Issues and Ethics of Billing Insurance Companies
In Massage Therapy
Being able to bill insurance companies is a mixed blessing for the massage
profession. On one hand we want our work and our profession, to be recognized as
an integral part of health care. We want to be able to bill insurance companies
as a service to out clients. We want to provide additional income for our
businesses. We want successful and rewarding practices.
On the other hand, the insurance industry seems to have their own version of
what healing involves. Insurance companies will set limits on what you are paid,
set rules about how long and how many times you can treat and restrict you to
what services you can provide. Healing to insurance companies means
"working on and getting rid of symptoms" and "fixing"
clients. The main focus of insurance companies is to get the patient back to
work which may be different from our goals of getting the patient to a
"pain free" or healthy state. In other
words, they require that we
"fix" clients and require us to prove how we do that. They will only
pay when the situation is considered to be "medically
|
Participating in the profession is necessary
for it's advancement! We need you to
Share your comments,
feedback, opinions and
questions on the blogs
www.thebodyworker.com
|
necessary". They
often do not realize that massage can assist in preventing disease and injuries that
are due to high levels of stress that can be addressed through massage. Pain and
illness is often a message of a deeper issue that usually involves the body, the
mind and emotions and the spirit. Pain is a sign that the body is alive and is
needing something.
The latest findings of doctors John Sarnos (Healing Back
Pain) and Art Bernstein (Healing Back Pain Naturally) show that people may have
herniated discs, but they don’t necessarily all have pain. Both doctors ay
that emotions have more to do with pain than anything. What makes the difference
in who experiences pain? What causes pain? The Psychological Bulletin (Jan. 2204
A
Meta-Analysis of Massage Therapy Research.)
recently published a research study that found that massage effects the mind
more than the body. The insurance companies do not understand the value of the
therapeutic relationship that occurs between a massage therapist and the client
most likely because it can’t be measured or proven. They just want to know if
the clients’ symptoms have decreased and can they resume normal activity. They
do not care about whether a client is still in pain and they often assume that
pain is normal.
I also see many clients who will only get the appropriate care that they need
if the insurance will pay for it. I have had many clients who came regularly
when the insurance was paying and said they would continue after their benefits
ran out. Very few will continue and pay for what they need. They relinquish
their responsibility of healing to the insurance company. I often find that
clients who pay cash for their sessions rather than relying on insurance
companies often are more serious about their healing. People who rely on their
insurance company often seem to want
"someone to fix" them. (I also realize that this is a generalization
and there are many people who are seriously injured in MVA's and they are
serious about getting better. I am talking more about people who use their
personal health insurance. ) While there is nothing really wrong with that,
is it the direction we want to be going with our profession or in your practice?
In general, clients who pay for their sessions out of their own pocket are taking more
responsibility for their health and are more empowered by the process of massage
and healing. They believe in the power of massage and touch to heal themselves
and take responsibility for their pain. They value themselves enough to pay for
what they need. (That is not to say that all people who use their insurance
benefits do not have real pain or dysfunction or take massage for granted.)
I have also found that in general, people who are having their insurance
company pay are also the most likely to forget their appointment or cancel at
the last minute because they are not paying directly for the appointment. I also
tend to see more motor vehicle accident victims who tend to become creative in
describing the symptoms just so they can continue getting massage. Their
physicians continue to refer them for massage long after they are well to
inflate the bills to make the injury look worse than it was. The people who do
that may be thinking that they are going to get a big settlement from the
insurance company. Don’t get me wrong though. There are many who are hurt and
require treatment and are serious about it. It is just that people can abuse the
system quite easily.
There is also a very thin line between treatment massage and maintenance or
wellness massage. Often a client will continue on past their
"recovery", because the physician may continue to refer them or
because they just like the massage. When sessions become maintenance or wellness
massage, the insurance company is no longer responsible for paying for such
treatments. Knowing when and how to set boundaries is necessary to determine
when the line is crossed.
