Insurance Billing in Washington State

Guest post by Julie Onofrio, LMP

WA State massage therapists have had the luxury of billing health insurance companies for massage services since January 1999, when the US Supreme Court made the last decision in the long battle for insurance reform in WA State. This final fight was over the the Every Category of Provider Law that was mandated in 1993 by then insurance commissioner, Deborah Senn. Senn, along with the Clinician Workgroup on the Integration of CAM, filed a report in 2000 to help create a working relationship between health insurance companies and providers.

WA massage therapists are able to become contracted providers with all health insurance companies in the state after they apply to and pass a credentialing process. In exchange for being listed as a covered provider on the insurance’s website, therapists must agree to the fees set by the company, as well as agreeing to perform insurance massage only when it’s medically necessary.

An example of a Medical Necessity clause:

Massage therapy is considered medically necessary as adjunctive treatment to another therapeutic procedure on the same day, which is designed to restore muscle function, reduce edema, improve joint motion, or for relief of muscle spasm. Massage therapy is not considered medically necessary for prolonged periods and should be limited to the initial or acute phase of an injury or illness (i.e., an initial 2-week period).” [source]

Each plan varies in its definition of medical necessity, but in general a massage therapist can work on patients who have a current prescription, diagnosis, and treatment plan from the doctor. Insurance does not cover maintenance massage or palliative care. Large companies that are self-insured are exempt from this mandate.

The one major problem now is that many of the insurance companies have closed their provider lists – massage therapists cannot apply to become credentialed providers anymore. The companies say that they have too many massage therapists in each area of the state and can’t take any more.

In the early years after the Every Category law was enacted, many insurance companies paid their therapists very well – sometimes over $90 for an hour session. Through the years, though, the insurance companies have reduced their allowable fees and benefits. Doctors will refer patients for things like back and neck pain, hip pain, arm and shoulder pain, and many other conditions such as fibromyalgia and headaches, and these are covered by insurance. However, most insurance will not cover conditions such as anxiety and depression, even though there is compelling research showing that massage is one of the best options for these conditions. [source]

When Deborah Seen spoke at a convention I attended, one of the things she said was that, in the beginning, insurance companies did not understand that adding massage therapy to policies would decrease their overall expenses. For example, insurance companies thought that they would have to pay $10,000 for carpal tunnel surgery plus another $1,000 for massage services. They did not realize that, in many cases, massage therapy would eliminate the need for surgery entirely.

Today everything is done online. We bill insurance through programs such as Office Ally, which is free for providers. Insurance company websites and portals (such as One Health Port) make checking benefits, billing, and getting paid so much easier. The turnaround time for payment is generally only one to four weeks. We don’t usually have to send chart notes to companies, but we do need to keep SOAP charts on clients and have the prescriptions on file in case they are requested.

With the passing of the Affordable Care Act, the WA State insurance commissioner is creating a health exchange network that may or may not include massage. AMTA WA is watching this closely to make sure the Every Category law is preserved. In an effort to keep massage therapy covered, AMTA WA, along with Diana Thompson (former president of the Massage Therapy Foundation) and others, published a paper on the medical benefits and research findings of massage therapy. View the PDF here.

We don’t yet know how the ACA will affect the hard-won rights of Washington massage therapists, but we hope it will make things better both for us and for those therapists in rest of the country.

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Insurance Credentialing and Beyond

Even though the Affordable Care Act has not been rolled out in its full form, licensed massage therapists in most states are already able to take some kind of insurance, be it health insurance, PIP (personal injury protection), or both. If you don’t yet take insurance, but you want to when the insurance expansion begins, why not start now?

I’m going to provide the details and resources you’ll need to get credentialed with the insurance companies, bill insurance successfully, and keep track of payments and dues. I’ll tell you about CPT codes and how insurance companies like to obfuscate whether they actually provide massage coverage. I’ll walk you through the different ways you can set up your practice to best handle insurance billing and collecting payment.

It won’t just be me jabbering at you endlessly with tons and tons of details. There will be graphics! Links! At least one video! Stay tuned.

And if you already take insurance, there will still be new and exciting content related to your interests. Information about what IHPC is doing in congress, how the ACA will affect your already-thriving practice, more discussion about accepting CAM providers as legitimate medical professionals, and so much more!

Oh, and have I mention that there’s an awesome survey that you should fill out? Make your voices heard!

