Julie Onofrio

WA State has long had the ability to bill and get paid by health insurance companies.  It came about because of a bill called ‘the every category law’ that was created in 1993 by the insurance commissioner at the time – Deborah Senn.  I have heard her speak a few times and she will tell the story of how it all came to be.  She was in an auto accident and used massage therapy to help her heal from the injuries.  She also had an office assistant named Lori Grassi (Belinski) who was a massage therapist who was also a lobbyist.  Together they fought the insurance companies for over 6 years until it was made final by a Supreme Court Decision.  You can read the full timeline of how it came into being here. (on this site)

When the law was created, the insurance companies also did studies on how to implement it into their systems and created this document (at the bottom of the page): Issues in Coverage for Complementary and Alternative Therapies: From the Report of the Clinician Workgroup on the Integration of Complementary and Alternative Medicine January 2000.  Washington State.

In about 1999/2000, the insurance companies opened up their provider panels and allowed massage therapists to become credentialed with them. Credentialing is just a process of filling out paperwork that tells them who you are, what your training/licensing is and checks on whether or not you have had insurance claims against you.  It also checks to make sure you have a valid license and liability insurance.  No extra training is required beyond the state licensing boards educational requirements which is currently 500 hours and has been since about 1990.

We signed contracts with the insurance carriers making us credentialed with them that allowed us to work on people who had their insurance and in the beginning, they found us mainly from being on the list of providers.  Doctors started referring for things like headaches, carpal tunnel, back and neck pain, knee pain, plantar fasciaitis, fibromyalgia and other musculoskeletal conditions.  Massage therapy is for rehab.  Maintenance and wellness massage therapy ARE NOT covered.

All sessions have to meet the insurance companies definitions of medical necessity and each company has a slightly different version but in general they say that massage therapy for pain AND loss of function will be paid for by the insurance companies, when the person has a prescription from a doctor.  It does not cover maintenance massage therapy or massage therapy just because they want massage therapy.  You can read insurance plans to find out the definition of medical necessity and to find any other clauses regarding massage therapy sessions.  Here is an example of Premera Blue Cross Medical Policy (PDF) says:

The patient has a documented condition causing physical functional impairment, or disability due to disease, illness,injury, surgery or physical congenital anomaly that interferes with activities of daily living (ADLs).

AND

The patient has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on specific diagnosis-related treatment/therapy goals

AND

Due to the physical condition of the patient, the complexity and sophistication of the therapy and the therapeutic modalities used ,the judgment, knowledge, and skills of a qualified PM&R-PT or medical massage therapy provider are required.

Learning how to bill and work with insurance companies.

It was a bit of a learning curve learning to bill but I already knew how to bill for PIP and workers compensation. AMTA-WA was instrumental in getting us up to speed in being able to bill health insurance.  They were involved in the workgroup put together by the Office of the Insurance Commissioner to identify issues, barriers and solutions for implementing the legislatively mandated changes.   The workgroup met for 3 years and included insurance carriers as well as representatives from the massage therapy profession, chiropractors, medical doctors and naturopaths, but NO lawyers.  They worked on making decisions about coverage,technology, medical necessity, collecting data and the gathering of literature on costs and practices, wellness vs condition care, an integration of CAM services.   Reading the report from the workgroup now made me realize that this must have been an amazing time with so many working together to create and implement everything.

AMTA-WA hired two healthcare attorneys and had them on retainer for many years so their members could ask them questions.  They taught classes at the conventions and annual meetings.  The Government Relations (GR) volunteer kept up to date on laws, issues and organized panel discussions of insurance carriers, the insurance commissioner and more.  We were taught classes in SOAP charting mainly by Diana Thompson, author of Hands Heal (5th edition).  One insurance carrier actually required that we take a class on charting from Diana.   AMTA-WA had articles in their Journal and information was shared throughout the Units that were once a part of the AMTA-WA network but are out on their own now.  AMTA-WA hired a lobbyist to keep us in the game in the legislature.  The Every Category Law is often challenged.  AMTA-WA had a health care integration committee for many years after the first workgroup.   They would keep in touch with the carriers.  The group was disbanded for unknown reasons.

The AMTA Chapter fee of $35 supported our efforts as part of that fee came directly to the chapter.  AMTA-WA managed their own bank accounts and wrote their own checks and were able to do what was needed to help massage therapists figure all this out.  As one of the largest chapters with probably about 4500 members at the time (now about 5500 members), that was a chunk of money.  AMTA National did away with the extra chapter fees which hurt the chapter significantly.

Most recently AMTA-WA was a part of getting specific language in our scope of practice that allows us to ‘evaluate’ or assess clients conditions which is an essential part of treatment massage.

WAC 246-830-005

10) “Evaluation” means the assessment of soft tissue in order to facilitate decision making regarding effective forms and techniques of massage, and identifying cautions and contraindications to ensure client or patient safety. Evaluation does not mean diagnosis.

In the Beginning

In the beginning the insurance companies paid reasonably well – anywhere from $54.00 to $120 for 4 units of 97124 or 97140.  Some companies only allowed 97124 but more are now allowing it to be billed and they will pay it.

I can’t remember if we started this way or now but all bills are processed electronically through a company called www.officeally.com or some insurance carriers can be billed through another system called www.availity.com.  In the beginning, I used to check benefits for every client and had to call them to get the information.  That often meant time on the phones waiting for verification.  Now I can check their plans and benefits online through the webportal that most insurance carriers use – www.onehealthport.com

Prescriptions are needed to provide the diagnose code for us and treatment plan recommended by the doctor as we are not allowed to diagnose conditions in our scope of practice. (Some plans customer service representatives have told that they are not needed causing some major confusion and frustrations.)

