Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
Yes I was surprised also that at least 5 different people at Medicare did not know the rule and also that they advised me to appeal. I spoke to them over a 3 week period and not one of them knew, and said they needed to research further.
I am not sure I agree that section 160 in the CMS manual states that the words AND apply here, however, I will concede that the potential outcome does not look good. My Psychologist is NOT aware of the Medicare rules as he is not currently a Medicare provider.
I am looking for another Psychologist, but this type of thing does not happen overnight. In the meantime, I am taking advantage of my appeal rights. Anyway, thanks for your response and the links.
Last edited by jzeig104; 06-22-2014 at 11:58 AM..
Reason: because
Yes, I think it's terrible that Social Workers who have Masters degrees are okay but Masters Level Psychologists are not. I have made a few calls this week and no "hits" yet. One guy called back but later I learned he had terrible online reviews. Another one never called back. Hopefully my therapist will have some recommendations. My psychiatrist did not. The insurance company mailed me a list, but they are all big clinics and I prefer small, independent practitioners. This is going to be a real challenge. Anyone ever heard of this type of denial before?
Well, if you think about it, clinical psychologists provide healthcare services ( mental health), while social workers provide social services ( like information or referrals for housing, healthcare practitioners, Medicaid or other assistance programs). A social worker will assess a client's needs for services and refer the client to where he/she can have those needs met.
Yes travelassie, except that under Medicare, CSW's are authorized to provide mental health services, not social services. That's the rub, IMO. Not fair.
Yes travelassie, except that under Medicare, CSW's are authorized to provide mental health services, not social services. That's the rub, IMO. Not fair.
I didn't realize that. Now that you mention it, if Medicare pays for MSW's to provide mental health services, it doesn't seem fair that they insist that clinical psychologists have PhD's, so I see what you mean.
Not sure CMS would see it that way- from all indications they pass those regulations, and expect no questions and blind obedience, even for regs that don't make any sense. But good luck!
Yes travelassie, except that under Medicare, CSW's are authorized to provide mental health services, not social services. That's the rub, IMO. Not fair.
It's very fair, since LCSWs are not only trained to do the systems work, we are also trained to do clinical therapeutic work. Many people think we are all CPS workers-we're not. I trained long and hard to be a clinician. The feds know that. That's why we qualify to bill Medicare. We can do therapy, referral, and advocacy as well.
You have a couple of options. I am somewhat familiar with insurance, am on Medicare, and have seen a LMSW for therapy sessions, as well as a psychiatrist for years who does not take my insurance. But my psychiatrist is so wonderful I am not going to see anyone else. She gives me a cash pay discount so I can afford to see her. My LMSW used to take my insurance, but when I switched to a different plan, she is not on it. She also gives me me a cash pay discount for being a current patient. You might ask about that. Also, almost every patient who appeals something to the insurance company wins. It's just a thing the insurance company does in an attempt to discourage the patient from trying to get them to pay something. Unfortunately, it usually works, because the patient automatically assumes they won't win a battle against the insurance company.
I don't accept the word "No" from these clowns. I am on an expensive migraine medicine that is not covered by my insurance company's formulary. The company wanted to put me on a crappy generic medicine that doesn't work as well for me instead. So I called them and told them their job is to cover me, not to not cover me. After a few phone calls and gripe sessions, they said yes, and now pay all but $85/month of my $500+/month medication. I have done this for a few other things, a glasses and a tetanus shot among them. You just have to be persistent and nip at their heels, like a little Chihuahua dog. Good luck!
Uncertain if this applies in your case, but just for the info, in many states a psychologist cannot be licensed (or even call themselves a psychologist) without a PhD. Because this is a difficult route, many masters degree level grads opt to take the Marriage and Family Therapist (MFT) licensing exam. Some patients do not even understand that the 'psychologist' they are seeing is licensed in this (totally legal) way. BUT, Medicare does not pay for MFT's.
It's very fair, since LCSWs are not only trained to do the systems work, we are also trained to do clinical therapeutic work. Many people think we are all CPS workers-we're not. I trained long and hard to be a clinician. The feds know that. That's why we qualify to bill Medicare. We can do therapy, referral, and advocacy as well.
Um, no, what is not fair is that Masters Level Social Workers can bill Medicare but Masters Level Psychologists cannot. I am not begrudging you that you can bill Medicare. I am begrudging that MA Licensed Psychologists, who have just as much training as you, cannot.
You have a couple of options. I am somewhat familiar with insurance, am on Medicare, and have seen a LMSW for therapy sessions, as well as a psychiatrist for years who does not take my insurance. But my psychiatrist is so wonderful I am not going to see anyone else. She gives me a cash pay discount so I can afford to see her. My LMSW used to take my insurance, but when I switched to a different plan, she is not on it. She also gives me me a cash pay discount for being a current patient. You might ask about that. Also, almost every patient who appeals something to the insurance company wins. It's just a thing the insurance company does in an attempt to discourage the patient from trying to get them to pay something. Unfortunately, it usually works, because the patient automatically assumes they won't win a battle against the insurance company.
I don't accept the word "No" from these clowns. I am on an expensive migraine medicine that is not covered by my insurance company's formulary. The company wanted to put me on a crappy generic medicine that doesn't work as well for me instead. So I called them and told them their job is to cover me, not to not cover me. After a few phone calls and gripe sessions, they said yes, and now pay all but $85/month of my $500+/month medication. I have done this for a few other things, a glasses and a tetanus shot among them. You just have to be persistent and nip at their heels, like a little Chihuahua dog. Good luck!
Thanks Scooby. I can't afford to pay cash. I am on very limited $, otherwise I would do that with my current therapist. I have "asserted myself" regarding medications brand/vs/generic also before. It does pay to persist.
Although I appealed the denial of my therapist, I am not optimistic. Very unhappy so far with this Medicare Advantage Plan.
Update: Did some reading. I just learned that ALL insurance plans after 2010 are to provide the opportunity and the instructions for a patient to appeal denial of services/payment as part of health reform. It's law now.
It used to be that way a number of years ago, too. Unfortunately, I could only document and forward the medicare appeals. If it was an in-house BC/BS appeal, I had a bit more leverage. I could send email or call the department. I wasn't authorized to visit the claims department on the third floor, so I would just follow someone into the elevator and visit when I had a big problem. While there were a few good, hardworking people in that department, most of them were useless. They would lose, dump claims and appeals quite often. I don't think that they can get away with that nonsense any longer.
Keep good notes. Write down names, dates, time of day and keep copies. I just, finally, got Verison to stop billing me hundreds of dollars I didn't owe them. It took five months. I had names, dates and good notes.
Please register to post and access all features of our very popular forum. It is free and quick. Over $68,000 in prizes has already been given out to active posters on our forum. Additional giveaways are planned.
Detailed information about all U.S. cities, counties, and zip codes on our site: City-data.com.
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
Anyone ever heard of this type of denial before?
