Update on Medicare Reimbursement for Clinical Social Workers Practicing in Skilled Nursing Facilities

June 6, 2001

 

Issue

Clinical social workers in some areas of the United States are being denied Medicare Part B reimbursement for services furnished to skilled nursing facility (SNF) patients.

Background

The Omnibus Budget Reconciliation Act of 1989, Section 6113 of P.L. 101-239, expanded Medicare Part B coverage to clinical social work services, with the specific exception of SNF inpatients. The Act also formally defined clinical social workers and clinical social work services.

The Balanced Budget Act of 1997 (BBA), Section 4432 of P.L. 105-33, instituted the Prospective Payment System for Medicare as well as Consolidated Billing (CB). CB requires SNFs to submit Medicare claims for all Part A and B services furnished to residents unless exempted by statute. As clinical social work services are not specifically excluded in the statute, SNFs are responsible for them as part of the entire package of services that must be furnished to a patient, since such services are subject to the CB requirement. HCFA repeatedly postponed implementation of this change due to letters of concern written by NASW and its members as well as HCFA system modification delays; the effective date slipped to April 1, 2001.

The Medicare, Medicaid, and SCHIP Benefits Improvements and Protection Act of 2000, Section 313 of P.L. 106-554) clarified the CB requirements with regards to SNFs. The application of CB to non-covered SNF stays was repealed. Thus, CB now only applies to services rendered to SNF patients during the course of a covered Part A stay and for physical, occupational, and speech-language therapy in both Part A and Part B settings.

Given this change, it appears to NASW that clinical social workers, at the discretion of their Medicare carrier, should be able to continue billing Medicare Part B directly for services rendered to SNF patients. In fact, the Medicare Skilled Nursing Facility Manual (Transmittal 368, HCFA Pub. 12, change request 1323) dated May 24, 2001- it states:

"Beginning with services provided on and after April 1, 2001, the intermediary will make payment for SNF Part B services under a fee schedule if there is a Medicare fee schedule established. This applies to 22x and 23x bill types." A fee schedule exists for clinical social work services. (HCFA Carrier Manual Part 3, Sections 2152, 4162, 5010.4, and 5113) With regard to bill types, 22x refers to SNF inpatients covered under Part B while 23x is for SNF outpatients.

However, other than the above, HCFA has provided no official guidance to carriers or NASW on this issue. Additionally, HCFA also asserts that discretion has been granted to local Medicare carriers as to the acceptance of clinical social work claims furnished to SNF patients under Part B. As a result, the situation remains unresolved. NASW strongly recommends that practitioners stay in close contact with their local Medicare carrier and be mindful of their opinion on this matter.

Remedies

NASW has always been advised by HCFA that a statutory change is required. The Medicare Social Work Equity Act was introduced in both the 105th and 106th Congresses to no avail.

NASW is working to reintroduce the legislation in the 107th Congress and hopes it will be successful this time. It will be entitled the Clinical Social Work Medicare Equity Act of 2001. The legislation has not been introduced yet, due to the lack of a Congressional Budget Office score, which measures the fiscal burden posed by the legislation. Without such a score, the legislation will be considered dead on arrival for House and Senate Republicans. However, given the recent power shift in the Senate, NASW currently strategizing on this issue so that we may achieve success as swiftly as possible.

Please note HCFA is not our obstacle here. In fact, the agency has been sympathetic. On October 19, 2000, HCFA published a proposed rule (HCFA-1088-P) that would "permit separate Medicare Part B payment for certain psychotherapy services of clinical social workers furnished to a skilled nursing facility resident" during a non-covered stay. The Bush Administration at the beginning of 2001 put a moratorium on the issuance of new regulations (i.e. final rules). And while NASW understands that the moratorium has since been lifted, HCFA has shared with NASW that they do not expect the aforementioned proposed rule to be published in a final form before November, 2001.

NASW has been working within the confines of the existing political climate to push this legislative change through Congress. It is a high NASW priority but a low Congressional priority.

NASW is working diligently to resolve this impasse, but the issue is not one of pure persuasion, as we need a statutory change. There is no such thing as a quick fix in this situation and again, given the power shift in the Senate-- all bets are off and it is a brand new day legislatively. That is not to say that action hasn't been taken on this matter-- NASW has been actively working on this issue over three Congresses (1998-2001)-- but at this time, NASW is not in possession of a workable solution to this serious problem.

Also realize that any proposed change to the Medicare Prospective Payment System (PPS) is not taken lightly by Members of the House and Senate. Such action is a precarious venture-- since there are many, many groups who ask Representatives and Senators to fix the PPS to suit their particular issues and a request for assistance granted to one particular group puts the camel's nose in the tent for the remainder of the groups.

As soon as additional information becomes available on this matter, it will be posted on the NASW website. In the meantime, you can help by writing your federal Representative and Senators about this important issue. You may send such a letter from the NASW website. Go to the NASW Home Page (www.socialworkers.org) and scroll down to the News/Information heading on the left side of the page. Click on the For Action link and then on the next page, click on the Government Relations Action Alerts link. Choose the Senate & House Cosponsors Needed for the Clinical Social Work Medicare Equity Act of 2001 link and on the next page, scroll down to the red Take Action! Button. Click it and from there, our Congress Web software will assist you in sending letters to your Representative and Senators.

For more information, please contact Francesca Fierro O’Reilly, NASW Government Relations, at 1-800-638-8799 x 336 or fforeilly@naswdc.org.