Massage Insurance Billing

If we are not at the table, we are on the menu.

October 15, 2019 By Julie Onofrio Leave a Comment

If you are not at the table, you are on the menu is a political saying that supposedly comes out of WA DC in about 2000 with no known origin. I first heard it said that the Alliance for Massage Therapy Education Conference (I think in about 2010) in Tuscon AZ by John Weeks, publisher/editor of the Integrator Blog News and Reports.

What it means is that if you/we don’t have a seat at the table with the insurance carriers, insurance commissioners, hospitals, doctors, nurses, legislators in every state, legislators in WA DC – we will be on the menu. You will have other agencies, politicians, insurance companies creating policies, rules, laws and you won’t have a say in creating allowable fees, benefits and policies. For example: one of the biggest issues we are having currently in WA state is that the insurance companies are drastically reducing allowable fees. The insurance companies set allowable fees using formulas that consider the amount of work the provider does(time and intensity), liability insurance costs and practice expense data. The insurance companies do not have any data on practice expense from the massage profession so they just guess and use their own data. We haven’t had any association representing us with the insurance carriers.

In terms of having massage therapy covered by health insurance, it is clear that there is a movement calling for massage therapy to be involved in fixing the Opioid epidemic.

Comprehensive Accreditation Manual for Hospitals: The Official Handbook of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), updated in August 2000, recommends massage as a non-pharmacological therapy that can be used successfully in pain management.
The Joint Commission (PDF) has been mentioning massage therapy in their reports in 2015, 2016 and 2018
The ACA 2010 provided an opportunity for massage therapists to organize and demand coverage of massage therapy.ABMP on the ACA

ABMP believes Section 2706 provides additional justification for insurance companies to reimburse massage therapists. For example, when massage therapy is a covered benefit of a health plan, it is not uncommon for an insurance company to reimburse massage provided by a physical therapist, chiropractor, or osteopathic doctor – but not massage therapy provided by a massage therapist. Evidence shows that massage therapy, especially when performed by a massage therapist, is a cost-effective delivery method of health care.

Integrative Healthcare Policy Consortium – calls for massage therapy

When a massage therapist treats any health condition covered in an insurance plan (e.g., back pain, neck

pain, etc),the massage therapist is eligible for reimbursement, so long as that provider is licensed by his or her state and can treat the condition within his or her scope of practice.

AMTA of course said they did not want massage therapy to be covered under the ACA. See Laura Allen’s blog post. citing that 50% of their members did not want that to happen. What about the other 50% that did?

ABMP wrote a position paper supporting massage therapy. -“A comment on the Prevention Strategy of the National Prevention,Health Promotion, and Public Health Council December 2010

January 2012: The Integrative Health care Policy Consortium (IHPC) Announces State-by-State Campaign for “Correct Implementation” of Section 2706 (The integrator blog – http://theintegratorblog.com/index.php?option=com_content&task=view&id=858&Itemid=1)

IHPC Launches Campaign with Former WA Insurance Commissioner Deborah Senn to Secure Non-Discrimination (Section 2706) announcing a critically important campaign to help implement the ACA.

Section 2706 of the Affordable Care Act of 2010 promises “non-discrimination in health care.” The provision was lobbied by the American Chiropractic Association and the Integrated Healthcare Policy Consortium (IHPC) and championed by U.S. Senators Tom Harkin and Barbara Mikulski, MD. The intention was to honor citizen choice by broadening access to non-MD providers. Of greatest interest to Harkin and the duo lobbying organizations are those classified as licensed complementary and alternative medicine practitioners.

2011: 42 percent of hospitals are using complementary and alternative therapies (AMTA statistic).

