Contracted Providers
4.
Private Health Insurance
–HMO’s, PPO’s, Affinity Plans
Becoming a Preferred Provider:
To have your massage therapy
services covered by an HMO or a PPO, you will need to become a provider with
that organization and follow the rules of that insurance company. Most states do
not recognize massage therapists as providers. Here in Washington State they do
allow massage therapists enacted by
the insurance commissioner, Debra Senn in 1996 called the “every category law”.
It requires all insurance companies to allow massage therapists to become
providers and requires insurance companies to pay for our services. Companies
fought this at first, but it was overturned and is now constantly being
challenged. I am not sure at this time what can be done to get massage
therapists to be accepted nationwide. As I discussed in the first chapter,
I also have some concerns as a profession about becoming part of the
health care system.
The rules and regulations vary
state to state and each company has various plans. In general, most require
that you have a referral/prescription from the Primary Care Physician (PCP) as
massage therapists are not allowed to diagnose conditions. Also you will find
that massage will only be covered when used for rehabilitative purposes (when
there is an injury or health problem). Relaxation /wellness massage not covered
at this time.
There are a few things to
consider when thinking about joining a PPO or HMO:
·
You usually will not be reimbursed for your full fees. The
insurance company determines what they will allow for massage therapy services.
For example: I charge $80 per hour of massage. One PPO I belong to will only
pay $59. When you are under contract with such an organization, you are not
allowed to bill the difference to the client. The PPO can change what they pay
at any time and you must accept that as final payment.
·
Each year they have been reducing the amount that they will allow
and are constantly making it more difficult to get paid. They also are
continually decreasing policy benefits for massage therapy services.
·
The insurance company determines which codes and services you may
provide. For example: The PPO I belong to at first allowed me to bill for using
hydrotherapy (ice or heat packs) and would allow me to bill for this service
separately (meaning I could make more money per session). They decided to not
allow this service, which decreased my income. Since I signed the contract with
them, I have no alternatives but to go along with what they decide.
·
Your work hours will be increased with the amount of paperwork and
phone calls you need to make to collect on the bills. You will often get
insurance companies denying payment if you fill out the form incorrectly and
they seem to lose the bills often.
On the other hand becoming a
member in such an organization will bring you a continual stream of clients.
You will get a listing in their provider directory. Potential clients will
often seek you out because you are close to their work or home and it will be
easy to get to your office. You may be working more, but it may be for less
money. Although this may assist you in building your practice, it is not
advised to base your practice solely on insurance income.
Here in Washington State, most
insurance companies providers lists are closed as they supposedly have too many
massage therapy providers..
To help you decide whether or not
you want to be on a provider list, figure our your
cost per client in the appendix section. Will joining this company
increase your income enough that your cost per client will decrease and your
profit increase? If you are not able to become a contracted provider (as
with most states except for WA and Fl), you can take some steps to make this
happen. (Discussion note: Do we really want that to happen? Read my challenge
to the profession…
Massage Magazine Nov/Dec. 2005
