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News & Press: Clinical Alerts

Information for Private Practitioners in a Changing Health Care Landscape

Friday, December 1, 2017   (0 Comments)
Posted by: Jamie Klufts
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NASW-MA is keenly aware that members in private practice are dealing with many problems related to retroactive claim denials (clawbacks), reimbursement rates, and other changes to the healthcare landscape. These issues include, but are not limited to:


  • Beacon Health Options’ current audit through Nokomis with those in private practice and subsequent retroactive claim denials, or clawbacks
  •  The Centers for Medicare and Medicaid Services (CMS) and their failed quality measurement system, Physician Quality Reporting System (PQRS), leading to reducing reimbursement rates by 2% for those Medicare providers who did not dot every "i" and cross every "t"
  • Tufts Health Plan’s reimbursement rate changes to match the Medicare Physician Fee Schedule
  • Fear of the unknown as MassHealth transitions to an Accountable Care Organization (ACO) based model for delivery of care through the 1115 waiver

One of your biggest concerns has been "What is NASW doing for me?" NASW-MA staff care about you, your problems, and has not and will not sit silently by as clinical social workers are treated so poorly. We are here to support and advocate for you and all social workers. We hear your concerns through our private practice shared interest groups, private practice Google Group, and the dozens of calls and emails we answer each week. We are consistently advocating for you through our managed care commission, various statewide coalition and working groups, and in the State House through legislation and public policy. Here are highlights of the things we are doing:



NASW-MA sent a letter to the CMS Regional Director of Behavioral Health, who is a LICSW and a good friend to the Chapter. He wrote back that he is addressing our concerns and discussing options with his regional colleagues. Additionally, multiple letters were sent to NASW National’s clinical and government relations staff, seeking their support to directly address the PQRS debacle with CMS in Washington, DC.


In addition, NASW-MA will be sending out a separate email requesting that all LICSWs forward the email from CMS, with the letter you may have received from CMS about filing an “Request for an Informal Review” (which was due December 1, 2017), along with their individual NPI#, to The deadline date is still to be determined.  The Chapter will use this information from Massachusetts LICSWs to submit a request to CMS to review all such cases and to rescind their rate reduction.


Helpful CMS & PQRS Resources:

Beacon Health Options & Nokomis: 

NASW-MA has responded to dozens and dozens of individual calls and emails from our members in November on this issue alone. Rebekah Gewirtz, NASW-MA Executive Director, convened a meeting with Beacon senior management to discuss the Nokomis audit and the unacceptable clawback of hundreds, and sometimes thousands, of dollars from social workers. After this meeting Beacon agreed to hold a webinar with our members to discuss payment integrity and audit practices. The webinar took place on November 3, 2017, and was attended by more than 50 of our members. Melissa Berdell, VP of Payment Integrity ( at Beacon led the webinar. Highlights from webinar are below. Additionally, a meeting was held with other advocacy and trade organizations to discuss a united response to this issue and the group is working to arrange a meeting with EOHHS. Most recently, during a conversation with MassHealth’s Office of Behavioral Health, NASW-MA was assured that Beacon will be changing the way they are conducting program integrity reviews. More specific information on these changes is coming.


In the meantime, NASW-MA suggests that Social Workers appeal all retroactive reimbursement requests from the Nokomis audits. When you submit the appeal, update each of your progress notes, as you are legitimately and ethically allowed to do, with the start and stop time of that session.  Be sure to initial and date each change.  There is no guarantee that Beacon will accept these changes and grant your appeal, but, importantly, these updates are legal. 


November 3rd Webinar Highlights:

  •  NASW-MA major points (as stated by Rebekah Gewirtz, NASW-MA Executive Director)
    • Beacon did not adequately inform providers of the record requirements before they began auditing and clawing back thousands of dollars from unsuspecting social workers
    • NASW-MA is requesting that Beacon freeze or drastically alter the audit process while they evaluate and assess the impact of the way they have been conducting the audits
    • Give providers an opportunity to resubmit their notes now that clinicians have a better understanding of what Beacon requires. This suggestion was based on a finding by our Massachusetts attorneys that it is legal to amend records and progress notes, as long as the clinician initials and dates the edit.
  • Progress note information:
    • This is a HIPAA-compliant encounter note, not a "psychoanalytic note"
    • Two sets of notes are indeed appropriate to keep, and Melissa sent us a NASW Practice Update, written by Mirean Coleman in 2005, stating that psychotherapy notes are protected by HIPAA, and should not be sent to insurers; they are different from progress notes, which insurers can demand, and which should demonstrate that the services billed for were indeed provided.
  • Progress note requirements:
    • Start and stop time or duration (emphasis added)
    • Service code (eg: 90834) that will be billed
    • Number of units billed (ie: 1)
    • Detailed progress note
    • Date of next session
    • Plan for next session, as appropriate
    • Cancelled/missed appointments are indicated on the document plan for the next session
    • "Authenticated" with signature, credentials (LICSW) 
    • Date
    • Additional requirements:
      • Must be legible
      • If handwritten, in blue or black ink; no white out
      • Not a copy of another note (a "cloned" record) from a different date or patient
      • Amendments must be clearly marked
    • In addition: treatment plans should be reviewed and signed by clinician and patient, and updated when necessary