2012: The Hospital-Based Massage Therapy task force (HBMT-TF) was formed within the Academic Collaborative for Integrative Health (ACIH, formerly known as the Academic Consortium for Complementary and Alternative Health Care). The purpose was to explore the need for a set of standards or competencies, gather information about current standards for the field, and possibly develop HBMT-specific competencies that could be shared with all interested parties, particularly hospitals, massage therapy educators, and massage therapists in the field. HBMT-TF membership consisted of MK Brennan, RN, LMT (ACIH CWG member), Dale Healey, DC, Ph.D. (ACIH EWG co-chair), Carolyn Tague, MA, CMT (ACIH EWG member), and Beth Rosenthal, Ph.D., MBA, MPH (ACIH Assistant Director).

Massage Magazine: Hospital-Based Massage Therapy: A Call for Competencies

Hospital Based Massage Therapy: A Call for Competencies

2013: 51% of AMTA members do NOT want massage therapy covered by health insurance, while 49% do.

Feb 2013: The Integrative Health Care Policy Consortium (IHPC) creates a blog for integrating massage into health care. https://ihpcmassage.wordpress.com/

07/10/2013: Laura Allen’s Blog reports that Diana Thompson, well-known author and leader in the massage profession, wrote a letter to AMTA requesting support for the ACA and integrating massage therapy into health care.

“With the exception of the massage representative from the AMTA, all the clinical speakers were excellent and very supportive of the ACA and interested in doing everything possible to support coverage by practitioners within their discipline. These clinicians expressed similar concerns regarding the ACA and how it may or may not affect CAM services. There were also clinical examples provided about how the ACA may positively impact certain disciplines, particularly NDs who provide primary care… On a side note, I am very concerned about the position of the AMTA…”

AMTA: Supporting Massage Therapists for the Affordable Care Act (or Not?)

August 2013: The AMTA’s approach to the Affordable Care Act is still undecided and the organization has taken limited action. https://www.amtamassage.org/articles/1/News/detail/2805/amtas-approach-to-the-affordable-care-act

“The American Massage Therapy Association (AMTA) understands there has been much discussion and debate about the Affordable Care Act (ACA) and the potential role for massage therapists that it might provide within health insurance based third-party reimbursement. Similar debates are taking place among other health care professionals as the ACA presents many challenges for everyone involved in health care, from professionals to consumers. While the law was enacted more than 3 years ago, it continues to be debated, analyzed and scrutinized. Meanwhile, the law has evolved and implementation will continue to evolve, especially as states determine their approaches to it.”

June 2014: IHPC letter to Centers for Medicare & Medicaid Services Department of Health and Human Services calls for the inclusion of massage therapy in health care under the Affordable Care Act section 2706. https://www.amtamassage.org/uploads/cms/documents/ihpc_6.5.14.pdf

2014: Diane Mastnardo creates Massage Northern Ohio Practice-Based Research Network.

2014: Integrative Health Policy Consortium www.ihpc.org (IHPC ) creates www.covermycare.com to help implement the Affordable Care Act section 2706.

2015: Over 125 hospital-based programs listed on the Society for Oncology Massage website. http://www.s4om.org/health-care-professionals/hospitals-incorporating-oncology-massage

September 2016: Hospital-Based Massage Therapy Task Force Presentation 2016

https://integrativehealth.org/hbmt-ewg-cwg

https://integrativehealth.org/hbmt_competencies

July 19, 2013. Kahn’s keynote speech at the Alliance for Massage Therapy Education conference as reported by Massage Magazine, noted that “We get in each others’ way as a profession,” she said. For example, “There are people really concerned [about working in the health care system], they don’t want to take insurance and have someone 20 miles away … tell them how many sessions they can do [on a client], and so they’re going to say we shouldn’t go there.“I want to say, you shouldn’t go there if you don’t want to deal with those problems—[but] if you don’t want to do that, let’s figure out a way you don’t have to and I still can,” she added.Another barrier to moving through the doorways of opportunity, Kahn said, is the lack of a clear, articulate voice in Washington representing therapeutic massage “and helping policymakers and the public underhand how we can fit into the new health care system in a an expanded way.”

2017: AMTA Fact Sheet (https://www.amtamassage.org/infocenter/economic_industry-fact-sheet.html) reports:

“Massage therapists and consumers favor the integration of massage into health care.

