Very nice manual for clinicians

In the section Education and Credentialing, I recommend changing the wording from "Earning the direct clinical contact hours required to become an LCSW in a given
state, which may vary from zero to 1,500 hour" to remove the "from zero to 1500 hours since there are some states that require more than 1500 hours. Just keep it "may vary".

It seems very thorough and complete. There is certainly a need for this. Thank you for your work on it.

I recommend some changes in the language and style of the self-care section and conclusion. It seems as though the style changed at this point in the document.

This is a fantastic, needed resource. Thank you for putting this together. As a private practitioner, it can feel taxing and isolating when dealing with a client crisis and I'm wondering how addressing crises in private practice can be addressed in this manual, without providing supervision in the manual, of course. Maybe something about having a plan in place if a crisis occurs with a client (i.e. what resources/numbers to give to the client, who will you consult with, what information you will need from the clients, etc.)?

I have read through the entire document, which is very well put together. There are, however, a number of spelling, grammar, and formatting issues, which I have marked up on my copy. Is there a way I can provide my marked up pdf copy for your review?

Thank you for the hard work. It is very informative and is a good tool to use if you are opening a practice or to review what ways to improve marketing strategies.

I have a number of comments and will find time this month. This manual should not be published without discussing Reinstatement and how the dramatic effect it can have on your patients and your practice. Reinstatement effects private practitioners differently than agency social workers. It is not talked about in this field and there is no preparation for it. Happy to contribute!
Barbara Reese, LCSW, BReese@ResilienceTherapyLLC.com

Teletherapy, pros, and cons of becoming licensed in other states, independent contactor VS private practitioner (especially considering online platforms like BH), marketing, supplementing income, seeking consultation, navigating credentialing and billing, and LAPSW consultation ideas (the advanced degree is often overlooked).

p.14 expense to have own personal health insurance. non revenue for collateral phone contacts (probation officer, school counselor). state business licensing fees are missing. p.18,59,61 no mention of co-insurance. p.18-recommend to get an insurance reference number when contacting insurance companies. verify if video conferencing is benefit. p.19-EAP tend to be free sessions and obtain an authorization number. p.45-electronic transactions missing (Zelle,Venmo).p.53-be aware for minor confidentiality regulations.p.59-be aware if professional liability covers audio or video conferencing sessions or cyber security. p.60 missed appointments usually are not paid by EAP. p. 83. There is an extra period. Overall written clearly and simply. Administrative and clinical forms to be included.

With the current climate I feel there should be a shift to address the negative disparities with social work practice elements. The current document fails to address the systemic practice elements which impact African American and First Nations peoples. I would incorporate thoughts from these two groups.

Best,

Private practice should be overseen by a LCSW. Many are confused about LSWs role in private practice. And some LSWs believe they can conduct psycho education groups, support groups, and therapy without supervision from a LCSW or LPC. LSWs are apparently charging clients for services.

It needs to be very clear the expectations of all roles. "Clinical social worker" needs to be "Licensed Clinical Social Worker". LSWs can work in a private practice under the supervision of a LCSW not independent of a LCSW. Many LSWs believe they are "clinical social workers " because they do clinical work. In recent weeks I have had 2 LSWs ask me about them opening their own private practice, I referred them to the PA licensing board for review of expectations and limitations of the LSW.

Interns/MSW students: roles and responsibilities

In general, this is an excellent and comprehensive document. Thank you for the work put into this and the opportunity to comment on it.

Some concerns:
pp 9-10 I appreciate that there are different kinds of private practice. This document indicates a private social work practice can address mental health issues and/or it may address other needs such as case management, community organization or social policy, for example. However, at least in the state of Maryland, "private practice" has a specific meaning under regulation (emphasis mine): "Private practice" means the provision of PSYCHOTHERAPY by a Licensed Certified Social Worker-Clinical (LCSW-C) who assumes responsibility and accountability for the nature and quality of services provided to a client in exchange for direct payment or third-party reimbursement, or an a pro-bono basis as stated in Health Occupations Article, ß19-101(q), Annotated Code of Maryland. [COMAR Title 10 Maryland Department of Health, Subtitle 42 Board of Social Work Examiners, Chapter 02 Social Work Practice]
There could be other states that also have their own definitions. This should be made note of when defining private practice.