Accepting insurance is also an easy way to get new clients and build your
business. If you become a contracted insurance provider (only WA and FL allow
massage therapists to become contracted providers at this time), you will get
referrals automatically. That is one of the benefits of joining. When you start
working with motor vehicle accidents, you most likely will build a network of
referrals through the lawyers, chiropractors and other physicians who deal with
such injuries.
While this will be great for business, I believe that it takes something away
from the massage when the client doesn’t have to pay for the service. We get
away from really having to educate our clients, because we think that they will
come regularly when the insurance company is paying. I believe that if we as a
profession choose not to participate in the medical model and insurance
industry, we will force our profession into being more responsible for itself
and the clients who use our services. We will become truly a service business
and will gain a greater acceptance by the public, the legislative bodies and
ourselves.
Here in WA State we are able to become providers with companies like Regence
Blue Shield, Premera Blue Cross and Aetna. More and more insurance companies here in WA State are requiring us to prove
medical necessity. We are required to take a SOAP charting class in order to
learn how to chart functional outcomes (the functions that people can and can’t
do like sitting or standing). Massage must be shown to be necessary for their
improvement in function of a condition or injury. Insurance companies are
covering massage for acute conditions. They don’t want to pay for chronic
conditions and consider this to be palliative care or maintenance massage
(wellness massage). The insurance companies don’t care about reducing pain,
hypertonicities or what muscles we worked on. They don’t really care what we
do, as long as we show improvement in function and/or get the worker back to his
job, even if they still are in pain. Most often conditions don’t have any loss
of function and only have pain and stiffness, so this is often difficult to
prove.
|
Healing and health care, in my opinion requires a team of practitioners
who are willing to support the client in whatever may arise for them.
Healing is just not an absence of pain or injury. Healing is the process
of finding our already innate wholeness –body, mind, spirit wholeness.
Healing is becoming aware of who we are as physical body, an emotional
body, a spiritual body. It is waking up to the true sense of who we are.
It can’t be limited by insurance money. |
Here in Washington State, insurance companies are required by law to include
alternative therapies such as massage therapy in their benefits coverage. The insurance commissioner, Debra
Senn,
in 1996 enacted a law called the "every category law". The insurance
companies fought the law and were later over-ruled by the Supreme Court. Now the
only companies who don’t have to comply with it are those who are excluded
such as self-insured companies who are exempt from the insurance laws. We are
allowed to be providers for companies such as Aetna, Regence Blue Shield, and
Premera Blue Cross. I have been a provider for three years and have seen the
allowable fees reduced and the procedures that we are allowed to do change
(manual therapy, ice/heat packs, neuro-muscular education). They have recently
started denying payments and have discontinued service more and more. There are
also car insurance companies that are becoming members of groups such as
Alternare (that manage the alternative healthcare of the major providers.)
This means that we will have to accept being paid the provider rate on MVA
cases. This is usually less than my normal fee that I charge. It is only a
matter of time before other auto insurance providers start realizing that they
don't have to pay us our going rates and they will join such groups to limit the
amount that they have to pay out. On the
other hand, I have clients calling constantly from being on the provider lists.
In general, I am working more hours and being paid less. I am having to
deal with arguing with insurance companies to get paid. I am forced to
wait 2-6 weeks to get paid. I am forced to prove medical necessity (which
is ok, it they would tell me what their definition of medical necessity includes
as far as massage therapy).
It takes much more time and energy to deal with insurance companies and that is
reflected in having to raise my rates and charge everyone more.
Currently, WA and Fl massage therapists are able to become providers. I
believe more research is needed to determine if we (you) really want to be a
part of such networks. We seem to be just reacting and jumping right into
networks without considering what we really want to be doing.
One of the other issues that emerges when you start billing insurance
companies is what can you charge?
Massage therapists often get into the medical billing because they believe
they can make more money per session. While you can in general, the costs of
getting paid are also higher.
There is also much confusion in the industry as to what you can legally
charge for work that is considered "medical massage" or
"treatment massage".
What can we charge when we bill insurance companies? What can we charge
when we do "medical massage" or injury treatments?
I have asked this question to many of our leaders in this industry (Diana
Thompson, [Body_Work] Yahoo Group members, David Luther, Vivian Madison-Mahoney,
Ed Denning (massagecpt.com) and each time I get a different answer. We all
seem to have adapted our own defense system about what we want/can charge.
