Q: In the January 2006 issue of Counseling Today you answered a question concerning MCM 2050.1 (the “incident to” provision that allows psychological services coverage under Medicare for master’s level counselors). In living in Nebraska, I have been researching this piece of information and have been told something completely different — that I would have to bill the client’s supplemental plan, which I have done in the past but have been denied payment. My question then would be, who should I call to find out the specifics so I can (a) give the OK for my billing agent to go ahead and (b) let other LPCs in Nebraska know? I have gone to Medicare directly, to different people outside of customer service and to the regional administrator, who gave me the above method of billing. What should I do?

A: You have another way of working with Medicare, albeit a difficult one. By billing Medicare and getting denied, you can then file for secondary insurance if it is available. You have shown much patience and are doing a service for the Medicare client. Some send them elsewhere. According to www.wpsic.com/

medicare/policies/wisconsin/phys004.pdf and www.cignagovernmentservices.com/partb/lmrp_lcd/id/cms_fu/98-003.html, “incident to” should work. Both are legal for LPCs or LCPCs.

Q: As program director for a mental health counseling program, I often get requests for information on whether counselors are able to go into private practice in California. While I know that there is no licensure in California for counselors, I was not sure if this ultimately makes private work impossible for counselors due to reimbursement issues. Any information would be very much appreciated.

A: California has not passed a counselor licensure bill yet, but all optimism is pointing to a license in the near future. The bill jumped most hurdles, but it got held up on the last step. Our sources in California tell us that counselors can practice in “exempt settings,” which are nonprofit agencies and government and educational settings.

If counselors have 12 units of marriage and family courses in their master’s training, they may qualify under the current MFT license already established in California. For more information from the “horse’s mouth,” visit the California Board of Behavioral Sciences website at www.bbs.ca.gov or call 916.574.7847.

Q: I am an LCPC in private practice. One of the worst insurance companies I contract with takes over six weeks to mail the authorization to the providers, and they pay only $40 a session. We have complained to them by phone and in writing. I have also asked them to just fax the authorizations, but to no avail. In our community, no one else will take this insurance. The problem is, state (of Illinois) employees, two local hospitals and the local school district all have this carrier. Are you receiving complaints from anyone else, and is there anything else we can do?

A: Dealing with the insurance company directly is the logical starting point. Most insurance companies are responsive to provider’s requests; however, some are not. In these instances, the provider needs to deal with the Human Resources department of the client’s employer. It has been our experience that some HR departments are unaware of low reimbursement rates and their insurance company’s lack of cooperation. If you and other counselors present your concerns to the employer’s HR department, the employer can confront the insurance company and at least get the authorizations and payments to you on a timely basis. It is more effective if the client is also willing to complain to the HR department, as the employer likes to have happy employees.

The second issue is the $40 per session reimbursement rate. That fee is very low. Our suggestion would be to advise the HR department that you cannot treat their employees at that rate. If the employer is unwilling to renegotiate a more competitive rate with the insurance company, you may want to resign as a provider for that insurance company. If you have a contract (managed care), make sure to follow the provisions in the termination clause (usually a letter notifying them of your intent to resign in 60 to 90 days).

Note to readers: Never underestimate the power of dealing with an employer’s HR department. In January, I had an old client who wanted to return to counseling with me. He had a new job and a different insurance company. He had Blue Cross Blue Shield of Kansas. However, he worked in Illinois where I am licensed. As a Blue Cross Blue Shield-approved provider in Illinois, we called to verify insurance coverage and were told Blue Cross Blue Shield of Kansas would not cover my services. After numerous “faxes” of my Illinois license and malpractice insurance with no response from Kansas, my client called his HR department (from my waiting room) to complain. “Mitz” in HR took on this problem personally, and she became bound and determined to get coverage for her employee. It took her only one “fax,” and now I am an approved provider with an ID number for Blue Cross Blue Shield of Kansas. Look for presentations on this and other private practice topics at the ACA Career Center at the ACA/CCA Convention in Montréal (for more information on the Career Center, see page 36).

Q: I am an LPC and RNC. I currently do not have a private practice. I am working in a counseling center for an LCSW. I am interested in combining energy medicine/psychology EFT with traditional therapy in my work with clients. Do I need to carry increased or special insurance? Do I get them to sign informed consent? I am working in New Jersey.