pp 10-11 Under Pre-LCSW, it is stated that "There are two parts to an MSW becoming an independent Clinical Social Worker." There are seven bullet points under Pre-LCSW. The 4th, 5th and 6th bullet points are not required to become a pre-LCSW. I believe the three bullet points mentioned belong under LCSW. Just as passing the ASWB CSW exam is done by a pre-LCSW in order to become an LCSW, so are the aforementioned bullet points.

p 34 When in doubt about a proper action, consultation with one's liability insurance lawyer, usually provided free of charge, should also be specifically recommended.

p 46 Re: minor patients...who are unable to give legal consent indicate their assent for treatment by their participation. Assent for treatment cannot be considered a substitute for informed legal consent.

Some states permit some adolescents under the age of 18 to consent to treatment without permission of their parents or guardians. In that instance, is the adolescent's signed consent to risks & benefits of treatment, as well as the Social Worker's legal obligations such as duty to warn or report, considered sufficient for "informed" consent?

I worked in a foster care agency and a family service agency for 18 years prior to beginning my own private practice 22 years ago. I am active in CSWA and the Greater Washington Society for Clinical Social Work, as well as being a member of NASW. I do think CSWA's resources should be given more than a passing mention in this document, as I think more LCSWs should be aware of more organizations that can assist them in addition to NASW. Each organization has many strengths and we are stronger working together.

Best,
Judy Gallant, LCSW-C

Comments on the document “Clinical Social Workers in Private Practice: A Reference Manual”
Respectfully submitted by Kathy T Rider, LCSW, BCD, CGP, FAGPA Austin, Texas
Page 10 Section on “Education and Credentialing”

Please consider this language… “Earning the direct clinical hours required to become an LCSW in a given state”. Probably do not want to specify hours as these requirements vary from state to state.


Page 11/12 LCSW Section
In this section…Please consider these statements/language: Those who graduated with a clinical focus should meet the minimum requirement of two (2) years of supervised clinical experience.
Those who graduated with a nonclinical focus should take clinical courses that would be the equivalent of the clinical social work curriculum provided in an accredited MSW degree program.
All states have legal regulation for independent clinical practice, and practitioners must be licensed in this category to engage in the independent private practice of clinical social work.
Possessing the knowledge base and clinical skills to diagnose mental health conditions as specified in the International Classification of Diseases, 10 Revision, Clinical Modification (ICD-10-CM) (or later editions) and the Diagnostic Statistical Manual V (or later editions), and to provide psychotherapy using the accepted methods of practice agreed to by NASW, CSWA, and AGPA.


Page 12 Section on “Continuing Education”
All states have provisions for continuing education in their requirements for renewal of social work licenses.

Page 13 Section on “Business Planning”
Please consider including: One of the first business planning tasks is the structure and formation of your practice which includes the projection of income and overhead. A practitioner must plan for a monthly salary draw in addition to ongoing monthly expenses. There are initial startup costs which will not be ongoing monthly expenses, such as furniture and equipment, but still must be planned. Office expenses such as lease/rent, business cards, stationary with letterhead, janitorial services, cleaning supplies, office supplies (incl equipment…copier, fax and credit card machine, file cabinet), and printing of forms (incl intake, history, consent, releases and billing). Computer-related expenses such as a designated work
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computer, internet services, printer, and supplies for computer and printer. Note: some lease/rent agreements include janitorial services. Administrative services such as practice management, i.e., support staff, and billing services. Again, some lease/rent arrangements include a receptionist and/or a messaging center. Taxes such as estimated tax payments, income taxes, business and property taxes. With regard to Nonpayment of fees for services rendered, it is important to have written policies to be given to client at first appointment regarding fees for less than 24 hour cancellation notices and no-show appointments. This is a business so having a separate bank account and a dedicated business credit card will make it easier to track income and expenses for the purposes of income tax filing.