Nearly two-thirds of adult Americans (64 percent) would like to see their insurance cover massage therapy.⁴
The vast majority of massage therapists (97 percent) believe massage therapy should be considered part of the health care field.^”

Feb 2017. American College of Physicians recommends massage therapy for back pain.

Sept 2017. The National Association of insurance commissioners have asked for it to be used to battle the drugs. (See the letter PDF)

“When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe

effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care.”

October 24, 2018, the President signed into law: H.R. 6, the “Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act” or the “SUPPORT for Patients and Communities Act,” which addresses the opioid crisis by reducing access to and the supply of opioids and by expanding access to prevention, treatment, and recovery services. Passage was overwhelmingly bipartisan (98-1 in the Senate and 396-14 in the House). (www.ihpc.org newsletter)

October 2017: The inaugural Integrative Pain Care Policy Congress was an invitation-only meeting that brought together approximately 70 leaders from 50+ organizations. They represented the full scope of licensed and certified healthcare professionals involved in pain care, along with insurers, regulators, people with pain, researchers, and policy experts. AMTA was invited but has not reported on whether or not a representative attended and what happened. https://www.integrativepainmanagement.org/blogpost/1677160/294358/The-Integrative-Pain-Care-Policy-Congress-Why-We-Came-Together

2018: AMTA Fact Sheet (https://www.amtamassage.org/research/Consumer-Survey-Fact-Sheets.html) claims:

Massage for Health and Wellness:

“67 percent of individuals surveyed claim the primary reason for receiving their last massage in the previous 12 months was medical (41 percent) or stress (26 percent) related, according to the 22nd annual consumer survey sponsored by the American Massage Therapy Association (AMTA).”

September 4, 2018: AMTA announces the organization reached out to Medicare advantage plans asking them for coverage of massage therapy.

November 28, 2018: CMS announces up to 270 Medicare Advantage Plans will include massage therapy in 2019.

2019: New Hampshire Bill proposal. HB 610-FN http://www.gencourt.state.nh.us/bill_status/billText.aspx?id=131&txtFormat=html&sy=2019&fbclid=IwAR2X1kg6FALvSkN6FfnkWLxNelzvyN8Gf9kRNBqmdlVfWDjFmEFP9KE_uGw

“When patients seek treatment for any of the myriad conditions that cause pain, a health care practitioner shall refer or prescribe to a patient any of the following treatment alternatives, when applicable, before starting a patient on an opioid; chiropractic, physical therapy, occupational therapy, acupuncture, massage therapy, and/or osteopathic manipulation. “

“2 New Section; Coverage for Nonopioid Treatment for Pain; Individual. Amend RSA 415 by inserting after section 6-w the following new section:

“415:6-x Coverage for Nonopioid Treatment for Pain; Individual. Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses shall provide to persons covered by such insurance who are residents of this state coverage for the costs of options to patients for evidenced-based non-opioid treatment for pain, including but not limited to*, chiropractic care, osteopathic manipulative treatment and acupuncture treatment. Policies issued pursuant to this section shall not have annual or lifetime numerical limits on visits for the treatment of pain. Reimbursement, coinsurance, copayment, and deductible amounts for pain management care utilizing chiropractic, acupuncture, and/or osteopathic manipulation shall be determined as a service under the Patient Protection and Affordable Care Act of 2009, as amended, definition of rehabilitation and habilitation.”

**”including but not limited to”–We need to make sure it says massage therapy!

2019: Virginia Bill Proposal: https://law.lis.virginia.gov/vacode/title38.2/chapter34/section38.2-3419/

2019: Oklahoma Bill Proposal: http://www.oklegislature.gov/BillInfo.aspx?Bill=HB+2652&session=1900&fbclid=IwAR3un4CZr0oHNWwloMCwbReEwCd6P0E31dqYx-svYRiO454GdI4l2N6qMrU

“Any health plan, including the State and Education Employees Group Health Insurance plan, that is offered, issued or renewed in this state on or after January 1, 2020, shall provide coverage for complementary and alternative medicine.”

