Counseling Today, Private Practice in Counseling

More on the ’incident to’ provision

Robert J. Walsh and Norman C. Dasenbrook February 19, 2006

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")