NASW Social Work Talks - EP35: Fighting Back Against Clawbacks

Episode Date: July 9, 2019

Clawbacks are when an insurance company requires a provider to return money they've been paid in the past. Clawbacks can occur months, or even years, after the service has been provided. Rebekah Gewirtz, MPA, Executive Director of NASW's Massachusetts Chapter, speaks with us about how her chapter is fighting against clawbacks in her state.

This is NASW Social Work Talks. I'm your host Aliyah Wright. Social workers are the largest group of mental health services providers in the United States. Many social workers who provide mental health services in private practice have experienced clawbacks. Clawbacks are when an insurance company requires a provider to return money they've been paid in the past. Clawbacks can occur months or even years after the service has been provided. These retroactive denials of health insurance claims make it difficult for social workers in private practice to know their true income. And they are leading some social workers to remove themselves from insurance panels, including

state Medicaid programs. This in turn hurts patients who need to use their insurance in order to afford mental health care. At least 24 states impose some limitations on the time an insurance company has to retroactively deny or adjust claims and to demand reimbursement from providers. In Massachusetts, there are no time limitations on clawbacks, at least not yet. Today we're speaking about this topic with Rebecca Gewirtz, Executive Director of NASW's Massachusetts Chapter.

Rebecca Gewirtz, Executive Director of NASW's Massachusetts Chapter Rebecca Gewirtz, Executive Director of NASW's Massachusetts Chapter Welcome, Rebecca. much for having me. So why are you interested in the issue of clawbacks? Clawbacks hurt social workers who are trying to help society's most vulnerable. This issue came to our attention a few years ago when we heard from clinicians and private practice in particular who were being audited and then clawed back for payments they had received from an insurance company. Perhaps one of the

biggest problems has to do with the fact that this involves mass health patients or Medicaid patients so some of society's most vulnerable patients are impacted in Massachusetts we have an opioid crisis right now where there is lack of access to providers who specialize in substance use disorder and we know that this is a time where we need to make sure we're expanding access as opposed to limiting access. CLAWBACS limit access. One example of a social worker member that contacted us about the problems he was experiencing with CLAWBACS, he is a social worker working in the city of Lynn, which is impacted significantly by the opioid crisis.

He provides substance use disorder services. He made about $25,000 last year, and he received a $3,000 clawback. He contacted us and told me that he really wasn't sure if he was going to be able to continue to practice. Wow. This is exactly the kind of thing we need to avoid. We need to be making it possible for social workers to do the work they're trained to do in the community, outside of the clinic, keeping people well. That is the role of social workers in a lot of cases. And when you have a practice that insurance companies can claw back payments that they already made to you any number of years back, like they can look back indefinitely, that creates a lack of consistency, a lack of many social workers end up feeling that they can't trust that a payment is an actual payment. They can't count on their income. And I don't know of another profession where those are the sort, you know, and I'm speaking about behavioral health in general, so there are other practitioners besides social workers, but where this is a reality, where you're paid, the service has been rendered, there's no question about medical necessity, and for any number of reasons, an insurance company can just decide to claw back without explanation. this seems really really unfair so the therapist provided the service insurance coverage was

verified and the therapist was paid only to be told after the fact that an error occurred these are errors that are not the therapist's fault so what's the Massachusetts chapter been doing about this well we've taken this issue very seriously we heard from our members through a listserv that we host, that there was a situation going on about a year and a half ago where one of the companies, one of the managed care companies that contracts with MassHealth was conducting an audit and was clawing back thousands and thousands of dollars from social workers. So we moved into action. We alerted our legislative allies that there were these clawbacks going on, that people didn't know why in many cases they were getting a clawback. They, in a lot of cases, didn't have

the resources to pay this claim back. They can't necessarily track down the person who paid the claim. And that's, a lot of social workers wouldn't want to do that anyway. A service was rendered, the insurance company paid the claim, and that's supposed to be the way it works, but it wasn't working that way. So again, we worked very hard. We were able to have some influence with MassHealth and they ultimately stopped this clawback situation. Can you explain to our listeners what MassHealth is? Yes. MassHealth is the state Medicaid program. In various different states, it has different names. And in Massachusetts, MassHealth equals Medicaid. So we were thrilled to be able to tell our members when the audits were being stopped.

And at the same time, we knew that this was not necessarily a permanent fix because it's still legal in Massachusetts for insurance companies to claw back payments going back any number of years. So we knew that we also needed to work on a parallel track of advancing legislation that would limit the insurance company's ability to claw back payments after a certain period of time had elapsed. So the bill that we're working on would limit both MassHealth and commercial health insurers to a 12-month period for recovering payments to a behavioral health provider, so social workers and others, for behavioral health services completed. It would also require the insurance companies provide a reason or a rationale when they do claw back within that window of time.