2019: Bill in Maine: http://www.mainelegislature.org/legis/bills/bills_129th/billtexts/HP025501.asp

“This bill clarifies that massage therapists and massage practitioners are health care practitioners and that massage therapy is a health care practice. It prohibits unlicensed persons from claiming to provide procedures that are described as “massage,” “bodywork,” “body therapy,” “manual therapy,” “neuromuscular therapy,” “touch therapy” or “myotherapy” or related terms.”

2019: Bill in North Carolina. Bill Summary for S 544 (2019-2020)

Bill: ESTABLISH NON-OPIOID TREATMENT ALTERNATIVES. (https://lrs.sog.unc.edu/bill/establish-non-opioid-treatment-alternatives)

PART I. NON-OPIOID DIRECTIVE FORPROVIDERS OF PAIN MANAGEMENT 12CARE13SECTION 1.1.G.S.90-106 reads as rewritten: 14″§ 90-106. Prescriptions and labeling. (a3) Limitation on Prescriptions Upon Initial Consultation for Acute or Chronic Pain. –A Upon the initial consultation and treatment of a patient for acute or chronic pain, a practitioner, as a first line of treatment, shall provide the patient with a referral to, or a prescription for, any of the following alternatives to targeted controlled substances, when appropriate: (1) Acupuncture. (2) Chiropractic care. (3) Massage therapy. (4) Occupational therapy. (5)Osteopathic manipulative treatment. (6)Physical therapy.

AMTA 2019 Massage Profession Report (highlights):

“Approximately 47.5 million people had a total of 214 million massages in the U.S. in 2018, compared to 47.1 million people having a total of 179 million massages in 2017. “

“Massage therapists supported the integration into health care, with 95% believing massage should be integrated with health care. But how that integration looks varied greatly. The two most prevalent ways therapists preferred to see health care integration was by having massage prescribed or referred by health care providers, or by having massage therapists work on a team with other complementary practitioners.”

“The primary reason consumers obtained massage continued to be for medical, health and wellness purposes, or for stress reduction. Sixty-two percent of massage consumers had a massage in 2018 for health or medical reasons. Of these, 41% had their last massage for a health or medical reason. Sixty-six percent of massage consumers got a for relaxation/stress reduction in 2018, with 26% getting their last massage for this reason.”

“Consumers continued to believe in the efficacy of massage:

Eighty-eight percent of consumers agreed that “Massage can be effective in reducing pain.”
Eighty-eight percent of consumers agreed that “Massage can be beneficial to your health and wellness.”
Seventy percent of consumers agreed that “Massage therapy should be considered a form of health care.”
Sixty-seven percent of all consumers said they have or would recommend massage to a relative or to someone they knew in 2018.
Thirty percent of consumers expected to get a massage in the next 12 months.”

“The number of massage therapists receiving insurance reimbursement increased in 2018Twenty-five percent of massage therapists were reimbursed by insurance for massage, up three percent from last year. Insurance reimbursement includes multiple types of insurance, not only health insurance. For practicing massage therapists, 11% were reimbursed by health insurance (either private payer or public system), 8% by auto insurance, 5% were reimbursed through workers’ compensation, and 2% accepted other insurance reimbursement.”

“The 2018 AMTA Industry Survey provides information on insurance reimbursement for auto, medical, workers’ compensation and other insurance.
Insurance reimbursement makes up between 12% and 28% of the total revenue for the average therapist that accepts insurance. Those that accept private payer medical insurance having the highest percentage of total revenue from insurance, and those that bill workers’ compensation insurance have the lowest percent of total revenue from insurance, consistent with 2017 data.
Depending on the type of insurance, the average amount of reimbursement received varied widely”

“The average amount of reimbursement increased for auto and worker’s compensation insurance increased last year and declined for medical and “other” insurance. Insurance reimbursement is determined by each state and health care policy and not all states permit insurance reimbursement for massage provided by a massage therapist.”