There doesn't seem to be one concise answer that is accepted by all. While
many think it is only a ethical issue, I believe that there is a legal issue in
this somewhere, but am unable to get a clear answer from anyone.
This in itself is worry some to me.
This is what I have come up with:
Massage Therapists have taken advantage of the fact that some insurance
companies like, automobile personal injury protection plans (PIP) will pay
higher than your usual fees. Just because you can charge more, doesn’t mean
you should. Your fees should be set according to what you do. You have to charge
the same amount for the same CPT code whether or not you are billing insurance
or not. For example: You charge $20.00 per unit of 97124 – therapeutic
massage. You have to charge this to insurance companies or cash paying clients.
Otherwise it is insurance fraud (Payer discrimination) and becomes a legal
issue. Some massage therapists have taken to charging more for the service
saying that there is much more paperwork and time involved in these cases and
that we have to wait for months for payment. They also say that the work they do
on injured clients is different from what they do (medical massage). I
personally treat all clients the same. I have never had a so-called
"relaxation massage" client come in without needing some specific
work. Do you automatically throw out all of your experience and knowledge that
you have in treating injuries when someone pays cash or wants a so-called
relaxation massage? They are also forming networks such as
www.simplecare.com
that say that they are giving cash clients a discount. All of these
"excuses", in my opinion are just making it more difficult for massage
therapists to get reimbursed for insurance claims. There are already legal
actions being taken against other professions to eliminate overpricing. It is
only a matter of time before the massage industry will have legal action taken
against pricing discrepancies. You are allowed to offer cash discounts to people
who pay for your services at the time of service. You are allowed to charge a
reasonable fee to cover your expenses that you pay a billing company to bill the
insurance companies. For example: you charge your cash clients, $70 per hour. An
insurance billing agency charges you 10% of that fee for billing the insurance
company and getting you paid. You can charge the insurance company $77 per hour
to cover your costs.
I have heard people who have been instructed to set their fees based on the
"Usual, Customary and Reasonable" (UCR) fee schedule that is
determined by Ingenix (www.ingenix.com). I also contacted Ingenix and asked them
how they compute their numbers and from whom do they gather the
statistics. They were very unclear about who they sample. I believe
they are reporting the correct prices, but I believe the prices are so high
mainly because massage therapists through the years have taken to raising their
prices BECAUSE the insurance companies will pay them. This creates a high
UCR that does not accurately represent the profession. I would wager that
most people they surveyed do not charge their cash clients the same amount. They
supposedly find out what companies are paying for massage therapy services in
your area. The UCR for Seattle is $132 per hour. While I have heard that
insurance has paid this amount to massage therapists, I have never heard of
people charging that to a cash client. That is what a UCR is – the same fee of
the same service needs to be charged to every client, regardless of who is
paying the bill. It is acceptable to charge different rates for different
services, but from what I have seen, massage therapists are using codes just
because they do allow a higher amount to be paid. Massage therapists are
charging more just because they can get it. (This is what I have seen in the
last 17 years that I have been practicing). I believe that the UCR fee charts
that the insurance industry uses, reflect the prices of what people charge just
because they can get it! When this happens, we are becoming a part of the
problem! When I hear of massage therapists doubling their rates for
"medical massage", I start to really wonder what it is really all
about. I have yet to have a client who is in for a so-called
"relaxation" massage, not have something medical that needs to be
addressed. Differentiating between medical massage and relaxation massage is
part of the issue. Isn’t all massage, medical? Relaxation massage can have as
many benefits as medical massage – and possibly even more.
There is also a new so-called movement in the massage profession to develop a
"medical massage" division. New organizations and companies are being
formed who are defining so called "medical massage". Who has the right
to determine what type of massage is "medial massage"? Isn’t all
touch medical (healing)? How is doing Swedish massage on a client when you
understand pathology not medical massage (even if you don’t know pathology)?
