How to Take Insurance (2) – Checking Benefits

Your first insurance client has scheduled a massage with you. She’s not sure about the details of her coverage, but you assured her that you would check on her benefits before she came in. How do you begin?

Information you need on hand before calling:

  • Your tax ID (SSN or TIN)
  • Your NPI number
  • Client’s name
  • Client’s date of birth
  • Insurance ID number – this is the main number on someone’s insurance card. Usually it’s just numbers; occasionally it’s a combination of letters and numbers.
  • Customer service phone number – this is usually found on back of the insurance card.

The customer service phone number is almost always the most direct line of contact when enquiring about benefits. If you don’t have it, that’s ok. Call the insurance company’s main number and say that you need to check on a client’s benefits; they will transfer you to the right place.

Now you’re on the phone with a customer service rep. They have just found your client in their database. What questions should you ask? What do you need to know?

  • Does the client have coverage for massage? What CPT/billing codes can the massage therapist use for treatment? As I’ve written about before, even though massage therapists can use the two main “massage therapy” CPT codes interchangeably, many insurance companies have different rules governing both of them. It’s best to find out these details early so that your claim will not be denied on a technicality.
  • What is the allowed number of treatments per year? What is the allowed amount of money for treatments per year? Many insurance companies will have a treatment number limit as well as a spending limit – they will stop paying for treatments after either one of these limits is reached*.
  • What is the copay or coinsurance for treatments? Copay is a flat amount of money; coinsurance is a percentage of the total bill.
  • Does the client need to meet his or her deductible before insurance will pay for these benefits? If so, how much is the deductible? How much of the deductible has the client reached so far? If the deductible has not been met, insurance will not reimburse you. Instead, they will add the billed amount to the deductible. Once the deductible is met, they will start paying for subsequent treatments.
  • You might be wondering: Do I have to go through the hassle of calling on the phone? What about checking for benefits online?

    Checking benefits online can indeed save time, but it depends on the insurance company as to how easy their website will be to navigate (and how reliable their information will be). I would recommend calling about benefits, at least initially, to best ensure accuracy.

    As an aside, all insurance companies will require you to register for their website in order to fully access it, which you can only do as an in-network provider.

    The customer service rep is giving you all the details about your client’s massage therapy coverage. What should you do?

    Write it down. All of it! Ask questions if you are unclear about what they tell you. Believe me – it’s better to know too many details about your client’s coverage than to have to call back an hour or a week later and go through the whole process again. The more you know up front, the smoother the whole billing procedure will be.

    *Restricting access to services by limiting the number of treatments available per year (or limiting the benefit amount) may not be legal under Section 2706, but because we aren’t yet sure of these details, this is still relevant advice.