Insurance Billing Fees

How much should you charge when you bill insurance for a massage?

If you’ve never taken insurance, you might not realize that this is quite the subject of contention, but it is. This is a big, troublesome question. Some providers don’t make a distinction between who they bill; they charge insurance exactly what they’d charge anyone else. Other providers charge insurance significantly more than they charge their cash-pay clients, with increases in the range of $100 or $150. Why would they do this?

There aren’t any specific laws about service fees, but there are several ethical points to consider. Let’s break the arguments down:

Why would you bill more for insurance?

  • There’s a separation between who’s receiving the massage and who’s paying for the service. Your client is your customer, with whom you’ve established a face-to-face, professional relationship. Your client is a person. On the other hand, the entity paying for the service is a large, faceless, organization. This makes it much easier to overcharge – you have no scruples about taking advantage of a large corporation.
  • There is a little bit of extra work involved in billing insurance. Besides submitting claim, you have to spend time checking on benefits (online or over the phone) as well as keeping track of money owed and hunting down missed payments. Some providers feel that they are justified to charge for the time doing these tasks.
  • Time of service discount. This is similar to the above reason, just seen from the other direction. Consider the rate you charge insurance to be your standard rate. If your client wants to pay for the massage immediately after the session, you can offer her a discount for not making you do extra work.
    • Sidenote: If your client pays you up front, but she is planning on seeking reimbursement from insurance on her own, you can’t charge her the higher rate. Time of service means time of service, no matter who is footing the bill in the end.

Why would you not bill more for insurance?

  • The cost of a service should be the same no matter who’s paying. This gets right down the core issue: Why should the monetary value of a massage depend on who pays for it? I understand that massages cost more or less in different states and towns, but that’s not the issue here. The same massage given by the same provider taking place in the same city should have the same cost.
  • Overcharging for services sends a very specific message to insurance companies. These companies already have difficultly grappling with the idea that massage therapy can be beneficial for acute, chronic, and preventative care; significantly increasing the cost of a massage will skew its worth even more.
  • Even if you expect that an insurance company will cut down your reimbursement and not pay what you ask, constantly overcharging them will just perpetuate the problem.

Several years ago, I had a client who came to see me every week for back and chest pain. Her insurance didn’t cover massage, so she paid for each session in cash. After a month she realized that, although the treatments were helping, the money was adding up. She decided to give physical therapy a try instead, since it was something her insurance covered.

After one session, though, she was back to see me. Although her insurance covered the bulk of the expense, her copay for the PT session was more than the cash price of an entire massage.

I’m certainly not here to argue that some modalities shouldn’t cost more than others (if nothing else, the overhead/equipment cost for a PT is well beyond that of an LMT), but I wanted to illustrate a point. If what you charge insurance is so high that it significantly impacts what a client owes, that isn’t making the situation better for anyone.

And that story brings me to another point. You might ask: Couldn’t I just waive what the client owes and overcharge the insurance companies to make up the difference? The resounding answer to that is: No. You cannot waive copays or coinsurances.

Copays and coinsurances help to keep the client engaged in his or her treatment. The cost (for massages, at least) shouldn’t be enough to break the bank, but it should give the client a stake in the outcomes. Even in some countries with universal health care systems, clients will pay a (largely symbolic) small amount for all medical services.

Secondly, if a provider chooses to waive copays, it would need to be done across the board, for every insurance company the provider works with. In the cases of insurance companies that pay out at very low rates, this would not be economically feasible.

And thirdly, waiving copays isn’t legal. When you sign your contract to work with an insurance company, you agree to collect copays and coinsurances from your clients. Waiving fees would mean breaking the contract. So don’t do it.

Instead, your insurance charges should be usual, customary, and reasonable (UCR) per your geographical region. Just because a massage CPT code may have an allowed amount of $45 per 15-minute increment, it doesn’t mean that this is the proposed amount that you should be billing. Keep in mind your practice overhead, your business expenses. The amount you charge insurance should have a direct relation to your cash rate (which, presumably, has a direct relation to other factors).