Page 17 Section on “Health Insurance Portability and Accountability Act”
Non-compliance with HIPAA can result in fines being levied.
Under the heading “Payment for Services”, please include
One of the considerations of forming and managing your private practice is the consideration of whether to accept third party reimbursements or to do fee for service only. Although there is federal legislation mandating parity with regard to behavioral health, there is not parity in third party reimbursement. Additionally, a practitioner must apply for and be accepted on an insurance panel. Many insurance panels are closed to the addition of new practitioners in a particular geographical area. Participation as a behavioral health provider in Medicare and/or Medicaid programs requires an application with a process which can take several months to be completed. Many practitioners only accept fee for service for a variety of reasons…confidentiality, in-network requirements of insurers, and low reimbursement rates. In these cases, the practitioners provide the needed documentation to the patient if the patient is filing their own medical health care insurance claim. Other practitioners choose to do a combination of approaches for payment of services rendered. One must be very clear with written policies on when medical health care insurance is accepted, when fee for service applies, and when pro-bono/sliding fee schedule is available with criteria clearly stated.



Page 18 Section on “Network Providers”
It is important to have a written policy outlining what the financial responsibilities are for the patient when their medical health care insurance does not make payments to the provider for the full amount of the billed services rendered. Some states have specific prohibitions against “balance billing” by the provider.

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Page 18 Section on “Out-of-Network Providers”
Some medical health care insurance plans do not provide reimbursement for “out of network” services. Either the provider or the patient must contact the insurer to see what the coverage is for a specific plan. It is not uncommon for an insurer to have multiple plans available with different coverages of services.

Page 19 Section on “Types of Insurers”
Sometimes the patient’s own employer has created their own self-insured medical health care system with eligibility criteria, coverage of services, rates of reimbursement, and paneled providers. These self-insured employer plans have their own rules and contracts. Generally, the panel of health care providers, including behavioral health providers, is small and specific as to specialty areas and geographic locations.
EAP services are provided by the employers to their employees and dependents at no cost to the employee. Sometimes EAP services are provided onsite with a contracted provider. Other times, EAP providers are contracted to deliver services at the provider’s offices. Typically, EAP services are time limited as to duration and number of sessions covered before the employee must utilize their medical health care insurance. EAPs will have specific provisions as to whether the employee can continue with the EAP contracted provider for long term outpatient services covered by the employee’s medical health care insurance after the EAP sessions have been fully utilized.

Page 20 Section on “Independent Clinical Private Practice Settings”
A clinical social worker licensed in their state to practice independently has decisions to be made in setting up their own private practice. There are basically three structures for one’s practice:
1) Solo practitioner in one’s own office space who is responsible for their own practice, lease agreements, support staff and collection of fees for services rendered.
2) Solo practitioner who is responsible for their own practice while sharing office space and overhead expenses with one or more behavioral health care providers. This may or may not include sharing on-call or emergency coverage outside of regular office hours. There is no sharing of fees collected for services rendered.
3) Solo practitioner who is responsible for their own practice while participating in a group practice setting wherein in addition to sharing office space and overhead, there is a sharing of fees collected for services rendered by all members of the group practice. This may include sharing on-call or emergency coverage. This structure will need to be reviewed by an attorney for income tax implications.


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The most common structure is the solo practitioner sharing office space and overhead expenses while maintaining full responsibility for their clinical practice. There is no fee sharing between practitioners.

Some clinical social workers choose to set up their practices within their own home. One would want to consult with a CPA and an attorney regarding tax and liability implications.

Overall consideration: With the pandemic, one might consider a section on telehealth services and the accompanying provisions for the safe and ethical delivery of clinical services.

Page 46 Section on “Informed Consent”
When a parent requests services for a minor, it is important to have copies of the documentation related to parental custody and the authority to request behavioral health services. When possible, both parents, regardless of the custody issues, should be interviewed by the practitioner to do a complete assessment of the minor child. Releases need to be obtained from both parents for contact with significant others in the child’s life, such as school personnel, caretakers, and other family members, with knowledge of the child’s behavior and interactions with others.

Page 57 Section on “Privileged Communication”
In most states, when a patient files a complaint to the state regulatory body, it is understood that the patient has waived the privilege and confidential information may be shared to the appropriate body.

Page 58 Section on “Subpoenas”
A subpoena is a legal document. A subpoena issued by a court of law with jurisdiction in the matter at hand must be responded to by the practitioner. However, a subpoena issued by an attorney at law may or may not require a response by the practitioner. It is recommended that the practitioner consult with their patient before any disclosure of information, including acknowledging receipt of the subpoena. If the patient and the clinician mutually agree to release information, then a release of information for the party issuing the subpoena must be executed prior to any release of information in response to the subpoena.



