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Issues and Ethics of Billing Insurance Companies

In Massage Therapy

By Julie Onofrio, LMP

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 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.

You can learn more about supervision in the massage profession at www.massagepracticebuilder.com

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.  You can purchase it at my sister site www.massagepracticebuilder.com separately of with a full membership.  

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.  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 or post your comments on the bulletin board at Community Bulletin Board.  I encourage everyone to start becoming more engaged in their practices and community.

Thanks for reading and participating in your (our) profession!

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