March 2019: The Veterans Administration lists massage therapists as Health Technicians, allowing the VA to hire massage therapists. See the VA Handbook for complete details (Document number 005/108: Staffing – Appendix G56 Health Technician (Massage Therapy) Qualification Standard). https://www.va.gov/vapubs/Search_action.cfm?formno=&tkey=&dType=2&SortBy=issue&sort=desc&oid=0&fbclid=IwAR148-S0ux6V2aQj1CrYppE1JIxV66VTH4BNRMLfg4WQpVWX7S01wvOMIWk

(It took over 15 years to make this happen. Now that it’s official the VA accepts massage therapy as a valid method of treatment, my guess is that having their insurance cover massage will be next. The VA has created a definition of massage therapy—something the massage profession has failed to do.)

May 2019: In 2016, the Comprehensive Addiction and Recovery Act of 2016 was passed and created The Pain Management Best Practices Inter-Agency Task Force. The purpose of the task force was to propose updates to best practices and issue recommendations that address gaps or inconsistencies for managing chronic and acute pain. The U.S. Department of Health and Human Services oversaw this effort with the U.S. Department of Veterans Affairs and U.S. Department of Defense.

The result is a new report on pain management best practices that includes calling for the use of massage therapy. The U.S. Pain Foundation has created a toolkit for taking action. https://uspainfoundation.org/advocacy/inter-agency-task-force-toolkit/

IF this does not get us moving, I don’t know what will.

Let’s get to the table.

Whether you like it or not, whether you want it or not, massage therapy will most likely be covered by health insurance….eventually….or so it seems with so many calling for it’s use. The thing is that we are not at any table at all. We do not have associations stepping up to the table to be our voice. It is important to start having these conversations NOW so that the massage therapy profession can bring our message to the table and create what we want as far as benefits and allowable fees. We need to be at the tables in each state with insurance commissioners, health care insurance carriers, and in state capitals where laws are being created. Otherwise it will be too late and we will be handed the leftovers.

To be at the table means that the massage therapy profession needs to attend meetings with State Insurance Commissioners offices, be talking to state and national health insurance plans and be involved in all efforts to help combat the Opioid epidemic. To get to the table requires making connections like the one that started it all here in WA State. The Insurance commissioner back in 1992 was Deborah Senn, who also had an office assistant who was also a massage therapist (Lori Belinski – now Lori Grassi who is the executive director of the WA state chiropractic association and lobbyist for the same group).

We need legislators in office at the state and national level that support massage enough to create laws that will make it so massage therapy is covered by health insurance. We need state and national lobbyists and political action committees. WA State has one of the of the only Political Action Committees that I know of in the US – the WA Massage Alliance for Health (www.wamah.org). We also have a person in the house of representatives, Shelly Kloba, that has been a massage therapist for over 20 year and sponsored a bill in 2017 on prior authorization.

There are some that also say that we need to up our education standards before anything can happen with insurance companies and laws…but I personally think that it is more an legislative effort because of watching what has happened here in WA. When the Every Category Law was created, WA MT’s were only required to have the minimum of 500 hours of education which was the norm at that time and still is the basis for licensing in many states.

Do we need more evidence as many MT say? I personally don’t think so based on what I have seen. We do have enough evidence right now to get started. More is coming out every day. We don’t have to wait any longer.

We just need people to step up and sit at the table for us.

State legislators that support massage therapy
State insurance commissioners that are willing to create laws that include massage therapy like the WA Every Category Law
Health care specialists (Lawyers, healthcare executives) who know how to deal with insurance companies to negotiate contracts and help us determine the best ways to talk to insurance companies. Do we need physicians networks or clinically integrated networks like some hospitals/physicians are moving to so that they can negotiate contracts while also providing health care services that are paid based on their results (values based care) instead of just fees for services?
Massage awareness networks that work to educate doctors, legislators and insurance carriers on just what massage therapy can do. (It is clear to me that the insurance companies still see massage therapy as a burden and think that they have to pay out the $25k or more for surgeries or thousands in drugs rather than using massage to eliminate those costs.) We do not have enough data on things like how much is massage therapy saving the insurance companies. The only thing we do have is the report from AMTA on Integrative Care and Pain Management.
Political Action Committees for every state and One National one. PAC’s raise money to help get the right candidates into office that support massage therapy.

