Health Insurance: Providence (2)

After I found out about Providence Health’s backwards rules for massage coverage, I emailed them for more details. Why did they decide that chiropractors were more qualified to do my job than I was? Why did a doctor’s referral for a massage make no difference? Surprisingly enough, Providence wrote me back.

The beginning of the letter explained that not covering massage was solely a business decision (ie, not good for their bottom line). And although the insurance policies stated that chiropractors were allowed to give massages, these providers really shouldn’t be massaging for more than 15 minutes at a time (a single CPT code):

We have discovered over the past year that many chiropractors are abusing the massage therapy service that is within their scope of practice. We have developed a new policy which will correct the misconception that members can get massage therapy services from a chiropractor. I have attached the policy to this email.

I took a look at the attached policy. It stated:

Massage therapy may be used as an adjunct service to manipulation, especially when there is documented muscle tightness, swelling, and/or motion limitation due to spasticity or guarding. However, there is rarely a medical necessity for a one-hour, full-body massage. Typically, massage therapy (97124) is a targeted procedure to address a specific condition with the intent to provide relaxation of specific muscles or to reduce swelling related to the target condition. This is generally accomplished with one unit of message (up to 15 minutes).

I didn’t even know where to begin; the misinformation in this policy horrified me so much. Let’s break it down:

  • Massage therapy may be used as an adjunct service to manipulation, especially when there is documented muscle tightness, swelling, and/or motion limitation due to spasticity or guarding. This is true. Massage is good at warming and loosening up the muscles in order for an adjustment to be effective. It should be noted, of course, that massage is not exclusively useful as an accessory to chiropractic. Which brings us to…
  • However, there is rarely a medical necessity for a one-hour, full-body massage. Excuse me? By medical necessity, do you mean that there’s no proof that a one hour massage might… provide relief from pain during cancer treatment? Lower anxiety? Improve immune function? Decrease inflammation? Lower depression scores? (And not to mention all the pain relief that massage provides without the assistance of a spinal adjustment.) Also, the idea that just because a massage is long means that it’s unfocused (ie, a full body massage) is completely unfounded. More than half of my clients on any given week just want me to work on their neck, shoulders, and upper back. I’ve spent a whole hour just working on someone’s left leg.

    And besides – wasn’t the choice not to cover massage specifically a “business” decision? Why try to dress it up with medical misinformation? (answer: because “it’s not cost effective to provide effective healthcare” didn’t make it past the focus groups.)
  • Typically, massage therapy is a targeted procedure to address a specific condition with the intent to provide relaxation of specific muscles or to reduce swelling related to the target condition. This is true, or at least it can be. As I said above, about 60% of my massages every week are focused on a specific problem area.
  • This is generally accomplished with one unit of message (up to 15 minutes). Ha! If this were true, if any “medical need” a massage could provide could be accomplished in 15 minutes, our jobs as massage therapists would be very, very different from what they are now.

The original email then went on to blame the insurance customers (my clients) for being unable to figure out their benefits. If they wanted massage to be a covered service, they needed to talk to their HR.

But that wasn’t my point. Why was massage being separated out from other CAM therapies in the first place? What made massage less “acceptable” than chiropractic, acupuncture, or naturopathic medicine? Why did no one making these decisions feel the need to consult the research first?

It’s very hard to argue with someone (or something, like an entire corporation) that refuses to take facts into consideration.

I replied to this email, and our conversation continued for a while, but nothing was achieved. I was told that the public didn’t view massage as a medical service (not true!), so Providence wasn’t going to challenge perception. I was also told that the only reason that massage was a covered service in Washington State was because the chiropractors have a very strong lobbying group, and it had nothing to do with the medical value of massage (also not true!)

And so, again, this is what we’re up against. Misinformation at the highest level. But the new healthcare laws are on our side. As long as you know your rights as an LMT, and know that, as a licensed provider working working within your scope of practice, you’re entitled to fair compensation for your services, insurance companies will have to play by the rules.

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Health Insurance: Providence

What’s the most irritating thing I have to deal with when it comes to insurance? It isn’t the amount of time I stay on hold while waiting for someone to answer my questions. It isn’t having to go through the insurance company’s automated answering system only to find out that the machine can neither answer my specific question nor forward me to someone who can. These things are frustrating, but I can handle them. It’s part of the deal.

No, the worst part about insurance is the complete disregard of the massage therapy profession that I often encounter. I’ll ask the customer service rep: Is my client covered for massage? Well, sure, if your client goes to someone who isn’t a licensed massage therapist, insurance will cover it.