LMT Interview – J. Lindsay

Name: Jen Lindsay

Name of your practice: Jen Lindsay LMP

Location: Kent, WA

Number of LMTs working there:

How long have you been massaging? just over 1 year

How long have you taken insurance? About 1 year

What type(s) of massage do you do? Swedish, deep tissue, trigger point

What’s your favorite part about taking insurance? It allows more people to experience massage therapy, as many of those who take advantage of their insurance benefits could otherwise not afford to get massages with any sort of regularity.

What’s your least favorite part about taking insurance? It sometimes takes a very long time to get paid. For example, I treated someone back in November, and I have yet to be paid for it by her insurance company (it is now February…they keep saying that the check is in the mail).

What do you hope the new ACA laws will accomplish? I hope it will allow more people to take advantage of more treatment options for their ailments, such as massage therapy.

What would you say to an LMT who is interested in taking insurance? Make sure you have enough cash clients to allow you to stay afloat while waiting for insurance payments, especially when you are just starting out.

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Are you also an LMT who takes insurance? Answer the survey here!

LMT Interview – A. Burnell

Name: April Burnell

Name of your practice: Jefferson Massage

Location: Charles Town, WV

Number of LMTs working there: 1

How long have you been massaging? 11 yrs

How long have you taken insurance? 6 months

What type(s) of massage do you do? myofascial release, lymph drainage, trigger point, deep tissue, prenatal, reflexology

What’s your favorite part about taking insurance? steady income from repeat visits

What’s your least favorite part about taking insurance? Have to wait several weeks for payment and don’t always get paid if you’re not extremely careful about which cases you take and how you file the claims.

What do you hope the new ACA laws will accomplish? Allow more people access to insurance coverage thus bringing me more patients and more steady income. No so much hassle filing claims and quicker turnaround on payments.

What would you say to an LMT who is interested in taking insurance? It can be worth it if you don’t mind spending extra time on paper work and waiting for your money.

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Are you also an LMT who takes insurance? Answer the survey here!

LMT Interview – J. Onofrio

Name: Julie Onofrio

Name of your practice: City Center Massage

Location: Seattle, WA

Number of LMTs working there: 3

How long have you been massaging? 25 years

How long have you taken insurance? 25 years for workers comp/car accidents, 12 years for health insurance.

What type(s) of massage do you do? deep tissue, triggerpoint therapy, structural integration

What’s your favorite part about taking insurance? It brings some consistency to my practice because people will come in for treatments when they are hurt and insurance is paying. It helps when the economy drops. They come regularly until they are better.

What’s your least favorite part about taking insurance? Not having enough support and a cohesive group to be able to stand up to insurance companies and demand higher pay and demand to have them open their networks.

What do you hope the new ACA laws will accomplish? We just hope that we will be able to continue billing. It is up in the air right now. I think it will also make companies that are self insured (who are now exempt from having to include massage in their benefits) have to pay us.

What would you say to an LMT who is interested in taking insurance? Just take a few clients at a time and learn the ropes. You will eventually be able to learn which cases to take and which cases not to take. Dealing with insurance companies, doctors and clients will challenge your boundaries more than anything so be sure to get the support you need.

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Are you also an LMT who takes insurance? Answer the survey here!

Research in Washington State

This is part of a larger article I wrote several years ago on the Affordable Care Act. Read the whole thing here.

Beginning in 1996, the state of Washington mandated that private insurance companies must cover every category of health care provider given that the provider is giving treatment for a basic service that he or she is licensed for. In short, that means CAM providers in the state of Washington are covered under private insurance policies in the same way that conventional providers are covered. A visit to an acupuncturist, for example, would be available as readily as a visit to a medical doctor.

From the mandate:

“(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall:
(a) Permit every category of health care provider to provide health services or care for conditions included in the basic health plan services to the extent that:
(i) The provision of such health services or care is within the health care providers’ permitted scope of practice; and
(ii) The providers agree to abide by standards related to:
(A) Provision, utilization review, and cost containment of health services;
(B) Management and administrative procedures; and
(C) Provision of cost-effective and clinically efficacious health services.” [source]

This wouldn’t mean that everyone in Washington would start getting CAM treatments, but it would mean that those who did utilize CAM weren’t just those who could afford to pay out-of-pocket. Recently, researchers took a look at two years worth of claims to see if patients who did and did not use CAM treatments differed in total medical expenses. Read the full analysis here.

