A Managed Care Toolkit for NASW Clinical Social Workers

Learning how to navigate the administrative process that guides the MCO operations and payment system is important and, at times, critical to maintaining a private solo or group practice. Developing a knowledge base about the MCO and a strategy for working with the MCO administrative staff will help to keep the clinical social worker in a functioning mode, able to accept clients and receive payment for services rendered. While much of the communication with the MCO will be online, talking with a MCO representative may be necessary to obtain answers to a specific question or if it is necessary to challenge a coverage, payment or other determination.

Where Do I Start if I Have Questions about the MCO’s Actions or Inactions?

Most MCOs have a “Provider Relations” unit that responds to questions from individual providers of behavioral health/mental health services. Starting in that unit and, if necessary, moving from a representative to the manager or Director would be an appropriate approach when seeking answers to most provider questions. Keep a record of the name of the MCO representative and the date of the conversation(s). Follow a telephone contact with an email confirmation of the conversation and, in particular, note any positive outcome or next steps. Email communication assists in maintaining a record — but notes from phone conversations should be documented as well. Communication should be marked “Confidential” if relating to a client matter. A separate file should be maintained for the correspondence — whether electronic or paper.

What Should I Have in Hand when Talking with a MCO Representative?

There are two important documents in the MCO/Provider relationship. These are the Provider Agreement and the Provider Relations Manual. Before beginning a conversation with the Provider Representative, review and highlight any paragraphs in the Provider Agreement and Manual that are relevant to your issue. (Some key contract provisions are outlined below.) However, it is acceptable to ask the Provider Relations Representative to identify for you the provisions of the Agreement and Manual that apply to your questions. If the Representative does not offer a specific reference, ask if he/she can email the information to you and confirm that promise in a follow-up email to the Representative. If there are no applicable references to the Agreement or Manual, it is important to ask for the reason for the response and to have that documented. It is also important to confirm that you have the most recent Provider Manual and any referenced items (Addendums, for example) that might have been added — such as an updated payment table or changes in the definition of terms. For a more extensive overview of the managed care contracting process, see Social Workers & Managed Care Contracts, 2008, excerpts of which are linked below.

What Are Some of the Key Terms of the Provider Agreement?

While the Provider Agreement as a whole is important to review, certain terms will be particularly important. These include:

• Authorization for Treatment — What are the required steps for approval?
• Medical Necessity — What is the definition and how will it affect the delivery of mental health services?
• Payment Procedures — What documents and signatures are required?
• Designation of Payment Rates for specific Services or Rate Tables — Are yours current?
• Authority /Process for Modifications to Designated Rates of Payment — What notice to Providers is required for a change in rates? What is the time frame for the notice? How should the notice be communicated — email, posted letter?
• MCO right to request Reimbursement or Set-Off —Is there any specific language that permits a recoupment of fees after a Provider has been paid?
• Provider De-Selection or Termination — What are the grounds for terminating the Agreement with a Provider? What notices have to be provided?
• Confidentiality/Security of Records — What are the Provider’s duties to protect records generated for clients treated under the MCO’s authorization? What computer equipment, programs and security protections are required for the electronic transmission of records?
• Maintenance of records — How long must records be kept for the MCO’s clients? What are the storage requirements, if any?
• Non-Compete clauses — Are there any limits on the Provider’s rights to contract with other MCO organizations while the Provider Agreement is in effect? And after it is terminated?
• Right to Appeal a MCO decision — What are the steps to appeal a decision of the MCO? What are the time frames and procedures that must be followed?

If the Provider Agreement references other documents such as a Provider Manual or separate statement of rates of payment (possibly in an Addendum), make sure that you have it, it is current and you refer to it in your communication to confirm its accuracy. You should request a copy of any referenced item that is not current or is missing; however, it is common practice for MCOs to make the Provider Manual and updates available in the providers’ section of the MCO website with an expectation that providers will stay current with all updates. It is, therefore, prudent to check the MCO webpage for Provider alerts and communication.

How Can I Challenge an Adverse Decision?

