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Contracted Providers
Please also check the
insurance billing manual updates and the
blog for more information.
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
Please also check the
insurance billing manual updates and the
blog for more information.
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