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One of my pet peeves in the massage profession has been this whole idea that medical massage is the future of the massage profession and that the massage profession should get involved with working with doctors and insurance companies as contracted providers. I am referring to working with HMO’s and PPO’s as a regular contracted provider and also some auto insurance companies who have joined networks. Medical Massage is not being defined by the massage profession itself so the insurance companies are doing it for us. Being in WA State where we are allowed to become contracted providers with insurance companies, I have been privileged to witness the demise of insurance billing in a few short years. This is what is happening here in WA and some reasons why we need to think twice about wanting to work with insurance companies.

1. The insurance companies are constantly reducing the allowable fee (what they pay you and that you accept when under contract with insurance companies.) When I first started in about 2000 accepting insurance one company paid me about $90 an hour which was a very acceptable rate. Within a few years they reduced that rate to less than $70 and it continued to be that same rate until this year when they gave us a $.40 raise - yes that is forty cents when the price of gas is sure to go over $4.00 a gallon.
2. The insurance companies are also constantly reducing their benefits in their policies with people. For example - one company who used to allow 45 sessions of massage and PT combined a year now only allows 14 sessions a year.
3. The insurance companies are constantly making it harder to get paid. One company in particular will ask that we prove medical necessity after 4-6 sessions of massage and then deny any further treatment no matter what it seems.
4. The insurance companies set the allowable fees and usually send out a rate chart in the beginning of the year or when you first contract with them. Although it hasn’t happened to me yet as a massage therapist, I have heard from a few chiropractors and an acupuncturist that they change their mind in the middle of the year and say they are paying too much and reduce the rates and MAKE YOU PAY BACK THE DIFFERENCE - yes I am yelling- and there is nothing that can be done except to pay them back or they will take it out of future payments. I do know of one Naturopath who almost went out of business because of it.
5. Out of network providers may often get paid more than in network providers- yes this is a fact too. There is one company doing just that. If you are out of network they only pay a percentage of the bill usually, but they pay contracted providers so poorly that even the percentage of the full bill which usually is about $132 (UCR) works out to be more than they pay contracted providers
6. One such health network includes a list of auto insurance companies who are using provider networks and rules to pay for services rendered. This means that you have to accept a reduced rate of pay.
7. Most of the companies have not increased their allowable fees since I started with them in 2000. So no raise for a contracted provider -not even to reflect a cost of living increase.
8. Insurance companies are also creating educational requirements for credentialing meaning they are saying what training and education is required to become a member with them. It doesn’t matter that we are licensed by the State Board of Health. The insurance profession is defining the massage profession.
9. Affinity networks are discount networks that some massage therapists unknowingly join thinking that they will get more clients not understanding that they are also taking a big cut in fees.

So does that make you still want to join a provider network and be able to bill insurance companies for your massage services?

See also the Insurance Billing Section on www.thebodyworker.com

2005 Guest editorial in Massage Magazine

Issues and Ethics in Billing Insurance Companies

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What is relaxation massage? What is Medical Massage? How is relaxation massage different from medical massage?

These questions are need to be answered by the massage profession now, because if we don’t start stepping up and defining ourselves - the insurance companies and individual state licensing acts will and are.

One of the reasons why this needs to be defined is that massage therapists are actually billing insurance companies and charging them more than their cash rates rationalizing by saying that what they are doing is medical massage. Since there is no definition of medical massage that reasoning will not mean anything in a court of law.

The thing about relaxation massage - is any massage ever really only a ‘relaxation’ massage? If you are doing a relaxation massage what do you do when you find a tight muscle or a triggerpoint? What do you do if the person says they have stiff neck from sitting at the computer all day? In 18 years of doing massage, I don’t think I ever did just a ‘relaxation’ massage. Do people at spas or resorts just do relaxation massage?

One of the things that the so called ‘medical massage’ group is trying to do is to separate what they do from someone who they are judging to be less qualified. Education and more hours of training does not necessarily make one more qualified although most of our society gets caught up in thinking so.