You heard that correctly: A client might be covered for massage, but only when said treatment is performed by someone who didn’t spend 600 hours learning exclusively about massage and is licensed specifically by the state to perform massages.

Which brings me to the first chapter of what I like to call Ways Insurance Companies Will Try To Deny Your Claims (I had a feistier title in mind originally, but I’m trying to stay professional here). First up: Providence Health Plans*.


Click image for expanded view

This is a section of one of Providence’s actual insurance policies. Chiropractors who do massage (soft tissue manipulation) are covered, but there’s no coverage for LMTs. Massage therapists are excluded completely from this policy. When I called the company to clarify, I was told that if a massage therapist billed out for massage, it would be denied. Worse than that, I was told that a doctor’s referral would not make a difference.

Let me repeat that: If a client came to see me who had been referred by a doctor to receive massages – thereby making the massages a verifiable medical necessity – Providence didn’t care. An LMT was still not good enough to give the treatment.

Starting next January, though, this will no longer be allowed. Section 2706 guarantees coverage for healthcare services like massage, regardless of the provider. Any licensed (and credentialed) provider would be able to perform the services within his or her scope of practice. Insurance companies will not be allowed to dictate which providers can do what. They won’t be allowed to, but they still will. They’ll try.

Insurance companies aren’t going to send their clients updated policies in January to let them know that massage is now a fully covered benefit from any licensed provider. They’re hoping that no one will notice this change and that they can continue denying services as usual. That’s why I’m teaching you what to expect – so you’ll know what to do when it happens.

After seeing this policy and learning what it meant, I emailed Providence directly to ask them why they chose to discriminate against massage therapists. What followed was a pretty infuriating conversation. More on that next week!

*Providence Health Plans offers coverage primarily in Oregon and Washington State. Because of Washington’s Every Category of Provider Law, massage therapists in that state do not have the same insurance restrictions as we do in Oregon. Guess which state saves more money?

Essential Health Benefits

Within its 2,400 pages, the Affordable Care Act did not create any sort of health plan; it left the details and specifics of those to the states. It was not silent on the general rules of healthcare, however, creating a list of ten criteria that it deemed “essential” to insurance coverage. Using this list as an outline, each state* is charged with creating a “benchmark plan”, a representative plan that would serve as a guide for all individual and small group plans.

(And by “create”, I really just mean “choose among several options already available in the state, federal, and small group markets”.)

List of Essential Health Benefits:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

As you can see, this list is very general, and most of the benefits will be open to a wide interpretation. Regardless, this helps to standardize coverage in an important way: The benchmark plan that each states comes up with must address all ten EHB, and this plan will be used as a point of reference (or, benchmark) for private insurance policies. That means that insurance companies can’t restrict policies to cover less than what’s spelled out in the benchmark plan, even for individuals with expensive medical conditions.

And while, yes, states will probably not interpret these benefits as broadly as they could, the EHB bodes well for CAM providers. Take a look at the first benefit: Ambulatory Services. Services that help individuals for issues with motion or movement. Issues with movement, like, for example, back pain.

And it hardly needs to said that massage is a great solution for back pain.

This list, coupled with Section 2706, is very good news. The EHB says that back pain is a covered medical problem. Section 2706 says that any provider who is licensed to treat back pain can be covered under insurance, no matter if the provider is a medical doctor, a chiropractor, or a massage therapist.

Another benefit that jumps out is EHB #9: Preventative and wellness services and chronic disease management. As I said above, these benefits are very general and will be interpreted differently by different states, but it would be a stretch to suggest that CAM providers didn’t have something to offer for wellness services or chronic disease (eg, chronic pain).

The benchmark plans don’t need to be solidified until later in the year – enrollment in the Exchanges begin in October – but it’s important to pay attention now to how each state understands and addresses those benefits that have been deemed essential by the Affordable Care Act.

*From what I understand, states that have chosen to not accept federal funds for Medicaid expansion are not obligated to create a benchmark plan.

FAQs

IHPC put together a list of FAQs regarding Section 2706, the non-discrimination provision of the Affordable Care Act, and they are now online! The link is in the menu above; or you can just click here!

CPT Codes

What are CPT codes?

CPT (Current Procedural Terminology) codes are a set of codes created by the American Medical Association that list medical procedures and treatments. These codes are a standardized way for providers to communicate with others in the medical field (peers, administrators, insurance companies) and record what techniques and procedures were performed during an appointment. Massage therapists use CPT codes primarily when billing insurance – letting insurance know what they did and for how long.

