Today I want to talk about how health insurance billing works in Oregon.
Similar to Washington, LMTs in Oregon typically have to be credentialed with insurance companies in order to get reimbursed. To get credentialed, we fill out paperwork to establish that we’re fully trained and licensed in the state and send it off to whichever companies we want to work with. Insurance companies don’t have to allow everyone who applies to join: some have certain criteria that must be met first (eg, one company only allows therapists who have been in practice for two years already), and others are closed completely to new applicants.
Even without being credentialed, though, a few companies may allow LMTs to bills as out-of-network providers for a reduced rate. However, being an out-of-network provider excludes you from one of the biggest benefits of working with insurance – having your name and practice listed on the insurance company’s website. When customers want to find a provider who takes their insurance, they typically consult this page to make their decision.
Once a client finds a therapist who takes her insurance, she can schedule a massage – no doctor’s referral required (for the majority of plans, at least). Insurance policies that cover alternative care work in one of two ways: Either the policy has a specified amount of money per year that goes towards these services, or there’s no set maximum amount but the client must meet his or her deductible first. From there, policies either have a copay (set dollar amount) or coinsurance (percentage of appointment charge) that the client owes for each session, and the insurance company picks up the rest of the tab.
This tab can be preestablished (eg, insurance saying that any 60-minute massage will only be reimbursed up to $64) or it can be based on what the therapist charges (eg, insurance covering 80% of the bill, leaving clients to pay a 20% coinsurance). If a therapist chooses to increase the cost of a massage for insurance billing, either to make up for paperwork hassles or to give a “time of service” discount to cash clients, the rates must still be reasonable.
I like that my heath insurance clients don’t need referrals. Sure, some of them will see a doctor first anyway to check on their issues, but others know that they just need a massage without anyone having to tell them. Not everyone wants to go to a doctor for every minor ache they have, and I’m certain that I would lose a good portion of my clientele if they all needed to get referrals first.
And honestly, I don’t know that every doctor would think to refer their clients to massage. Plenty of clients come to me saying, “well, my doctor says I need surgery, but I wanted to explore other options…”
As a side note, clients are still required to have a doctor’s referral when it comes to PIP insurance. This makes sense – PIP deals exclusively with injuries and trauma. Especially when it comes to car accidents, it’s best for the client to rule out anything serious before getting a massage.
Unlike Washington and Florida, Oregon doesn’t have any mandate that requires insurance to cover massage. That means that massage coverage is rather unevenly distributed, usually offered to those who can afford to add an alternative care rider to their policy. Some insurance companies consider massage an even more frivolous benefit than the rest of CAM, though, and make people (or, most typically, the companies that these people work for) pay for an extra rider on top of the alternative care rider (which includes chiropractic, acupuncture, naturopathic) in order to have massage coverage.
I’ve come across some policies that allow massage only when it’s performed by someone other than a massage therapist (eg, a chiropractor or doctor). Where’s the logic in that?
Personally, I think there are good and bad parts to both the Oregon and Washington approaches. I don’t think that health insurance should require a doctor’s referral for massage. I am a health care professional; I should be able to treat someone without the need for a doctor’s approval. At the same time, though, I wish massage coverage was available to everyone, not just those on ritzy insurance plans. I hope the Affordable Care Act can make my services accessible to anyone who needs them.
IHPC - Integrative Health Policy Consortium: Massage Outreach 