If a negative decision is conveyed verbally, it is important to confirm in an email, a fax or a letter your request to have that decision reviewed with a succinct statement of the reasons supporting your request. It is also necessary to review the appeal section of the Provider Agreement and to follow the appeal procedure if it applies to your situation. When in doubt, check the time period for filing an appeal and, within that timeframe, write a letter that requests review of the adverse decision and ask that it be treated as an appeal under the applicable provisions of the Provider Agreement. The main issues to be raised in an appeal are:

• An adverse decision is contrary to specific terms of the Provider Agreement
• An adverse decision contravenes the written policies of the MCO
• An adverse decision is contrary to past practice and/or to prior actions of the MCO
• An adverse decision failed to consider all applicable facts.

According to the Mental Health Parity and Addiction Equity Act of 2008, (26 USC 9812; 29 USC 1185a; 42 USC 300gg-26), health plans are required to provide:

• The criteria used by plans to make medical necessity determinations
• The reasons for any denials of payment for mental health / substance use disorders.
• An appeal letter should note these requirements, if the appeal involves denials of treatment.  Each issue in an appeal should be supported with a factual statement and quotes from any applicable provision of the Provider Agreement, the Provider Manual, other MCO policy statements or notes from conversations with the Provider Representative. A sample appeal letter is provided in the Resources below outlining the types of information that might be included.

Should I File for Mediation or Arbitration?

If a Provider agreement permits mediation or arbitration of disputes between Providers and the MCO organization, a decision will have to be made about whether to pursue an issue through voluntary dispute resolution. This should be an informed decision as it will at a minimum be time consuming, require consultation with an attorney, and could possibly result in a disappointing or adverse outcome. While mediation would not require the presence of an attorney representing the clinical social worker at the meeting of the parties, it would be beneficial to consult with an attorney before beginning mediation to sort out the issues to be addressed and to confirm the applicable procedures. If arbitration is available under the Provider Agreement, consultation with and representation by an attorney would be necessary as the process, though somewhat less formal, is similar to a court hearing. Under some limited circumstances, an arbitrator may permit an arbitration to proceed as a class action — where the effect of the MCO decision is considered as being applicable to all similarly situated clinical social workers in the MCO program. The U.S. Supreme Court recently upheld an arbitrator’s decision to permit a physician provider’s request for his claim regarding delayed payments to proceed as a class action in an arbitration claim filed against Oxford Health Plans (Oxford Health Plans LLC v. Sutter, 133 S. Ct. 2064 (2013)). While successful, the case took more than ten years to move through the courts and only the procedural issue of whether the physician’s claim could be decided by an arbitrator under the language of the Provider agreement was decided.

How Do I Deal with Questions about Rates of Pay?

There are some special considerations and limitations that apply to clinical social workers’ discussions about rates of reimbursement because of federal and state antitrust laws which prohibit social workers who are in different practices from discussing rates of reimbursement with each other. Clinical social workers who are in different practices are considered to be competitors and are prohibited by federal and state antitrust laws from sharing information about the rates that they are being paid. For this reason, questions about adjustments in rates, requests for increases and/or issues regarding payments should be addressed directly to the MCO Provider Relations specialist. (For a more detailed discussion of antitrust concerns for clinical social workers, see Social Workers, Managed Care, & Antitrust Issues, 2004, excerpts of which are linked in the References below.) Again, it is important to review the Provider Agreement and any related fee schedules to determine if payment is being made accurately and timely. A fee schedule for Medicaid related payments may not be included in the Provider Agreement, but may be published online because it is part of a publicly funded program. The Provider Relations representative should be able to assist in identifying the correct fee schedule or a written request may be necessary.

Can I Request an Increase in Reimbursement Rates or Protest a Decrease in Rates?

A clinical social worker who is a Provider for a particular MCO can ask the Provider Relations specialist or the Director of the Provider Relations unit about the reimbursement rate that she/he is being paid. If the social worker thinks that her/his qualifications and experience warrant a higher rate of reimbursement, it is acceptable to call or write the appropriate MCO representative and identify the bases justifying a requested higher rate — which might include educational degrees beyond the MSW, additional social work credentials, completion of specialized continuing education programs or extensive experience in unique areas such as work with post-traumatic stress disorder clients or specialized non-English language qualifications.

A clinical social worker may also protest a decrease in the rates paid. Any decrease in rates, when and if one occurs, should generally become effective after advance notice of the change is given to the provider. If the MCO is seeking reimbursement of monies paid for services already provided, it is important to check the Provider Agreement and Provider Manual to see if the demand for reimbursement is permitted or authorized and under what circumstances. If there is no authorization in the MCO Provider Agreement or the terms required for a reduction were not followed, a written appeal may be filed contesting the legitimacy of the demand for reimbursement. A sample letter is provided in the Resources below.