Learn to bill insurance NOW so you can start to understand the issues at hand and start learning about how insurance works so we can have more therapists and clients behind the people we get at the table. There is power in numbers. 350k + massage therapist and their clients = ??????????

ICD -10 codes for Massage Therapists

May 25, 2019 By Julie Onofrio 11 Comments

Yes ICD -10 codes are here and there is a lot of information that you will need to know. International Statistical Classification of Diseases and Related Health Problems codes are created by the World Health Organization and are used around the world. They are diagnosis codes that are used when doctors prescribe massage so you will need to be up on what is going on.

The next version – ICD-11 are already on the way. In May 2019, ICD-11 will be presented at the Seventy-second World Health Assembly for endorsement by Member States. In January 2022, Following endorsement, Member States will begin reporting health data using ICD-11. (WHO timeline)

ICD-9-CM codes were 5 digits

First digit is alpha (E or V) or numeric
Digits 2-5 are numeric
Decimal is placed after the third character
14,000 codes

ICD-10-CM codes are 7 digits and there are 69,000 codes to better capture specificity.

Digit 1 is alpha.The two main category of codes massage therapists will see most of are the M and S codes:
- M = musculoskeletal or connective tissue condition
- S = injury or consequences of external causes
Digit 2 is numeric
M00-M25 Arthropathies
(M00-M03) Infectious arthropathies
- (M05-M14) Inflammatory polyarthropathies
- (M15-M19) Arthrosis
- (M20-M25) Other joint disorders
- M40-M54 Dorsopathies
- (M50-M54) Other dorsopathies(M45-M49) Spondylopathies(M40-M43) Deforming dorsopathies
- M60-M79 Soft tissue disorders
- (M60-M63) Disorders of muscles
- (M65-M68) Disorders of synovium and tendon
- (M70-M79) Other soft tissue disorders
- M80-M90 Osteopathies
- M91-M94 Chondropathies
- M95-M99 Other disorders of the musculoskeletal system and connective tissue
- S00-T14 – Injury
  - (S00-S09) head
  - (S10-S19) neck
  - (S20-S29) thorax
  - (S30-S39) abdomen, lower back, lumbar spine and pelvis
  - (S40-S49) shoulder and upper arm
  - (S50-S59) elbow and forearm
  - (S60-S69) wrist and hand
  - (S70-S79) hip and thigh
  - (S80-S89) knee and lower leg
  - (S90-S99) ankle and foot
  - (T00-T07) involving multiple body regions
  - (T08-T14) unspecified parts of trunk, limb or body region
Digits 3–6 are alpha or numeric
For “M” and “S” category codes, the side of the body is indicated. Generally:
1 = right
2 = left
Note: There are a variety of different methods for denoting bilateral locations
Decimal is placed after the third character
7th digit is a special extension code that will be alphabetical and is required for injury codes that start with S.

A: Initial Encounter – Patient is receiving active care. You can use A on multiple claims for the same condition – it really isn’t just for the first encounter. “A” code for initial encounter is used for all sessions related to the “active” treatment for the symptoms called out in the ICD10 code.
D: Subsequent Encounter – After patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Rehab therapy is usually considered to be part of the healing and recovery phase. The “D” code is used for subsequent treatments to check on the patient/client after active treatment is completed.

S: Sequelae — Complications or conditions that arise as a direct result of the condition that are caused from the direct result of an injury or condition.
Fractures have a different extension code than other conditions based on open vs. closed, routine vs delayed healing, non-union or malunion.

ICD-10 codes will provide specific locations for injuries. They will also document chronic or acute pain issues. The new codes are much more specific and will provide us with much more information about diseases and their treatments which will help with health management and research.