Additional Beacon & Nokomis Resources:

Tufts Health Plan:

Those of who are on the Tufts panel received a letter in the mail notifying you of a reimbursement change coming in January 2018. You do not need to do anything to remain on the panel, just know that the reimbursement rate is changing. If you wish to leave the panel, you must do so in writing within 30 days. Tufts will be reimbursing social workers 80% of the Medicare rate for psychiatrists, as it is listed in the CMS Physician Fee Schedule. (Medicare reimburses social workers 75% of the Medicare rate for psychiatrists.); however, be aware:  Medicare changes its rates every January 1, and we do not know what the rates for our various CPT codes will be on 1/1/18. Therefore, we do not know what our Tufts reimbursements will be when this new system goes into effect, on 1/1/18. NASW is monitoring this closely and will provide updates as soon as they are available.


MassHealth & 1115 Waiver:

To better understand changes to MassHealth and what they mean for social workers, especially those in private practice, NASW-MA participated in the 2017 Annual Cost Trends Hearing, attended the National Academy of Social Insurance Improving Collaboration between Health Systems and Social Services to Combat Social Determinants of Health conference, and hosted Suzanne Curry from Health Care for All and Stephanie Brown from the MassHealth Office of Behavioral Health in our offices to provide an overview of the changing MassHealth and health care landscape. 


There are approximately 1.9 million Massachusetts residents on MassHealth (Medicaid). The new 1115 waiver awarded to the state by the federal government will bring in $1.8 billion over the next five years, with an emphasis on treatment of substance use disorder. Some of these funds will also be used for workforce development initiatives such as student loan forgiveness for social workers. The waiver aims to address the social determinants of health by creating a more integrated system of care that creates provider networks through the use of Accountable Care Organizations (ACOs) to better manage care in a more coordinated way. As part of this waiver, MassHealth has announced 17 ACOs, including one that is made up of 14 different community health organizations that will get off the ground in March 2018. A handful of familiar health plans like Steward and Tufts make up these ACOs, and a majority of them use Beacon as their behavioral health vendor.


MassHealth members will be given three insurance options: Accountable Care Organization (ACO), Managed Care Organization (MCO), or Primary Care Clinician (PCC) Plan. Anyone who has MassHealth as their primary insurance is eligible for ACO enrollment. MassHealth members do not need to change their health plan, they can stay with their primary care provider, and their ACO will be built around their lead provider. This may disrupt behavioral health treatment for members who have social workers who are not in the same network as the member’s primary care provider/ACO. This is why it is important social workers get the information they need to help their clients make informed decisions. As more information becomes available, NASW will continue to provide members detailed information they need. MassHealth members received notice of these changes between November and December 2017 and will be able to select their plans between March and May 2018.


                Additional MassHealth & 1115 Waiver Resources:

Policy & Legislation:

  • Amendment #143, Protect Mental Health and Addiction Treatment Providers from Insurance Clawbacks, filed by Senator Rodrigues, to the HEALTH Act passed in the State Senate, limiting the clawback window to six months after the services were performed for all commercial insurers and MassHealth. NASW-MA is advocating in the House to ensure this amendment remains in the bill and include other provisions to further protect clinicians. Thank you to those of you who joined us and Clinicians United, SEIU 509 to make calls and urge your legislators to make this a priority!
  •  Amendment #2, Health Care as a Right, filed by Senator Cyr, to the HEALTH Act passed in the State Senate, creating a study to determine if a single payer healthcare system is right for Massachusetts.
    • Rebekah Gewirtz was also invited to speak at the Right to Health rally in November, where she advocated for a single payer system to get for-profit insurers out of our health care. Watch her speech here and read our statement here.

Your NASW-MA Contact:

Jonas Goldenberg, LICSW, Director of Clinical Issues & Continuing Education

Contact Jonas: | 617-227-9635 x14


About Jonas:

  • Almost 40 years of social work experience 
  • NASW-MA Chapter Director of Clinical Issues & Continuing Education for more than five years
  • Staffs the Private Practice Shared Interest Groups, the Private Practice Google Group, the HMO/Managed Care Commission, the Social Work Therapy Referral Service (SWTRS) Commission, and several other groups and initiatives related to continuing education
  • Has responded to more than 4,000 consultation and advocacy calls/emails from NASW members and other social workers in the last 5 years
  • Jonas is extremely knowledgeable about private practice and the travails of being a private practitioner. He shares your anger and frustration and your motivation to take action and get results, as do all NASW-MA staff! 

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