advocacy
National Association of Social Workers
750 First Street, NE, Suite 800
Washington, DC 20002-4241
Phone: 202/336-8336 or
800-638-8799 Ext. 336
Fax: 202/336-8311
E-mail: pgorman@naswdc.org

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The National Association of Social Workers is the largest organization of professional social workers with 155,000 members. It promotes, develops and protects the practice of social work and social workers. NASW also seeks to enhance the well-being of individuals, families, and communities through its work and through its advocacy. A professional social worker has a degree in social work and meets state legal requirements. Professional social workers practice in many settings including family service agencies, child welfare, community mental health centers, private practice, schools, hospitals, employee assistance programs, and public and private agencies. Professional social workers are the nation's largest group of mental health services providers.

The National Association of Social Workers (NASW) is located at 750 First Street, NE, Suite 700, Washington DC 20002-4241. Telephone is 202/408-8600, FAX 202/336-8311 and TTD 202/408-8396.