Since these are diagnosis codes and massage therapists can not diagnose clients, the codes will come from the doctor. The doctor may or may not write the actual description of what the code means so you may have to look the code up to know what it means. It is best to get the actual code from the doctors so that you can put the same code on the bill as the doctor does to tell the insurance that you are working on the same condition. Often times there are a variety of codes that can be used for one condition so it is important to know which one the doctor is using. There are many free code look up databases online. See ICD 10 Look up from CMS.

Here also are some common orthopedic codes that are used for rehabilitation

M54.2 Cervicalgia
M50.01 Cervical disc disorder with myelopathy, occipito-atlanto-axial region
M50.02 Cervical disc disorder with myelopathy, mid-cervical region
M50.03 Cervical disc disorder with myelopathy, cervicothoracic region
M54.30* Sciatica, unspecified side
M54.31 Sciatica, right side
M54.32 Sciatica, left side
M54.40* Lumbago with sciatica, unspecified side
M54.41 Lumbago with sciatica, right side
M54.42 Lumbago with sciatica, left side

There are specific codes just for pain. It has been previously said that massage therapists can use pain codes to bill the insurance without a prescription. I have never seen a health care plan that does not required massage to be medically necessary which means a prescription is needed. Pain needs to be carefully diagnosed to rule out more severe injuries or conditions like heart attacks, kidney stones etc. Here are common pain codes:

Shoulder — M25.511 (R), M25.512 (L)
Upper Arm — M79.621 (R), M79.622 (L)
Elbow — M25.521 (R), M25.522 (L)
Forearm — M79.631 (R), M79.632 (L)
Wrist — M25.531 (R), M25.532 (L)
Hand — M79.641 (R), M79.642 (L) (excludes fingers)
Hip — M25.551 (R), M25.552 (L)
Thigh — M79.651 (R), M79.652 (L)
Knee — M25.561 (R), M25.562 (L)
Lower Leg — M79.661 (R), M79.662 (L)
Ankle — M25.571 (R), M25.572 (L) (excludes foot/toes)
Foot — M79.671 (R), M79.672 (L) (excludes toes)
Thoracic Spine — M54.6
Low Back Pain — M54.5

As you can see, these codes are much more specific so that will give you so much more information and tracking the codes will provide data for various conditions to see what therapies work best.

There is much more to billing insurance then just putting an ICD-10 code on a bill. Learn to bill insurance and see my plan to get massage therapy covered by health insurance in every state in my book : Massage Insurance Billing.

Other resources:

CMS Provider resources

World Health Organization

Originally written Aug 6th 2015. Updated Jan 30 2016, Updated 05/25/2019

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Medicare Advantage Plans to cover massage therapy

December 11, 2018 By Julie Onofrio 4 Comments

Step by step…little by little…. massage therapy is being accepted by health insurance.

The latest step is the news that 270 Medicare Advantage Plans WILL be covering massage therapy. It was a part of recent efforts by AMTA to make this happen.

AMTA News Brief September 4, 2018: AMTA Reaching Out to 700 Medicare Advantage Plans

The Centers for Medicare & Medicaid Services (CMS), the federal government department that administers the Medicare program, recently issued guidelines that named massage therapy as a medically-approved, non-opioid treatment alternative.

AMTA News November 28, 2018: CMS Announces Up to 270 Medicare Advantage Plans Will Include Massage Therapy in 2019

The CMS Press release says:

Medicare Advantage enrollment is projected to increase to an all-time high from the current enrollment of 20.2 million to 22.6 million in 2019, an 11.5 percent increase compared to 2018.

As a result of the new flexibilities on supplemental benefits available for the first time in 2019, about 270 plans are providing nearly 1.5 million enrollees with access to the following new types of benefits:

Expanded health related supplemental benefits, such as adult day care services, in-home support services, caregiver support services, home-based palliative care and therapeutic massage; and

Medical advantage plans are HMO or PPO plans that are approved by Medicare. There are many different types of Plans so it is not clear where the massage therapy benefits will come into play. People purchase these plans above and beyond their Medicare coverage.

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare pays these companies to cover your Medicare benefits.

What does that mean?

