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News & Press: Clinical Alerts

Novel Coronavirus Outbreak & Clinical Practice

Tuesday, March 10, 2020  
Posted by: Jamie Klufts
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Novel Coronavirus Outbreak & Clinical Practice

Considerations for Telemental Health

Updated April 3, 2020

As the situation has evolved, many clinicians have moved to incorporate tele-therapy in their practice, in part or fully. Some have used this medium already, and many are utilizing it for the first time. Below is information we hope is helpful to all at this time.

 

Note: we are using the terms telehealth, telemental/tele-mental health, and teletherapy interchangeably.

 

SAFETY CONSIDERATIONS

We recommend folks follow the guidelines from the CDC, as well as directives and guidelines from state and local governments, which are changing sometimes on a daily basis. We cannot tell you what to do with your practices, other than to encourage you to follow guidelines from the CDC to the best of your ability and use sound judgement. 
 
Highlights From CDC Include:
  • Use telework (in your case, teletherapy) as often as possible
  • Put distance between yourself and other people (the virus can spread between people who are within about 6 feet of one another)
  • Encourage clients who are sick, seniors, or those with significant underlying conditions (conditions related to heart, lung, kidney disease; diabetes; and conditions that suppress the immune system) to stay home, when possible
  • Practice good hand hygiene by washing hands frequently, for at least 20 seconds at a time, using soap and warm water. When not feasible, use a hand sanitizer that contains at least 60% alcohol. 
  • If seeing clients in person, disinfect surfaces in between sessions
  • Make hand hygiene supplies readily available in workplaces, including in waiting rooms
  • Avoid handshakes and other forms of physical contact
  • Avoid touching your eyes, nose, and mouth with unwashed hands
  • Cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow, then discard used tissues and practice hand hygiene
  • Clean and disinfect frequently touched surfaces daily (doorknobs, light switches, tables, desks, keyboards, handrails, chair arms, etc.)
  • Increase ventilation by opening windows or adjusting air conditioning

 

LICENSING CONCERNS

  • Per the Social Work Licensing Board, regulations generally require that you be licensed in the state where the client is physically located at the time of service.
  • A waiver may be available, but you need to contact the Board in other states to inquire about possible exceptions.
  • ASWB has compiled a master document with updates on relaxed licensing regulations and reciprocity during this time. This version was updated March 27, 2020.
  • On March 17, 2020, Governor Baker issued an Executive Order that permits telehealth across state lines for college students. See order here and additional details below:
  • The order includes the following language: "During the state of emergency, no Massachusetts board of registration shall prohibit any licensed nurse, social worker, psychologist, or medical doctor in good standing from providing services using telemedicine across State lines to their established patients who during the 2019-2020 academic year have been enrolled in a college or university located in Massachusetts."
  • Please note that we are not entirely certain about the scope of this yet and are awaiting further guidance from the Social Work Licensing Board and others
  • Our understanding is that you will not be reprimanded by the MA licensing Board if conducting telehealth across state lines with your pre-established college student clients
  • We still advise that you be in touch with the Board(s) in state(s) your college student client(s) currently reside/s until further guidance is issued. Some states have relaxed their regulations in this regard.
  • We would also advise consulting your liability insurance company

MALPRACTICE INSURANCE

  • Review your malpractice insurance policy regarding provisions around telehealth and where it is provided (for example, from your home in the event that you cannot use your office due to any quarantine or containment requirements in your area)
  • On March 17, 2020, NASW Assurance Services issued a bulletin to policyholders reminding them that the RRG professional liability policy provides coverage for tele-therapy as long as it is an accepted practice conducted according to the individual practitioner’s state regulations, state licensing board requirements, and HIPAA privacy standards which vary by state and are continually evolving
 

INSURANCE PLAN COVERAGE AND UPDATES (EXCLUDING MEDICARE)