So called ‘relaxation’ massage does have it’s place in medical massage since most medical conditions can in one way or another be linked to stress. Eliminating relaxation massage from the medical equation would be a great disadvantage to the profession. We need more research to prove that there is a difference -if any- between relaxation massage and medical massage.

Relaxation massage as far as I understand is also basic Swedish massage. When you learn the benefits of Swedish massage the main things talk about the medical benefits - reduces blood pressure, increases circulation. increases range of motion,
What therapies would be included as being medical massage? What therapies would be excluded? Is medical massage just the ability to work with a physician and an insurance company?

In order to be paid by an insurance company one needs to be able to show improvement in a condition and be able to write medical chart notes that prove medical necessity. The sessions must show that they have outcomes in mind when doing the session. Anyone can learn to write chart notes that way. Hands Heal is a great book that will teach you all you need to know and more.
Other reading : www.thebodyworker.com

Medcial Massage - Marriage or Monster - by Deane Juhan Massage and Bodywork

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After attending a seminar put on by the AMTA WA and two attorneys John Pieck and John Conniff, I was shocked and awed with the amount of information and mis- information that is prevalent in the massage profession.

While they said that they would be putting out a book and creating a website with this information, I am posting my take on it here with the hope of creating discussions and awareness of these issues that face us as massage therapists. The big difference for massage therapists in WA State is that we are licensed as health care practitioners and have rules to follow under that category as well as our massage licensing requirements.

The main points of the seminar included:

• it it illegal to charge different clients different fees (no matter what you think might validate your reason for doing so, you have to be able to prove it)
• it is illegal to get paid a % when working for someone as it violated kickback laws
• it is illegal to talk about fees, talk about issues that may influence whether or not someone signs a contract with an insurance company and it is illegal to organize a group to fight insurance companies unless it is an association or union.
• When you sign a contract with an insurance company make sure you understand what you are responsible for. Read all of the contract, the addendum’s and other materials put out by the insurance company and make sure you have all of those papers - sometimes they don’t send these to you.
• doing business with insurance companies is a risk. Make sure you know what you are getting into and make an informed decision. I highly recommend taking this class by the attorneys at Peick and Conniff that is offered occasionally through AMTA WA.

Resources from Peick and Conniff:

Discounting fees for health care services - newsletter

Am I an Independent Contractor or Employee?

Provider Agreement Analysis Sheet

Business side of caring

Laws and Statuates:

Insurance Fraud : RCW 48.80.030

Federal Fraud and abuse lawsÂ

HIPAA Fraud : 42 USC 1320a-7c
False Claims 31 USC 3729

False Statements: 18 USC 1035

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Medical massage is already being defined by insurance companies. If we don’t step up and define it someone else will do it for us. It is evident in the laws too regarding massage therapy as I see from the research I have been doing for my site www.massagetherapycareers.com.
This is from an application form from American Whole Health Network credentialing application for therapists in WA State.
“Clinical Massage Practitioner Application”