An appeal should be timely filed under the procedures provided in the Provider Agreement or Manual with copies retained by the clinical social worker. The letter should identify in the heading that it is an appeal, it should state the facts in chronological order and should include references to the Provider Agreement or manual in the letter, if applicable. The letter can also identify the effect that a general decrease in rates paid to clinical social workers has on the availability of mental health services in the state. (See the sample letter in Resources.) The social worker’s appeal should be addressed to a named manager, preferably the Director of Provider Relations or other Executive level person, with a request for a written response.

What if My Appeal Is Not Answered?

If there is no response or acknowledgment after 30 days or the period identified in the Provider Agreement, a second request for review can be sent, identified as such. A copy of the correspondence, with a cover letter identifying the lack of response from the MCO, may also be sent to the person responsible for managed care issues in your state Insurance Commission. (See Resources below for a list of the state insurance commissions.) If your appeal is ignored, but you are committed to seeking a review, consult with knowledgeable health care legal counsel to consider your options for a formal legal challenge which might include filing a small claims court action or an administrative claim with your state’s insurance commission or with other state or federal agencies.

Conclusion and Resources

For clinical social workers practicing in the MCO environment, it is important to stay current with the MCO’s provider requirements. Checking the Provider portion of the MCO website and reviewing the Provider Manual updates and the original Provider Agreement should offer answers to many practice and payment questions. Establishing a positive communication base with one or more Provider Representatives will assist in resolving issues that arise. Understanding the options available when problems cannot be resolved at the lowest levels will permit informed decision making about pursuing appeals or external dispute resolution. While various suggestions are offered in this Tool Kit and the attached Resources, they are not intended to be a substitute for legal advice from an attorney in the state in which you are practicing. Particularly for matters involving contract interpretation, challenges to an administrative decision or use of the mediation/arbitration dispute resolution options, consulting a knowledgeable health care attorney is advisable. For legal matters meeting the case funding criteria for the NASW Legal Defense Fund, financial assistance for legal fees may be available through the NASW Legal Defense Fund application process. Consultation with your NASW Chapter Executive Director regarding a managed care issue is appropriate to determine if the problem is widespread and of concern in your state. The references and resources below provide additional information that may assist in managing your managed care relationships.

References

Oxford Health Plans v. Sutter, 133 S. Ct. 2046 (2013). Available at www.scotusblog.com/case-files/cases/oxford-health-plans-llc-v-sutter/.

Mental Health Parity and Addiction Equity Act of 2008, 26 USC 9812; 29 USC 1185a; 42USC 300gg-26; see also, U.S. Dept. of Health & Human Services, November 8, 2013, Administration issues final mental health and substance use disorder parity rule. Available at www.hhs.gov/news/press/2013pres/11/20131108b.html.

Polowy, C. and Zula, M. (2005). Social Workers & Alternative Dispute Resolution. (NASW General Counsel Law Note) (New edition to be published by NASW Press in 2014)

Polowy, C., Diaz, D. and Friedman, P. (2004). Social Workers, Managed Care and Antitrust Issues, (NASW General Counsel Law Note). Excerpts linked at www.socialworkers.org/ldf/legal_issue/2013/antitrustcitationsforsocialworkers.pdf.

Polowy, C. and Morgan, S. (2008). Social Workers & Managed Care Contracts, (NASW General Counsel Law Note). Excerpts linked at www.socialworkers.org//ldf/legal_issue/2013/selectedexcerptsfromsocialworkersandmanagedcarecontracts.pdf.

Resources

Clinical Social Workers in Private Practice: A Reference Guide. 2005.www.naswpress.org/publications/brochures/clinical-swers.html.

Draft Sample Letter to MCO (2013): www.socialworkers.org//ldf/legal_issue/2013/draftappealletter.pdf.

Insurance Commissioners by State: www.patientadvocate.org/index.php?p=178.

NASW Legal Defense Fund: www.socialworkers.org/ldf/application.asp.

Psychotherapy Notes and Reimbursement Claims, 2005, available at www.socialworkers.org/practice/clinical/csw0805.pdf

Third-Party Reimbursement for Clinical Social Work Services. 2008. www.naswpress.org