A: It would be best to ask whoever covers your professional liability insurance if they cover energy medicine/psychology EFT with traditional therapy. Generally, liability insurance covers most treatment modalities. If there are “hands-on” (massage or manipulation) activities, you may need to clarify that specifically with the insurer and the ACA Code of Ethics on the ACA website at www.counseling.org/ethics. Also, ACA endorses HPSO malpractice insurance (www.hpso.com), which is very comprehensive. As far as having the client sign an informed consent form, we strongly recommend you do so. An example of informed consent wording is at www.counseling.org (first click on “Counselors,” and then click on “Private Practice Pointers”)

Q: I have interviewed (for employment) with a medical clinic. They would like to hire me. However, the issue of LCPC (master’s degree licensed counselor) nonpayment for Medicare seems to be the roadblock. They seem to have a large percentage of Medicare clients, and they believe they would lose money hiring an LCPC. Help! This is my last effort to seek employment with this medical group. Do you have any ideas?

A: Medicare rules allow payment to LCPCs if they are employed by a psychiatrist under the “incident to” provision. (The following is taken directly from the policy of Medicare management, Wisconsin Physicians Service.)

“Incident to” services are defined as “services or supplies furnished as an integral although incidental part of the physician’s personal professional services” (MCM 2050.1). The “incident to” provision also applies to coverage for psychological services furnished “incident to” the professional services of nonphysician practitioners.

For the complete explanation, go to www.imhca.org/incident.

html. Also, we would advise checking the rules in your state and then presenting this information to the employer as reason to hire you. Good luck.

Q: I have had my own practice for the past five years. Recently a colleague received her MSW, and we are interested in creating a partnership. We are unsure how to go about establishing a partnership with my existing practice. Any information or suggestions you could provide would be helpful.

A: Without knowing how your solo practice is presently set up, we can’t say for sure, but let’s assume you are a sole proprietor (not a subchapter S or PC). The simplest and least expensive method is to set up a “joint venture” with your social worker partner. I have been in private practice with a licensed clinical social worker for 23 years and we have a joint venture.

As I understand it from my accountant, in this type of partnership you and your partner pool a set amount of money to pay for common/shared expenses. From this pool of funds, which are split 50/50, you pay items such as rent, phone, utilities, office help, etc. These expenses are reported on each of your taxes on schedule C. No other income or revenues generated by you or your new partner are comingled, thus each partner’s income is based on production (number of clients treated and fees collected) and not dependent on the other partner. As always, please consult your accountant. Good luck in your new venture.

Q: I am having a difficult time gaining access to managed care companies if a new client wishes to see me and I am not with the managed care company that handles the client’s mental health coverage.

A: We have developed the following strategy (we call it the “Three-Part Response”) to respond to denials by an insurance claim or refusal to allow a clinician to be a member of a managed care panel. For the most effective response, all letters should be sent.

1. A letter is sent from the client (after a release signed by the client) to the managed care or insurance company explaining why he or she wishes to see this particular licensed therapist. A copy is sent to the client’s benefits manager.

2. The clinician sends an appeal to both the client’s employer benefits manager and the managed care or insurance company outlining the clinician’s credentials and the reason why the client was referred to the clinician.

3. The clinician asks his or her state organization to develop a response to denials. This letter outlines the type of license, the training and the extent of practicum involved. This is sent to the client’s employer with a copy to the insurance or managed care company.

We’ve found this to be an effective way to respond to denials. The clinician is usually listed as an “ad hoc” provider with the assigned new provider number. Many times, the clinician is included in the managed care company’s database as a regular provider. More information, including examples of letters, is available on the American Counseling Association’s website (www.counseling.org). Click on “Counselors,” then “Private Practice Pointers,” then “Managed Care Response Templates.”

Editor’s note: The American Counseling Association has partnered with Robert J. Walsh and Norman C. Dasenbrook, authors of The Complete Guide to Private Practice for Mental Health Professionals (see www.counseling-privatepractice.com) to provide information on private practice issues. ACA members can e-mail their questions to walshgasp@aol.com.

In addition, ACA members can access a series of free bulletins on various private practice topics. From the ACA home page at www.counseling.org, click on “Counselors” and then click on “Private Practice Pointers.”