  • For the current COVID-19 State of Emergency, many temporary policy changes have been put into place. The following are the changes that are in place as of March 19. We expect further changes and will keep this page periodically updated. 
  • On March 15, 2020, Governor Baker issued an Emergency Order Expanding Access to Telehealth Services. Highlights from this Order:
  • Mandates commercial insurers to cover video and phone treatment, and to cover these services at rates equal to in-person treatment
  • Note that the mandate covers only in-network providers, and does not apply to "self-insured" plans, although the Division of Insurance has issued instructions for insurers to encourage those plans to follow these mandates.
  • Also in March, MassHealth issued a Bulletin regarding Coverage and Reimbursement which applies to all its plans. Highlights from this include:
  • Permits qualified providers to deliver clinically appropriate, medically necessary MassHealth-covered services to MassHealth members via telehealth (including telephone and live video)
  • MassHealth is not imposing specific requirements for technologies used to deliver services via telehealth
  • Rates of payment for services delivered via telehealth will be the same as rates of payment for services delivered via traditional (e.g., in-person) methods
  • Providers must include Place of Service Code 02 when submitting a claim for services delivered via telehealth
  • Providers will be able to bill MassHealth for these services delivered via telehealth beginning April 1, 2020, for dates of service beginning March 12, 2020
  • Commercial insurance policy temporary changes (Note: this is not an exhaustive list. More updates will be provided as they become available.):
  • As of March 17, 2020, Cigna (the following applies to in network and out of network providers with the exception of the first bullet point):
    • Is not requiring attestations for in network providers; never been a requirement for out of network providers
    • Is allowing providers to conduct telephonic sessions when other technology is not available
    • Is referring providers to the American Telehealth Organization on the guidance for the delivery of telehealth
    • For billing, enter “02” for Place of Service and “95” modifiers
    • Additional Cigna-specific information here
  • As of March 18, 2020, Blue Cross Blue Shield Massachusetts (BCBS-MA):
  • Is expanding the definition of "Telehealth" to include Telephonic sessions for all BH codes
  • Is removing all member cost share (copayments, co-insurance, and deductibles) for telephonic and virtual/video appointment services for all COVID-19 and non-COVID-19-related services for in-network providers, for the duration of MA state of emergency. 
  • Is removing the HIPAA-secure requirements for Televideo platforms for the duration of the COVID-19 crisis
  • Includes all BCBS-MA plans, including self-insured plans
  • For billing, GT or 95 modifiers should be used
  • Additional BCBS-MA information here
  • See a BCBS-MA update to providers from March 24, 2020, here
  • As of March 19, 2020, Optum:
    • The use of audio or video communications can be used immediately.  Providers do not need to attest. We encourage HIPAA approved technologies, but providers can conduct sessions immediately using any nonpublic-facing remote technology.
    • Optum Behavioral Health is expanding our policies around telehealth services for our Medicare Advantage, Medicare Part B, Medicaid and commercial membership, making it easier for patients to connect with their behavioral health provider. Optum Behavioral Health will waive the Centers for Medicare and Medicaid’s (CMS) originating site restriction for Medicare Advantage, Medicaid and commercial members, so that care providers can bill for telehealth services performed while a patient is at home. This change in policy is effective until April 30, 2020, but we may extend that date as necessary and will communicate through all appropriate channels.
    • Standard member cost sharing and benefit plan terms apply
    •  Optum Behavioral Health will reimburse telehealth services which use standard CPT codes and a GT modifier or a Place of Service of 02 for both video-enabled virtual visits and telephonic sessions to indicate the visit was conducted remotely.
    • UMR plans follow all Optum policies
    • Additional Optum information here
  • As of March 19, 2020, Tufts Health Plans and Tufts Health Public Plans:
    • Will compensate providers at 100% of the in-office rate as specified in their provider agreements or fee schedules for telehealth
    • Is allowing all Tufts Health Plan contracting providers to provide telemental health, including by telephone
    • For fully insured members, Tufts Health Plan will waive member cost share for any in-network primary care and behavioral health service, and OON primary care and behavioral health services when authorized because services are not available in network
    • Modifiers are not required for Behavioral Health claims
    • Additional Tufts Health Plan information here
  • As of March 20, 2020, Beacon:
    • Is not requiring signed attestation
    • Is encouraging providers to use appropriate HIPAA compliant telehealth platforms, but apps such as Skype and FaceTime are permissible
    • Telephone evaluations are temporarily allowed
    • Additional Beacon information here
  • Effective March 6, 2020, Aetna:

  • HIPAA:

  • On March 17, 2020, HHS issued a notification announcing it will "waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communications technologies during the COVID-19 nationwide public health emergency." Full text is here.

  • We advise caution with this, and to utilize HIPAA-compliant platforms if at all possible, or consult your liability insurance company.
  • Typically, you need to choose a HIPAA-compliant platform. Some are free, and some involve a cost, especially for full HIPAA compliance.
  • You may need to sign up with a Business Associate Agreement (BAA) for true HIPAA compliance. Read the platform policies carefully.
  • Some available platforms are listed below. None are endorsed by NASW. The first two listed have been recommended by a number of NASW members.
  • doxy.me
  •  www.vsee.com
  •  www.simplepractice.com/telehealth
  •  www.vidyo.com
  •  www.polycom.com
  •  https://zoom.us/healthcare
  •  www.securevideo.com
  •  https://oncallhealth.us/
  •  https://www.regrouptherapy.com/
  •  https://www.wecounsel.com/
  •  https://www.thera-link.com/
  • Attestations: Some plans require that you go to their website and attest to having an appropriate platform (Note: some are temporarily waiving this requirement)
  • Informed Consent: Some insurers may require a signed telehealth informed consent form
  • This is good practice regardless of whether or not the insurers you work with require it
  • Here is a Telemental Health Informed Consent template from NASW that you can use
  • Billing: Billing is generally done in the same way as in-person sessions
  • Use same CPT codes as for in-person treatment
  • Check each insurer for requirements for modifier and place of service codes
  • For reference, under typical circumstances, the following may be true:
  • Phone sessions are not covered by any insurance plans
  • Reimbursement for video telehealth varies dramatically; policies for each plan need to be checked
  • Reimbursement rates may be lower for telehealth as compared to in-person sessions  

MEDICARE

  • On March 17, 2020, Medicare issued new guidelines that allow for reimbursement for telemedicine. It covers video treatment for BH, but not telephonic treatment.
  • Place of Service code is 11. Note that POS 02 will pay at a lower rate. 
  • Modifier is 95
  • A Medicare Telemedicine Health Care Provider Fact Sheet is available from CMS
  • Contact Congress here to advocate that Medicare coverage includes telephone-based treatment 
 

ADDITIONAL GUIDANCE AND CONSIDERATIONS

 

Information like this is only possible because of our members. If you found this helpful and are not yet an NASW-MA member, please join here. We look forward to counting you in our ranks... after all, we're stronger together.  

 


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