Application Checklist for
Clinical Massage Practitioner

Applicants may qualify as a Clinical Massage Practitioner, with the
following documentation:
X Valid State or local license as Massage Therapist/Practitioner
X Entry level certification by the National Certification Board for
Therapeutic Massage and Bodywork, or
equivalent State Exam *
X Attestation to at least 60 hours of documented continuing education
course work in massage in past 4 years
X Copy of certificate of completion of at least one advanced massage
training program of 25 contact hours or
more
X Documentation of at least two calendar years in active clinical
practice
X Two Professional Reference Evaluations from health professionals
attesting to personal and clinical practice
characteristics, at least one of which must be from a referring or
supervising MD, DO, DC, PT, RN or from
an AWHN credentialed clinical massage practitioner who has supervised
your practice.
PLUS
X Certification by a recognized national advanced clinical massage
certification exam
OR
X Documentation of supervised contact hours** performing clinical
massage
500 contact hours required for applicants with only a basic 500-hour
massage education
OR
250 contact hours required for applicants with 1000 hour basic
massage education that includes clinical assessment,
clinical pathology, and clinical charting,
OR
Postgraduate clinical training equivalent to 250 contact hours after
their basic 500-hour education
With submission of verification documents for any postgraduate
course, fellowship, preceptorship, or
clinically supervised practice
Please submit the following materials (obtain the forms at
www.wholehealthpro.com):
X Completed AWHN network covered benefit and discount contract with
signed agreement to business and financial
contract terms. If you are employed by an institution or group, your
employer must contract for you as an associate.
X Completed AWHN credentialing or recredentialing application for
clinical massage, this includes your online profile
listing for the AWHN web directories***
X Applicable credentialing fee
X Copy of your Published Fee Schedule
X Copy of your current professional liability (malpractice) policy
face sheet
(At least $200/500,000 limits are required, GHC contracted
practitioners must have 1Million/3Million)
X Copy of your current unrestricted state license and/or NCBTMB
certificate
X Copy of the AWHN Attestation for Specialty Training and Experience
form with supporting documents
X Send the Professional Reference Evaluation forms to your
professional references to submit directly to AWHN, note
the names of the professional references on your credentialing
application
* States with equivalent exams:
AL,AK,CT,DE,DC,FL,IL,IA,KY,LA,ME,MD,MS,MO,NE,NH,NJ,NM,NC,OR,RI,SC,TN,
UT,VA,WV,WA,WI
** Supervised clinical experience means a) session hours treating
persons presenting with clinical problems in a setting
involving some combination of assessment, treatment planning,
documentation of status and progress notes, and b) the
availability of mentoring and clinical supervision by one or more
experienced massage, physical therapy, medical, or
chiropractic practitioners. Can include practice sessions during
advanced training or preceptorship/apprentice programs.
Documentation includes affidavit by practitioner and/or statement of
completion by employer/supervisor/referring
practitioner.
***If you are listing other professional health services outside of
the scope of massage practice, you must have an AWHN
contract covering the licensed profession involved and meet AWHN
credentialing standards.
Please call the AWHN Network Development office if you have other
questions or need assistance in the
application process.

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After attending a seminar on doing business with third party payers (insurance companies) I have become inspired to start searching for answers for the profession.

What is going on is that for the most part we are all uninformed as to what we are responsible for in doing business with the insurance companies. The contracts are so complex and not easily understood that we need an attorney to decipher the details. Without being properly informed the risk of committing insurance fraud is such a great risk. Insurance fraud is a Class C felony punishable by 5 years in prison and $5000 fine for each count not to mention the cost of hiring an attorney to defend yourself.

In that seminar I also learned that the only way to be able to work with these companies to make changes is to work through an association or union. While we do have a few associations, they are not strong enough or united enough to provide the support and knowledge that we need to be efficiently informed particularly when doing business with insurance companies.

What needs to happen from what I see right now is that we need to define medical massage and define it so that all types of massage therapy are included - reiki, polarity, structural integration, trager, swedish massage, reflexology, shiatsu, acupressure, therapeutic touch…every single type of modality has it’s place in medical massage.

I have thought at various times that we needed a type of organization to do just that and I myself do not know much about what it takes to create such an organization. But from what I have just learned we are powerless without it and the insurance companies will continue to walk all over us.

The other part of this has to do with a massage therapists ability to build a cash practice and how the insurance companies make us “fix” people and ignore healing. It also has to do with how we value ourselves as individuals and as profession. Are massage therapists turning to insurance companies when they can’t make a sustainable living with cash clients? What will it take to educate the public about the benefits of massage enough so that they understand that they have to take responsibility for their health and leaving it up to insurance companies who’s sole reason for being is to make a profit?

I don’t know the answers to these issues but the one thing is that we need to start thinking about these things and set aside our excuses and differences and decide what it is that we want for massage as a profession.

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