Because most CAM research relies on self-reported data (ie, whether the patient feels better after a treatment), these studies often have an inherent bias. Whether or not CAM treatments provide tangible evidence of being effective, they often lead to a general sense of well-being. While the interaction between mental and physical health cannot be denied, this was not what researchers wanted to study. Rather, this study took a “cost-minimization approach” in order to find out whether CAM users differed from nonusers in their medical costs.

In an analysis of insurance expenditures for matched groups of CAM users and CAM nonusers, it was found that CAM users had significantly lower overall expenditures. Specifically, while they did have a slightly higher expenditure for outpatient visits (including massage appointments, chiropractic adjustments, etc, which the other group – by definition – did not utilize), inpatient expenditures and other expenditures (imaging, lab work, etc) were significantly lower. It was found that CAM users were less likely to be hospitalized, less likely to get a hysterectomy within one year of diagnosis, and more likely to have some type of imaging done and done early. Although having more imaging done should seemingly be more expensive, the imaging was typically of a less expensive variety. And because the imaging was done early, it had the benefit of being a preventative measure.

Researchers predicted that, given the findings, CAM users would save an enormous amount of money:

“Given the expected $356 lower expenditures for each CAM user, we would expect an overall $9.4 million lower expenditure in a group of 26,466 CAM patients with these medical conditions compared to a similar group of CAM nonusers of equal size.”

For some analyses, subjects were divided into three levels of “disease burden”, which created groups based on their expected resource use. The low disease burden group were generally healthy individuals, high disease burden group were generally unhealthy individuals, and the medium disease burden group was in between these two. When divided in this way, CAM users in the low and medium groups had higher overall expenditures than CAM nonusers – they had more outpatient visits to CAM providers, and neither group had many inpatient visits or labs. But in the high disease burden group, CAM users had significantly lower expenditures than nonusers, which more than made up for the higher expenses of the healthier groups. CAM was used for preventative care by the high risk group, just like in the other groups, but it was also the less expensive way to treat acute problems.

What should we take away from this study? First of all, it means that insurance companies are currently doing things exactly backwards. When they limit CAM coverage to those who are already healthy or those who can afford to pay extra, they lose money. Insurance companies should be begging their less healthy clients to utilize CAM treatments for both acute issues and preventative care.

We’ll be hearing from some LMTs in Washington later on to see how these laws affect the providers on a day-to-day level. I’ll also be interviewing Deborah Senn, JD, the architect of the Washington law, who is now working with IHPC for the implementation of Section 2706 of the Affordable Care Act.

LMT Interview – V. Madison-Mahoney

Name: Vivian Madison-Mahoney

Name of your practice: Advanced Health Care of PBC

Location: Gatlinburg, TN and Lantana, FL.

Number of LMTs working there: Just myself.

How long have you been massaging? 29 years

What type(s) of massage do you do? Structural Integration, NMT, Bowen Technique.

How long have you taken insurance? 29 years

What types of insurance cases do you accept? Anything that will pay for my services. Mostly Auto, Work Comp, Slip & Fall & Health Policies that do not restrict in policy.

Do you do your own insurance billing? No, My daughter was my billing clerk for over 15 years.

What’s your favorite part about taking insurance? The fact that those in need are able to learn about and obtain massage services that can change their medical condition. The fact patients who cannot afford to pay for these services can now benefit. It increases business because in all my years of accepting insurance I would venture to say that 99% or better who came for massage by prescriptions had never heard of massage therapy. So this opened doors to our profession that would have never been opened otherwise.

What’s your least favorite part about taking insurance? I personally did not have anything I didn’t like about accepting insurance because I LOVED the challenges. There were many, but those challenges helped me to grow, to help patients win when they would have otherwise given up. I love helping massage therapists find their way in the murky waters of insurance acceptance and seeing them grow their businesses. All because of insurance acceptance!!

What do you hope the new ACA laws will accomplish? I hope it will open the doors to so many more people being able to receive the services that could change their lives like it did for me. To finally put a stop to insurance companies saying, ‘We do cover massage therapy, we just don’t pay massage therapists to perform or bill it”.

What would you say to an LMT who is interested in taking insurance? Please learn to do it right. We are so in trouble now in FL with PIP (personal injury protection insurance) because new LMTs did not know the rules, laws and guidelines, and causes red flags to be raised. They allowed themselves to be USED and, ultimately, fraudulent billings took place. If they KNEW the laws and rules, much of this would not have happened.

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Are you also an LMT who takes insurance? Answer the survey here!