Everything was going well for many years.  Insurance companies were fairly easy to bill and not much more had to be done to get paid.  Chart notes were done for sessions but most insurance carriers never asked for them unless there was some issue.

These were the good years – 1999/2000 through about 2010 or so when the first insurance company that paid over $100 reduced their allowable fee to below $60.00.  Gulp.

In 2009, one insurance company started asking us to send in the prescription with the first bill to monitor medical necessity (PDF FORM)which I have now heard caused many problems for them.  The did not think that we would have them.  We did that for a few years until they stopped it.

Other insurance carriers are dropping their allowable fees too now.  Part of the problem is that WA State massage therapists have not had anyone at the table for them with the carriers to provide data on income and the cost of doing business.  Carriers create the allowable fees using complicated formulas that usually include this data as one of three parts of the formula.  The other 2 parts are the cost of liability insurance for massage therapists and the amount of skill/time that goes into the session.

Most massage therapists are just one person sole proprietor businesses or are owners that hire up to 10 or so employees and we are not able to negotiate contracts or allowable fees because we are such small entities.  The insurance companies will just usually say no.  We also are not able to talk about fees even through our associations – AMTA -WA and WA State Massage Therapy Association (www.mywsmta.org) as it would put us at risk for price fixing.

Another thing that was added by 2 insurance companies was having to get prior authorization for massage therapy sessions in order to get paid.  Premera Blue Cross and Regence Blue Shield both hired a third party company called eviCore to handle prior authorizations.  To get a prior authorization, massage therapists have to either use their website which is a very unuser friendly system which takes too much time and put the diagnosis code and plan information into a computer where it then approves the number of sessions which currently tells the number of units allowed.  This severely is limiting clients from being able to use their full medical benefits.  Plans may cover 12-25 sessions and the prior authorization process limits that number to whatever they deem is medically necessary.

In the Spring of 2018, a bill was passed that did allow us to give 6 massage therapy sessions without having to go through the prior authorization process.

After 6 sessions are completed, a request can be made for more sessions to be authorized through their online system or by calling.  They require information about the clients condition – pain and loss of function- and are now asking about whether or not the clients’ condition caused them to take more pain medications (That just started Nov 1, 2018 and I am not sure if we can do that as it is not in our scope of practice.)

The process of implementing prior authorization is seen by the office of the insurance commissioner.  https://www.insurance.wa.gov/prior-authorization-processes-and-transparency-r-2016-19

The next step is in the works with a proposed bill waiting in the wings to require third party companies to be regulated by the OIC.  This is from the WA State Chiro Trust (PAC)

Regulating benefits managers: Benefits managers like ASH, eviCore and others are hired by insurers to implement some, or all, of the following services; prior authorization, clinical review, billing, network creation and management. We are working to introduce legislation that would require them to be licensed by the Office of the Insurance Commissioner. This legislation would also include provisions that would require disclosure of the agreements between the benefits managing company and the insurer, exposing financial incentives to blocking access to care.

The current challenges in billing health insurance in WA State.

• Decreasing allowable fees along with increasing cost of living make it difficult to make a living just billing health insurance cases.
• Decreasing massage therapy benefits in health insurance plans.
• Insurance provider lists are closed and a few have been closed for over 15 years.  New therapists out of school cannot participate unless they are hired by an office that has a group umbrella where they can see insurance clients just through that office.
• The provider lists are not accurately updated.
• Clients/patients are having a more difficult time finding providers that will take their insurance because of some of the issues noted above.
• Our voice at the table is mainly through volunteer board members with knowledge of billing.  Having people with a background in healthcare administration and policy may help us get a better handle on the issues.

The Missing Pieces

Here is the thing though that I have learned and seen by working with health insurance for over 20 years- the insurance companies do not understand that massage therapy can help reduce the cost of healthcare by reducing surgeries and eliminating the need for Opioid drugs which is every state’s main concern when it comes to healthcare today. They still think that they are having to pay for surgery, recovery and drugs to relieve pain and resolve injuries and conditions.  They do not realize that massage therapy can reduce those surgeries and prescriptions (and the resulting Opioid epidemic) They are still clueless about how it is helping.  That is the area that needs work and advocacy for the massage therapy profession.

Also doctors do not really know how to use massage therapy.  I see mainly prescriptions for back and neck pain from tech workers sitting too long at the computer.  A few headaches and fibromyalgia cases.  Insurance also requires that there be a loss of  function along with the pain problem and often there is not a loss of function which would mean that massage would not be covered.

We need more support from professional associations to get to the table for us too.  AMTA is the most likely candidate, but they seem so far behind in this area.  What is the answer?

WA State also has a Political Action Committee that has historically raised approximately $5,000 a year to give money to political candidates campaigns.  After watching the bill on prior authorization go through the legislature in Spring 2018, I saw many legislators on the health care committee hearings asking the right questions of the insurance carriers and seeing right through their objections to the prior authorization bill.  When looking at how this came about, I found that the WA Chiropractors PAC and the PT PAC both raised about $100,000 each year.  I am currently working with the WA State Massage PAC – The Massage Alliance for Health (WAMAH) to try and raise that amount of money and create more awareness about what massage therapy can do.

So why push for massage therapy to be covered by health insurance?

Because it could change everything in healthcare if it gets covered.

It could hurt the profession more, but here is the thing….from what I have seen in the last few years, more and more organizations, insurance commissioners, physicians and legislators are asking for massage therapy to be covered by health insurance and it is coming whether we want it or not…whether it is good for the profession or not… whether we are ready or not.  So why not start learning and be a part of creating this for the massage profession rather than just having it handed to us by the powers that be.  Why not be at the table and create policy that supports coverage? Why not start learning how to bill so you can learn what challenges there are and work to find better ways to deal with health insurance?