Insurance billing expert (and IHPC volunteer) Vivian Madison-Mahoney writes regularly about insurance for Massage Today (articles can be viewed here). She wrote a great article about fees in 2002, and the sentiments remain the same:

If you can comfortably and confidently answer to any judge, jury, and especially a defense attorney, why you charge what you charge, and can prove sufficient functional outcome for the patient because of your therapy, then set your fees to what you think you should be getting. Otherwise maybe you had better stay in the safe zone. But remember, thinking you are worth excessive fees is no grounds for an insurer or patient /client to think the same.

This offers providers a flexible but still ethical solution. If you do bill more for insurance, can you comfortably justify the increase? Don’t just let yourself tempted by hypothetical profits. Analyze your business plans and goals in order make an informed decision about your billing.

Health Insurance: ASH (2)

Like most insurance companies, ASH enforces a limit on how many covered CAM treatments a client can have in a year. Depending on the version of the plan, this limit can be 9, 18 or 27 treatments. All CAM types (naturopathic, acupuncture, chiropractic and massage) are grouped together, so if someone sees several different provider types regularly, coverage can run out fairly quickly. Regardless, having this allowance spelled out clearly in the policy does motivate more people to utilize these benefits.

Utilize these benefits… up to a point. After five visits, ASH requires the provider to fill out a Continuation of Treatment Form (CTF) in order to prove that there is a “medical need” to continue with the specific type of treatment. With this form, ASH then decides how many treatment sessions (up to five) it will cover over a specific amount of time – after which the provider has to fill out another CTF.

The CTF is relatively straightforward. What specific areas of the body are in pain? Is the pain localized or radiating? Is the client also seeing another type of provider for this problem? The most important part of the form is the NPS, or Numeric Pain Scale. Out of 10, how bad is the current pain?

As the provider, you want to show the insurance company that the problems your client has are ones that you can take care of in a proper amount of time. But in many ways, massage is more of an art than a science. It’s impossible to accurately forecast how each individual client will react to treatment. Unfortunately, the insurance company doesn’t see it this way.

If the NPS number that the client gives is between 1 and 6, ASH considers this to be only “mild” pain. In such cases, ASH feels that the client will not need very many treatments before they are healed, and therefore will not approve the max-allowed 5 sessions. If the NPS is 8-10, however, ASH labels this pain as “severe”. In these cases, the provider should fill out another CTF sooner in order for ASH to determine that the current course of treatment is working – and so, again, they will not approve 5 sessions at once. That makes an NPS of 7 the best number, the one most likely to earn a 5-session approval, but even this “moderate” pain may be subject to scrutiny.

Time frames are routinely shortened as well. Perhaps you can get an approval for 5 massages, but only if they take place within 8 weeks. Working beyond this restrictive timeline would require the provider to fill out another CTF. The CTF might only take a few minutes to fill out, but who actually wants to do extra paperwork? Especially if you feel that the paperwork is just hindering treatment.

Perhaps most telling was the conversation I had once with a doctor from ASH, who told me very plainly that ASH does not cover preventative or wellness massages. The client in question wasn’t without pain, but it was the wear-and-tear type pain that comes from daily muscle use, not due to a specific accident or injury. Despite the fact that his pain could be easily managed with regular treatment – and not having this treatment would risk his pain becoming a more serious problem – my client would not be able to come in for monthly massages and expect his insurance to care.

Which would you rather assume: that ASH is unaware of any research regarding preventative care, or that ASH is very actively trying to make these benefits hard to utilize?

The most frustrating thing about the ACA is that it attempts to work with private insurance companies on their own terms. Sure, maybe insurance companies won’t be allowed to deny CAM coverage outright (thanks to Section 2706), but, as Deborah Senn warned us, they’ll create so many burdensome rules that it won’t even be worth it to practitioners to take insurance. They put caps on the amount of money someone can spend on CAM treatments and limit the number of sessions. Or, as in the case with ASH, they’ll depend on an algorithm to decide what’s “medically necessary” or not. None of that will be right, let alone legal. But it’s going to happen.

Earlier this year, the American Chiropractic Association filed a class action lawsuit against ASH due to misleading information, payment manipulation, restrictive pre-authorization and other completely unsurprising claims. Some of the allegations are even violations of ERISA (and, thus, a violation of federal law). I look forward to seeing how that plays out.