As you can guess, the CPT codes that massage therapists use most are about massage treatment. There are two CPT codes for massage:

97124 – Massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion).

97140 – Manual therapy techniques (e.g. mobilization, manipulation, manual lymphatic drainage, manual traction).

Each code represents a 15 minute increment of service, so LMTs bill for several units within one session. Because the two codes aren’t very distinct (ie, most LMTs wouldn’t be able to say exactly how long they spent doing “massage” versus “manual therapy”), massage therapists should stick to a single code type when billing for an appointment. Don’t, for example, separate an hour session into two units of 97124 and two units of 97140.

Why do the codes only represent 15 minute blocks? Why not an hour? Every procedure in the CPT set is broken down into small pieces, so that providers can mix and match codes. This isn’t very useful for massage therapists, since all we do is give massages*, but other providers (for example, chiropractors) might just give a short massage to their client before an adjustment – and would need to bill accordingly.

These codes are all nice and standardized, and they help make billing pretty simple, but insurance companies don’t always pay us the same favor in return. While, yes, technically the two CPT codes are too similar to distinguish and can be used interchangeably, some companies will only accept one code or the other. Some will accept both, but pay out at different rates (97140 usually earns more).

How do you know which insurance companies want which codes? You could try to read the credentialing contract you receive from each company, but sometimes the language in there can be unclear or misleading. The best thing to do is learn from experience (and take notes!). Try using each code on separate instances; see which one gets reimbursed better. If one claim gets denied, try again with the other code.

I have a pretty good system in place – I use 97140 for all of my billing except for the two insurance companies that only accept 97124. Other therapists have other strategies. Ask around!

*One other code that massage therapists can use, if applicable: 97010 – hot and cold packs (15 minute increment).

LMT Interview: D.M.

Name: D.M.

Name of your practice: David Maile, LMT

Location: Ft. Myers, FL

Number of LMTs working there: 1

How long have you been massaging? 22 years

What type(s) of massage do you do? Aaron Mattes (AIS), medical and rehab.

How long have you taken insurance? 22 years.

What types of insurance cases do you accept? PIP, Blue Cross/ Blue Shield, Workman’s comp.

Do you do your own insurance billing? Yes.

What’s your favorite part about taking insurance? More patients.

What’s your least favorite part about taking insurance? Paperwork.

What do you hope the new ACA laws will accomplish? Provide insurance for all people across the board to seek self-determination in the care they think is best for them.

What would you say to an LMT who is interested in taking insurance? Get adequate training in insurance and be very careful due to the changes in insurance provisions.

Are you also an LMT who takes insurance? Fill out your own survey here!

LMT Interview: P. Jontza Anez

Name: Patty Jontza Anez

Name of your practice: Pain and Injury Specialist / Patty Jontza Anez LMT. CNA. HHA.

Location: Naples, FL

Number of LMTs working there: Only me

How long have you been massaging? Since 1984, so 28/29 years.

What type(s) of massage do you do? Lymphatic Drainage, CranioSacral, Myofascial, Trigger Pt., Somatic Stretching, Shiatsu, Swedish, Thai, Kinesio Taping, Medical and Sports massage.

How long have you taken insurance? I had been taking insurance for 15 or 16 years. Now I do not.

What types of insurance cases do you accept? I used to work with all Auto PIP, Workers Comp, also I worked with the Sheriff’s Dept and Collier County Teachers. Now I am not able to bill any insurance .

Do you do your own insurance billing? Yes I did. As I said, not able to anymore.

What’s your favorite part about taking insurance? My favorite part, as I specialize in pain and injury, was the possibility to work with so many people who needed my service, but without insurance coverage, they could not afford it. So, being able to serve the working people, not only those who can afford to pay cash.
The Sheriff’s and Teachers were a group who so deserved the benefit and I was able to help so many avoid surgery.

What’s your least favorite part about taking insurance? All the paperwork, record keeping, medical notes, phone calls and faxes, and waiting months for payment. Sometimes not receiving payment at all.

What do you hope the new ACA laws will accomplish? I hope that massage therapy is included, as it is so important to healing, and it is very cost effective, and helps to avoid the high costs of surgery and hospitalization in many cases of injury.

What would you say to an LMT who is interested in taking insurance? At this time, I am no longer able to take insurance. I hope the new Health Care includes us as the valuable, highly trained, Licensed Health Care Providers we are.

Are you also an LMT who takes insurance? Fill out your own survey here!