Oregon Medicaid’s Solution for Chronic Pain

When the EHB Advisory Committee met earlier this year to discuss what Oregon’s 2017 Benchmark plan should look like, someone brought up the very good point that it should include the benefits found on the Oregon Health Plan (OHP), the state’s Medicaid program.

Image courtesy of Ambro at FreeDigitalPhotos.netThe reason behind this suggestion was that a huge number of people who will be on the exchange plans are constantly bouncing between OHP and private insurance, depending on their work situation and financial situation on any given month. Thus, having an identical scope of benefits between the two would provide a more-or-less seamless transition whenever the consumer qualified for Medicaid or had to purchase a private plan. If not the exact same providers (since not all providers work with OHP), then at least the same types of providers.

Alas, that was not to be. CAM providers were (yet again) not accounted for in the benchmark plan.

But were CAM providers really in a better position on OHP plans? Funny you should ask. In fact, back in March, the Health Evidence Review Commission (HERC), released a paper that suggested OHP take a very different approach:

Until now, the OHP has limited [back condition] treatment to patients who have muscle weakness or other signs of nerve damage. Beginning in 2016, treatments will be available for all back conditions. Before treatment begins, providers will assess patients to determine their level of risk for chronic back pain, and whether they meet criteria for a surgical consultation. Based on the results, one or more of the following covered treatments may be appropriate:

  • Acupuncture
  • Chiropractic manipulation
  • Cognitive behavioral therapy (a form of talk therapy)
  • Medications (including short-term opiate drugs, but not long-term prescriptions)
  • Office visits
  • Osteopathic manipulation
  • Physical and occupational therapy
  • Surgery (only for a limited number of conditions where evidence shows surgery is more effective than other treatment options)

In addition, yoga, intensive rehabilitation, massage, and/or supervised exercise therapy are recommended to be included in the comprehensive treatment plans. These services, which also have evidence of effectiveness, will be provided where available as determined by each Coordinated Care Organization (CCO). [emphasis mine]

Massage! Yoga! Manipulations! I love it. It feels like the people in charge are finally trying to figure out what actually helps reduce or manage chronic pain. This is a great development, and it has the power to change a lot of lives.

How do we solve the problem of chronic pain? For so long, the answer has been prescription medication. Hydrocodonebtibu75200However, as I wrote about earlier, many people and organizations are starting to realize that these medications have drawbacks and limitations. Indeed, one of the reasons alternative care has taken hold in this country recently is because of the need to find another way to treat chronic pain.

Having options is nice, but it’s a luxury that people with limited means can barely afford. When your health insurance covers prescription medicine but not alternative care treatments, what can you do? In such cases, the choice between painkillers and CAM isn’t really a choice.

And the long-term use of painkillers can become a problem. As illustrated in this article, “In 2012, more than 900,000 Oregonians received an opioid prescription…About one third of hospitalizations related to drug abuse here are due to opioids.” Indeed, the HERC document points out that, “OHP has spent a great deal of public money on treatments such as surgery and medications, without good evidence that they improve patient’s lives. At the same time, narcotics also carry risks of dependency, misuse and overdose.”

Starting in January, OHP patients will have a real choice in how they want to manage their chronic back pain.

The weird tangent to all of this, however, is that Oregon’s Medicaid will soon have a wider scope of provider types and covered services than most of the plans on Oregon’s Exchange. Even in private plans that do cover certain CAM services, the insurance companies will still be allowed to discriminate against providers until 2017. Whereas, if a provider wanted to work with a Medicaid patient, he or she would only have to talk to the patient’s CCO to make it happen. It seems to me that the state is actually invested in making people’s lives better, while the insurance companies are focused only on the short-term gains.

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Oregon and Rhode Island News

Oregon Locator MapI meant to write about this earlier: Back in April, Oregon signed into law House Bill 2468, which pertains to network sufficiency and provider non-discrimination. That’s right, Oregon’s very own Section 2706.

The details regarding network sufficiency are new (from what I understand, the ACA expressed that network sufficiency was necessary but didn’t go into specifics), but the non-discrimination provision is identical to Section 2706.

This is awesome! Such great news! Unfortunately, it comes with a huge caveat: The law doesn’t take effect until January 2017.

Postponing implementation for a year and a half was an apparent concession to the insurers, allowing them to drag their feet for just a little longer before they’re forced to comply. Essentially, insurers are admitting that they don’t have to follow the federal law – they’ll only listen when the same exact law is also mandated by the state.

Rhode Island Locator MapIn the meantime, Rhode Island has passed HB 168, their own state-version of the non-discrimination provision. While the bulk of the statute (which was already in effect) pertains to insurance reimbursement specifically for certified registered nurse anesthetists, the non-discrimination language that was added does not specify any single provider type (such as the Hawaii bill from earlier this year that has currently been deferred).

The best part about this bill? It takes effect immediately. I’m very curious to see whether the insurance companies will actually fall in line without having to be forced.

Credentialing with Insurance Companies In Oregon

I’ve had several people ask me about the steps to be a credentialed massage therapist in Oregon, since it’s already something the state allows (albeit in small, uneven doses). It’s a really easy process, and I wanted to put it all out on this blog for anyone to reference.

First of all, make sure you have an NPI number.

To apply to most insurance companies, you will need the Oregon Practitioner Credentialing Application, which can be found here. Fill out all of the sections that apply to you (many sections, such as Residencies and Hospital Affiliations, do not pertain to LMTs). Keep an unsigned and undated copy of the application in your files, just in case you want to apply to more insurance companies later.