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Page 59 Paragraph on “Copays and Deductibles”
The amount of the deductible applied for any given billing depends on the allowable fee determined by the insurer.

Page 62 Section on “Denials and Appeals”
Before any formal appeal is begun, please consider that denials frequently occur because the claim landed on a clerk’s desk who did not process the claim properly. It is also possible that you transposed the information resulting in the computer rejecting the claim. Always call and ask for the reason for the denial regardless of what is stated on the rejected claim. It is best to have your copy of the claim filed in front of you and to approach the interaction as one attempting to correct a mistake and have the claim re-processed. This is particularly true if previous claims for the same patient with the same CPT code have been approved and paid. If it is the insurer’s error, many times the clerk will re-process the claim immediately and/or allow you to fax the corrected claim form into their offices. Sometimes, the insurer has changed the way the form is to be filled out after notification. For example, requiring that whenever a year is indicated on the CMS 1500 form, it must be entered consistently either in a two digit format or a four digit format...otherwise the claim gets rejected.

Page 64 Section on “Record Keeping”
Medicare patients’ records are required to be kept for ten (10) years after the last date of service before being shredded.
State regulatory bodies will have in their Rules specific timelines for keeping of patients’ records. In general, records of persons who were minors at the time of service must be maintained until seven (7) years passed their eighteen birthday.

Page 75 Section on “Emergency and Disaster Planning”
Considering the experience of the 2020 COVID-19 pandemic and its impact for 2021, one might want to consider maintaining financial reserves for a minimum of nine (9) months to eighteen (18) months to cover unanticipated costs and changes in income.

Page 77 Section on “Professional Will”
Many state NASW chapters and state clinical societies have developed a professional will template in consultation with a health care attorney in their state. One would want to check with your chapter and/or society about available resources.

From: Sharon L. Payne LCSW CSAC Emeritus Professor of Social Work Virginia Wesleyan University, Private Practitioner

Page 11 I found the first paragraph confusing. The recommendation that SW'ers achieve 5 years supervised practice and additional coursework is certainly valid but seems to represent the disconnect between SW programs certified by CSWE that do not prepare students nor inform them about the path forward to practice and what it entails. This is a glaring problem and one that needs our attention.

Page 11-- the use of the term malpractice insurance is old. Professional liability insurance is more inclusive of the coverage we require.

Page 14-- "appropriate" social media presence. Here I would specify that practitioners follow the excellent document: Standards for the Use of Technology in SW Practice

Page 16--no where in the document do you address the possible structures that the practitioner should consider--solo practice, LLC etc. It is mentioned later I believe but not emphasized. This is crucial and I have colleagues who have suffered as a result of not being protected from partners' misdeeds. A more detailed explication of various structures would be useful with the caveat of course that we cannot give legal advice. We should suggest that legal advice should be sought from someone who understands small business structure and medical practice structures.

Page 21- again speaks to issues of group practice but not legal structure and the need to protect oneself

Page 22- goes into explicit agreement with the group- this area could use emphasis that this is a business agreement and needs to be legally formalized. The best of colleagues can have disagreements when money and property are concerned. A handshake is not the way to establish a business.

Page 36--reiterates the Code of Ethics

Page 47-reiterates the Code

Page 57-3rd party payers section doesn't provide the new practitioner information about where to learn what you recommend they need to know

Page 70- initially I didn't see the technology code being referenced but saw it here. The formatting of the document doesn't allow it to stand out.

The latter part of the document simply reiterated the Code of Ethics in many sections which isn't a bad thing because many practitioners are not conversant with what the Code says and doesn't say. However, the more explicit the information the better and the Code isn't explicit about establishing a practice. Formatting of this document with a detailed Table of Contents and perhaps bolded sections where the Code of Ethics is restated would make it more readable and useful. It's a lot to read through and clearly took a lot of work. Thank you for doing this for the next generation of clinicians.

Thank you for the opportunity to review and provide comment on NASW’s proposed private practice guidelines. The guidelines will provide a practical and useful resource for clinical social work licensees throughout the United States. ASWB is the membership association of the 64 social work regulatory authorities in the United States and Canada.

