Practice issues examined

By Catherine Robertson Souter
March 1st, 2014

For many psychologists, the issues that come up outside the therapy room are the ones that cause the most stress. From dealing with insurance regulations to communicating with patients beyond scheduled session times to understanding laws of inter-state commerce, practicing psychologists need to keep abreast of issues that could seriously impact their business.

In this article, we address a few of the concerns that have been brought recently to our attention:

Email communications

The prevalence of email has opened up new channels for communicating with clients, but it has also brought up a multitude of privacy concerns. Does email comply with the Health Insurance Portability and Accountability Act of 1996? What restrictions should be put around how it will be used?

According to Eric Harris, Ed.D., J.D., legal counsel to the Massachusetts Psychological Association, the main problem with email is the fact that it is not entirely private. While the therapist is bound by HIPAA rules, that third party is not.

“When you send an email, four people get copies of it: you, your internet service provider or ISP, your client, and your client’s ISP,” he says. “While you are bound by HIPAA rules, the ISP is not and would surrender any information if they were subpoenaed, by NSA, for instance.”

You could get around the issue by using an encryption system that you designed and then getting the code to the client privately, all of which is rather complicated, he explains. He does not recommend using a service for encrypted emails since the ISP would still have a copy.

“Especially if it is their encryption program,” he says.

Instead, Harris recommends setting written rules around how you will communicate via email, for instance only for appointment setting and then asking the client to sign a release form would cover this form of communication.

“An informed consent policy can be whatever you want it to be, he says. “It could even be possible to do therapy via email. But, from a risk management standpoint, what we recommend is to use email for non-clinical information only. You don’t want to encourage clients to communicate therapeutic information between sessions.”


Some see telepsychology as the future of therapy. Defined as the use of both auditory and visual equipment to provide therapy, telepsychology could become widespread as technology improves. It is being promoted as a cure for issues of uneven access to mental health care.

“The federal government has been pushing telepsychology because they believe that this is one of the primary ways that the misdistribution of medical resources can be addressed,” says Harris, who currently serves on the APA/ASPPB/Trust Joint Task Force on the Development of Telepsychology Guidelines for Psychologists.

The main concerns include whether long-distance therapy will be covered by insurance and how it will work across state, or even national, borders.

“There are 16 or 17 states who have passed legislation regarding insurance reimbursing intra-state telepsychology,” Harris says.

Inter-state issues have yet to be resolved anywhere. If a therapist and client are not located in the same state, which state’s licensing board would have jurisdiction?

“Licensing requirements vary state to state,” says Michael Goldberg, Ph.D., acting director of professional affairs for the MPA. “The Massachusetts Board of Registration of Psychology has stated that they consider that the practice of psychology takes place both where the psychologist is located and where the client is located. Thus, psychologists providing services to clients located in Massachusetts must be licensed in Massachusetts and psychologists in Massachusetts must be licensed in the state in which their client is located.”

The need to be licensed in both places would keep telepsychology from spreading widely since most psychologists could not be expected to be licensed in all 50 states.

It is a situation that has no easy answer but Harris believes that some compromise will need to be reached quickly.

“All of the licensing boards are trying to figure out how,” says Harris, “because the federal government has said that if ‘you don’t figure it out, we will make a federal licensing board.’”

Medicare Form CMS-1500

A revised version of the CMS 1500 claim form, created by the National Uniform Claims Committee (NUCC), was released earlier this year and has caused some confusion for local therapists.

Developed and maintained by the NUCC, the form is used by both federal payer programs (Medicare, TriCare, etc.) and by some private insurers when a paper claim form is allowed.

The form was updated to bring it into line with changes in the electronic forms and with ICD-10 reporting. As of April 1, only this version of the form will be accepted.

The problem, for some, has come when their forms have been rejected even before the April 1 cutoff. An issue with a new Optical Character Recognition system has slowed down processing and the new system will reject any claims not filled out exactly as outlined in their guidelines, which includes font, pica size and ink color. The new forms cannot be handwritten.

For more information on the forms and the guidelines on filling them out correctly, visit (click on “Resources,” “Tools and Materials” and “CMS-1500 Claim Form”).

MassHealth CarePlus

As of January 1, when the Affordable Care Act went into effect, certain Massachusetts residents found themselves switched to a new healthcare plan. In some cases, those residents, some who had previously been enrolled in various MassHealth plans, were not aware that they would be moved to a new plan and the change caused confusion for both the covered and for practitioners who work with them.

According to Julie Kaviar, deputy communications director for the Massachusetts Executive Office of Health and Human Services, the ACA mandated an expansion of the MassHealth program to offer new coverage to those whose income is at or below 133 percent of the federal poverty level. The expansion has affected approximately 300,000 people in the state, some who had not previously been covered by insurance and others whose previous insurance did not meet all the federal standards.

The new plan, MassHealth CarePlus, will take the place of Commonwealth Care. Some of those members were transitioned to a new plan, CarePlus, and others qualified for assistance to help pay for private health plans.

About 80 percent of MassHealth members were not affected at all. Those who were had been notified before the January deadline. Once they were assigned a plan, they received a welcome packet and confirmation letter.

“So, they received two additional notifications,” Kaviar says. “But our lives are busy and health care is confusing. If they did not choose a plan by January 1, to make sure that people have coverage, we assigned them to a plan based on their geographic location.”

Unlike traditional plans, the six plans offered through CarePlus have a monthly enrollment. Members can switch their plan at any time, with a first-of-the-month start date.

Concerns about the availability of practitioners in each market should not keep a member from staying with his current medical team, she adds. If one plan does not include a practitioner, another should, or the practitioner can approach the insurance companies to join.

“When we chose these six plans, in addition to meeting standards of care we made sure they had choices of providers in all geographic areas. Every location has to have at least two providers, if not more,” adds Kaviar.

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