Who has the right to determine whether or not Swedish massage, Reiki or other
modalities such as Polarity therapy, Reflexology or Shiatsu are
"medical" or not? By creating a "medical massage" division,
I feel that it is further dividing our profession.
I have been doing so called "medical massage" since I began my
practice in 1989 after 250 hours of training. It doesn't really matter how
much training you have. It isn't going to really make a difference in
whether or not you are going to get paid. I have heard of massage
therapists submitting bills to insurance companies who they are not contracted
providers with and getting paid because they were able to prove that the massage
helped resolve the condition or injury and surgery or more invasive, expensive
therapy was avoided. All it really takes is being able to communicate what
you do.
The answer to the difficulties in what to charge is setting our fees based on
what we need to make and charging it to both cash and insurance companies.
Include in the fee, the costs of running your office, which include paperwork,
phone calls and bookkeeping. Set your fees based on your cost per client. People
say that cash clients won’t pay the higher fee. I believe this associated with
the way we value our work and our self.
There is no reason that you can not be charging what you need to make per
hour to be a successful business. We feel we must charge "the going
rate". The most successful therapists are the ones who do charge more than
the "going" rate because they value their work. You need to charge
what you need to make a living. Figure out what your expenses are and divide
that by the number of massages a week you do (or want to do) and that is what
you should be charging. (period.)
So I have personally found billing insurance companies to be a mixed
blessing. At times, it has increased my income but has also caused me many
headaches.
I feel that we may be selling our soul to the insurance companies and
influencing the future of the profession.
The way out of being a slave to insurance companies is through supervision.
Supervision is the process of looking at ourselves first to discover our own
wholeness and learn to stay aware of it as we work with others who are looking
for wholeness themselves. It is the process of becoming aware and staying alive
while others are in their story of pain. Our stories are where we have come from
and what builds our defenses and limits us. It is finding out what our stories
are so that we can know when our story is having us rather than knowing that we
are in our story. Building a community of peer supervision groups and seeking
out individual supervisors where we can share our stories and come to know our
stories better, are the key to getting away from managed care and building a
profession that is accepted by the public. It is the key to creating successful
practices – a practice that is financially rewarding, emotionally connected
and spiritually alive! You can build a successful practice without billing
insurance companies if you are willing to look do the work to build your ideal
practice.
I challenge the profession to do more research to determine whether or not
billing insurance companies where we want our profession to go. What will
becoming a part of the medical system do for us in the future? Will we someday
all be required to have a 4 year degree or advanced education? (like what has
happened with nurses?) Will more education protect the public or eliminate
prostitution? Will more education fill our practices and allow us to be
successful and feel rewarded by what we do? What will happen to all the great
healers who count more on their intuition more than on facts? Will there be more
regulations and licensing requirements? Will there be more divisions that will
further separate our profession? What will happen to us if health care becomes
socialized and we are forced into becoming a part of a system that will most
likely pay us less than we need and will limit our sessions even further? Will
more requirements be put on us to "FIX" our clients become trapped in
the cycle of co-dependence?
I don’t know the answer to these questions, but I would really like to see
our profession start looking at what we really want to be doing.
I do have some strong feelings and opinions about this whole insurance
billing issue. Even with that I do believe that when we work with
insurance companies with more integrity and respect for what we do, we will be
able to create a working relationship with those companies. I envision
being able to get paid what I am worth, in a timely manner and work with people
who don't want to take advantage of the system. With that in mind I have
created an insurance billing manual that will guide you through the steps of
billing insurance companies while being aware of the impact we are having when
doing so. While there are many other resources and classes on billing
insurance companies, most have different opinions and procedures outlined.
Since each state, city and even each insurance company varies in their
procedures, my billing manual provides you with the information and questions
you need to ask to start getting paid by insurance companies.
I also would like to start more dialogue on this issue and see what other
massage therapists in the US and other countries are experiencing. I am collecting
information on what other states allow. When we
can find a
common ground to work from we will be able to strengthen the
profession and the provide a forum for healing. You can email me
your comments.
Thanks for reading and participating in your
(our) profession!
Under the Microscope A Meta-Analysis of Massage Therapy Studies By
Shirley Vanderbilt
