permissible scope of practice for each profession may further affect the availability of mental health services. Each state, through its legislative process, generates statutes to regulate a broad range of professions and occupations, including core mental health professions. These laws typically specify the nature of the training required to enter the profession, including a specified number of hours of supervised clinical practice. Some statutes fall under the category of “title acts” that are designed to distinguish who can use a professional title such as “psychologist,” and can be somewhat vague about the specific functions of a profession. Other statutes, typically referred to as “practice acts,” provide a much more comprehensive delineation of the activities that fall within a particular profession’s scope of practice.
A recent federal report expressed concern about whether state licensure laws can be used to determine a professional’s scope of practice for payment purposes. In a study of Medicare coverage of services provided by non-physician practitioners the authors reported that “…State scopes of practice are broad and as a result provide little guidance that carriers can use to process claims. Most scopes of practice contain only a general statement about the responsibilities, education requirements, and a non-specific list of allowed duties…” (Office of Inspector General, Department of Health and Human Services, 2001, p. ii.). While this may be true for states where the statutes are primarily “title acts,” this is not true across all states. In addition, nearly every state has “Administrative Rules,” published by professional boards that are authorized by the states’ legislatures to clarify the intent of the statutes. These rules often have greater detail on the activities that fall within a professional’s domain. Finally, it is important to note that the OIG report primarily considered licensure statutes for physicians’ assistants, nurse practitioners, and clinical nurse specialists, and therefore cannot be considered as representing mental health provider statutes.
Within the framework of state scope of practice laws, both public and private insurers have adopted a variety of payment policies for services provided by different types of mental health professionals. For example, Medicare does not recognize marriage and family therapists or professional counselors, but does recognize licensed clinical social workers, Ph.D. psychologists, psychiatrists and psychiatric nurse practitioners. Unfortunately, only a small percentage of mental health practitioners in these latter professions choose to practice in rural areas. Since commercial insurers such as Blue Cross/Blue Shield often follow the lead of Medicare, the net effect is to give some master’s-prepared practitioners little incentive to practice in rural areas, even if they are willing. A practitioner who is unable to bill third party payers directly must work in an agency setting or under the auspices of a reimbursable provider and both arrangements are more easily met in more populous areas. In the absence of mental