The way in which that helps is it provides some predictability. So social workers can know, okay, I've now passed this one-year period, and unless I've committed fraud, I should not expect a clawback, and it would be illegal for an insurance company to clawback payment. But right now, like I said, you know, a little earlier, insurance companies can go back indefinitely. So they might decide later, well, we're going to start clawing back for some infraction that was in fine print in the manual three years ago and take back thousands and thousands of dollars that they didn't, you know, claw back at the time, certainly, and that they paid out. these are claims that were paid out. We want that to stop. We need that to stop. We need consumers to be able to have access to behavioral health providers who accept insurance. And if insurance companies are going to employ practices like this, where they can go back indefinitely and take back money from providers, then providers aren't going to want to accept insurance. Listeners, we'll be right back. NASW Press is the leading scholarly press in the

Social Sciences. Our publications reach faculty, practitioners, agencies, and researchers in social work and related disciplines. Visit naswpress.org for scholarly books, reference works, brochures, and periodicals. And we're back. Rebecca, what can social workers expect if and when this bill passes? Well, social workers can expect more predictability. They can expect that when they when they are paid for a claim that that payment will stand there is going to be this period of time where the insurance companies can still look back but it is it is a limited period of time it is not indefinitely now callbacks are happening all over the country what can social workers in states without the time

limitations on clawbacks do if they experience this so the best thing a social worker can do is to contact their NASW chapter the people in the chapter offices are incredibly knowledgeable about these issues and what if one of our primary functions at NASW is to advocate for our members and to make practice possible both for them in their practice and for clients and communities so for consumers we know that we both need a workplace and workplace rules that are reasonable, and we need people to have, especially vulnerable people, but people across the board to have access to this important care that they need. So I would say organize. I would

say advocate, you know, with your NASW chapter, and I would say try to get more information about what's in law now in your state. We know that at least 24 other states impose some limitations on the time within which an insurer can retroactively deny and or adjust claims and demand reimbursement from providers. So that's a lot of states. And why is it important for NASW chapters to advocate for an end to this practice? Because this is where our members want and need us to be. They need us to be an advocate for them. They need us to be organizing with them, lifting up their voices, and making sure that decision makers, whether they be regulators, whether they be administration officials, whether they be legislators, are taking social workers

seriously and are addressing issues and needs as they arise. And we view that as really our primary purpose. Our primary purpose is to defend and advance social workers and the clients and communities that social workers serve. So I think this is an issue that if it happens in other states, it's a great issue for chapters to work on. Certainly here in Massachusetts, we are getting very close to getting this bill passed. And I think if it does get passed, it will be an enormous victory both for consumers to be able to have more access and for social workers to be able to practice. So do you think this is a winnable issue, and if so, why? I do think it's a winnable issue. I think it's from the conversations we've had with our

legislative allies and friends in the state house that people, legislators, just feel like this is an unfair practice. There should be rules. It should be that if you provide a service, You get paid for that service. It shouldn't be that sometime down the line, years later, someone turns around and says, just kidding, you know, or we're taking that back from you, or you didn't follow this rule that you should have at the time, or you didn't know that this person you were seeing was actually insured by somebody else. So we're taking it back. We don't think that's fair, and legislators don't think that's fair. And that's why there are more than 40 co-sponsors of the bill this particular legislative session. This issue, yeah, it's great. This issue was included in a health care omnibus bill last year that didn't quite make it over the finish line in the waning days of the legislative session. But this year, it's been moving much more quickly. In fact, it's advanced through two committees, and I anticipate it may be taken up in the House and the Senate this calendar year for passage. That's phenomenal.

So I feel really optimistic. Of course, I don't want to jinx it. You know, in legislation, you never can know definitively what's going to happen until it happens. But, you know, you do your best to talk to the people who do know about these things and people in leadership and the lead sponsors, and then sort of make determinations on what the likelihood is based on those conversations. Our lead sponsors on this bill are incredible. Representative Jim O'Day is our lead in the House, and he's a social worker from the central part of the state. He has been a fighter for social worker issues since he's been in office, and we're so lucky to have him. On the Senate, we've had two leads. We've had Senator Cindy Friedman, who is such a champion for issues of mental health and is so passionate about these issues, And Senator Michael Rodriggs, who's now the Senate Chairman of the Ways and Means Committee, and he has long been an ally of ours on these issues, and this issue in particular. So we're really lucky and fortunate in our lead sponsors, and fortunate that they have all taken this as a priority.

Rebecca, what else should people know about this problem? Well, I guess I would say you don't have to suffer this problem. You know that change is possible. that we can see problems like this in practice and working with NASW and other advocates and other advocacy groups together, we can change these things. I mean, seeing MassHealth put a stop to the audit or to the clawbacks really earlier this past year was really incredible. You know, it was such a wonderful statement that they made, that we are going to support our providers, we're going to support our practitioners, and we're not going to let these clawbacks continue in the absence of any firm understanding of why they're happening. And just sort of, I guess I would say randomly, because that's the way it has been.

We can make change. I have seen it. And I feel very optimistic that with the power of NASW, which is all these social workers joined together in common cause, you know, we can eradicate issues like this and make practice possible and access a true reality. Thank you, Rebecca. You're welcome. Thank you for having me on the show today. And thank you, listeners. We'll provide resources on this issue in our show notes. And if you like this episode, please be sure to leave us a review on iTunes. and to advance sound social policies. You can learn more at www.socialworkers.org. And don't forget to subscribe to NASW Social Work Talks

wherever you get your podcasts. Thanks again for joining us. We look forward to seeing you next episode.