ASWB publishes the Model Social Work Practice Act (model law) which informed the review and comment of the proposed private practice guidelines. First adopted in 1997, the Model Law reflects best practices for social work regulation. It is regularly reviewed and affirmed by all ASWB member jurisdictions during the association’s annual business meeting. More information about the model law is available on the ASWB website: https://members.aswb.org/best-practices/model-social-work-practice-act/

The document can be found here: https://www.aswb.org/wp-content/uploads/2013/10/Model_law.pdf



Page 9

Definition of private practice

The proposed definition of private practice encompasses two separate activities, both private AND independent practice. This may contribute to confusion in that state social work regulations more often than not differentiate between the two activities whether explicitly or implicitly. In many states, masters and/or bachelors social workers may practice autonomously or independently, however they are restricted from owning a private practice. Yet still in other states, a masters social worker is restricted from independent practice but not private practice. While the private practice guidelines offered by NASW emphasize clinical social work practice, differentiating these two practice activities is best practice and consistent with the social work laws in most states. Further, the proposed practice guidelines discuss independent practice in several different areas. Offering a definition for independent practice separate from private practice will provide clarity for the users.

NASW might consider clarifying that that private practice encompasses autonomous or independent practice; as well as incorporating the definitions for independent and private practice suggested by the ASWB model law.

The referenced definitions are as follows:

ASWB Model Social Work Practice Act p. 7
Section 109. Definitions.
(t) Independent Practice means practice of social work outside of an organized setting, such as social, medical, or governmental agency, in which the social worker assumes responsibility and accountability for services provided.
(w) Private Practice means the provision of Clinical Social Work services by a licensed Clinical Social Worker who assumes responsibility and accountability for the nature and quality of the services provided to the Client in exchange for direct payment or third-party reimbursement.

Page 11

Independent practice is not exclusive to clinical practice

As discussed above independent practice is not exclusive to clinical practice. The practice guidelines should be reviewed for any instances where it may suggest otherwise. For instance, this statement is not representative of the majority of state regulatory frameworks, where independent practice is permitted by bachelors and/or masters licensees: “Many states have legal regulations for private practitioners at a clinical or independent practice, and practitioners must be licensed or certified at this level to engage in independent private practice.” This statement may further contribute to confusion because of the lack of definition for independent practice.

Use of the term “independent clinical social worker”

In all states except one the receipt of the clinical license permits an individual to practice autonomously or independent of supervision. Nebraska requires an additional period of supervision to obtain the licensed independent mental health practitioner (licensed independent clinical social worker). Therefore, the use of the term “independent clinical social worker” is redundant. Further it may contribute to confusion as it relates to earlier comments made regarding independent practice being permitted by bachelors and masters licensees.

Page 12

Scope of practice

There are states that prohibit diagnosis and psychotherapy by licensed social workers
https://movingsocialwork.org/news/scoping-out-the-rules-mobility-and-scope-of-practice-requirements/

Page 41

Private practitioner’s qualifications and experience, including… please add “license”

Matters involving informed consent. Consider adding more information related to client welfare, self-determination, nondiscrimination, and a professional disclosure statement.
ASWB Model Social Work Practice Act p. 52 for more information.

Page 56
Privileged Communication

ASWB Model Social Work Practice Act has extensive information on privileged communications and implications in regulation
Article V. Confidentiality
Section 501. Privileged Communications and Exceptions.

This document is excellent and an invaluable asset. My one concern is the paragraph in the self care section (beginning with "In short we need friends...) It does not add to the premise of self care and is not consistent with the rest of the document.

The NASW Code of Ethics requires social workers to evaluate their own practice. I urge that language reflecting this ethical obligation be included in this Private Practice guidelines.

Bruce Thyer, Ph.D., LCSW

This is a very helpful document. I commend the parties who put so much time and effort into the project. Comments:
1. Thank you for stressing the issue of collecting co-pay, deductible under insurance contracts. This is a frequent problem. Most people think of it as helping clients, not as fraud. Important to understand the fraud element.
2.p 62 'determine if the plan is private of self funded'. There is much misunderstanding of the make up of insurance plans and companies. Consider clarification by listing the types of plans, recommend ways to locate the regulatory group that has oversight.
3.p.72 reasons for termination: add destruction of practitioner property
Thanks for this opportunity to comment. Look forward to seeing the final product.
Charlotte B. Cooper,LCSW
Director of Clinical Reimbursement Project, NASW/Tx