What you will need to submit to the insurance company:

  • Credentialing application
  • Copy of current license
  • Copy of current liability and malpractice insurance
  • Signed W-9 form

Some insurance companies may want you to fill out another form or two (about your specialties, etc), so make sure to look at each company’s website or call provider relations to figure that out. Other companies will want you to fill out the application online instead of sending in a paper copy, which means you’ll have to scan and upload all of the supporting documents.

After you fax or mail in the relevant paperwork to the insurer, it will take upwards of 30 days to hear back. Eventually, you should receive a letter welcoming you into the insurer’s network, along with some new paperwork and a contract to sign and return. And that’s it! Now you’re credentialed. Remember to check on benefits before your client comes in.

(Unfortunately, if the insurance company decides to not let you into their network, they may not tell you – so make sure to call and check up on any that you haven’t heard back from.)

What insurers are big in Oregon?

Below I’ve listed some of the insurance companies that are big in the Portland metro area, as well as those found on the Oregon Exchange*. To find out what insurers are prevalent in your area, talk to your clients and colleagues.

*Please note that insurers whose plans are only available via the Oregon Exchange might not have any plans with massage coverage, and therefore may not be accepting LMTs into their networks at all.

  • ASH: This is a CAM specific insurer that many other insurance companies use. Credentialing with ASH will allow you to work with Health Net, Aetna, and many others.
  • CAQH: Sign up here to get credentialed with Cigna, Optum, United as well as many others (see full list here.) CAQH uses an online form instead of the paper application.
  • The CHP Group: This is a CAM specific insurer that many other insurance companies use, including Kaiser Permanente
  • First Health
  • Lifewise
  • Moda
  • Pacific Source
  • Regence Blue Cross Blue Shield: Joining this network will also give you access to other BCBS health plans.
  • Atrio: A Medicare-specific insurer, serving Douglas, Klamath, and Polk counties via the Oregon Exchange.
  • Bridgespan Health: A new insurer with plans available via the Oregon Exchange. Credential with Regence BCBS (above) in order to work with this company.
  • Oregon Health Co-Op: A new insurer with plans available via the Oregon Exchange.
  • Trillium: Serving Lane county via the Oregon Exchange.

Section 2706 Guidelines in Oregon

It’s time to follow up on my last post. The Oregon Insurance Division finally released the official Section 2706 Guidelines. Here they are, in full:

Public Health Service Act (“PHSA”) Section 2706(a), as added by the Patient Protection and Affordable Care Act, prohibits an issuer of a commercial nongrandfathered group or individual health benefit plan from discrimination with respect to participation or coverage against a provider who acts within the scope of the provider’s license. Section 2706(a) applies to commercial nongrandfathered individual and group health benefit plans issued or renewed on or after January 1, 2014.

The Insurance Division of the Department of Consumer and Business Services (“the division”) will review complaints related to Section 2706(a) on a case-by-case basis under the division’s existing complaint and market regulation framework.

So… what does that mean? On the surface, there isn’t anything new; the guidelines merely states that Section 2706 is the law, and any breaking of the law will be dealt with. However, this is a significant (and positive) change from where things stood last year.

I only touched on it very briefly in this blog post, but last summer the Health and Human Services (HHS) Department had released their own guidelines regarding Section 2706. These guidelines showed a huge misunderstanding of the law itself and its intent, telling insurers that they could implement the requirements of this section using their own “good faith, reasonable” interpretation of the law, and that they didn’t have to accept all types of providers into an insurance network if they didn’t want to.

This wasn’t an accurate read on the law, but because these were the guidelines that HHS had provided, it was what the states were going to follow. That was the starting point of the conversations between the Insurance Commissioner and the CAM provider associations back in October. The fact that the law will now be enforced as it was intended is a huge accomplishment.

Of course, this doesn’t solve all the problems, especially not immediately. No one is going to get a new insurance policy in the mail saying that they now have CAM coverage. And, truth be told, most insurance companies aren’t going to change the way they process claims without some arm twisting. Claims will still get denied for matters involving provider discrimination.

But now we have recourse. Now we can (and are expected to) file complaints with the Insurance Division and point out this discrimination. And you know what? The Insurance Division is on our side. They want insurance companies to follow the law.

I’ve said it before, and now I really mean it: Getting this law enforced is going to take work. And now it’s up to us to do the work.

What can you do (as a CAM provider in Oregon)?

  • Get credentialed. We’re incredibly fortunate to work in one of the few states that allow massage therapists to join up with insurance networks, so we need to take advantage of that. There are a number of insurance companies that will happily accept LMTs into their networks, and there are some that will tell you they are no longer accepting new applicants. Apply to both types of companies, and document what happens if you get denied. I’ll talk more about this in the next blog post.
  • File complaints. If you are already an in-network provider with an insurer, challenge the claim denials you receive. The Insurance Division has a created a special Complaint Form for providers to fill out – you can file all of your complaints in one batch. You can find that form here.
  • Reach out. Tell your coworkers to get credentialed. Ask your cash-pay clients if you can try billing their insurance – even if you know you’ll get denied. Your clients can also register their own complaints using the main Complaint Form, so make sure to pass that along if they’re interested.
  • Communicate. Did an insurance company reject your credentialing application? Did you file a complaint with the Insurance Division? Let us know. Shoot me an email, or let AMTA-OR know (if you’re a member, of course). The more we communicate with each other and across professions, the stronger our case will be.

The future of this law depends on us. We need to do everything we can to make sure it succeeds.

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.

    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.