We don’t really know yet and don’t have enough information.

That specific language is concerning to me… do they mean that massage therapy will only be used in home based palliative care situations and not be a part of rehabilitation benefits to reduce pain and help deal with musculoskeletal injuries?

There is much that we will need to know. Here are some things to start asking:

What plans will cover massage therapy?
What is the language in each plan that says massage therapy will be covered?
Is there a definition of medical necessity in each plan around the massage therapy benefits? What does it say? Will massage need to be medically necessary?
Will a prescription be required? (It will need a prescription if it needs to be medically necessary but not sure if it would if it is palliative care, but many elderly people will have many other health issues that may be a contraindication and will need to be OK’d by a doctor and maybe also prescribed by a doctor.)
What will be covered? Will it cover massage for rehabilitation from surgery, injuries or just the palliative care?
Will it cover massage therapy for cancer recovery?
What will the benefits be?
What CPT code will be allowed? 97124 or 97140 are the two main codes allowed now by health insurance.
How many sessions will be covered?
How will medicare be billed?
Will billing insurance make your massage business more profitable? See the formula for figuring it out.

Now What?

Having Medicare recognize that massage therapy should be a part of their benefits is a good first step. Other health insurance companies may follow once they see that Medicare approves of massage therapy. If they are only approving it as a part of palliative care, then we have more work to do in that area. Massage therapy could help insurance companies save money in the area of Pain Management. AMTA at this time seems to be focusing on the pain issues and the Opioid epidemic with their recent report: Massage Therapy in Integrative Care & Pain Management

Massage therapy’s role in integrative health care has become widely accepted in major hospitals and in daily medical practice. A wealth of research has also shown the impact of massage therapy for pain management and relief.

Pain is only one very small part of what massage therapy can help with. As a massage therapist in WA since 1989, I have been able to work with clients and bill their health insurance for many conditions such as:

Headaches, Migraines
Fibromyalgia
Strains/Sprains
Herniated Discs
Neck, Shoulder, Back, hip, knee, foot, hand, forearm, leg pain of all sorts
Tendinitis

Health insurance in WA does not cover massage therapy for stress, depression and anxiety which could be added to the list.

As you may already know, WA State has been billing health insurance for medically necessary massage services since about 1999 with the creation of the Every Category Law that mandates coverage by every category of provider. It was introduced in 1993 and fought by the insurance companies until 1999 when it was upheld by a Supreme Court Decision. (See timeline of events. )

WAC 284-170-270 Every category of health care providers.

(1) Issuers must not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice for services covered as essential health benefits, as defined in WAC 284-43-5640 and 284-43-5642 and RCW 48.43.715, for individual and small group plans; and as covered by the basic health plan, as defined in RCW 48.43.005(4), for plans other than individual and small group.

For individual and small group plans, the issuer must not exclude a category of provider who is licensed to provide services for a covered condition, and is acting within the scope of practice, unless such services would not meet the issuer’s standards pursuant to RCW 48.43.045 (1)(a). For example, if the issuer covers outpatient treatment of lower back pain as part of the essential health benefits, any category of provider that provides cost-effective and clinically efficacious outpatient treatment for lower back pain within its scope of practice and otherwise abides by standards pursuant to RCW 48.43.045 (1)(a) must not be excluded from the network.

With the combination of Medicare recognizing massage therapy and the precedent set in WA State, massage therapy is on its way into healthcare – whether we want it or not. There are many issues in being a part of healthcare that we are not prepared for. We do not have enough in the way of advocacy in place to talk to the insurance carriers and legislators who create the laws. We need to be at the table or we will be on the menu.

I have my own ideas on what needs to happen to get massage therapy covered by health insurance from my experience of billing insurance in WA State (billing PIP, workers comp since 1990 and health insurance since about 2000) and working with the local massage associations and being a board member for awhile for WSMTA and now the Political Action Committee in WA State – WAMAH.

Getting massage therapy covered by health insurance in the US.

December 4, 2018 By Julie Onofrio Leave a Comment

All over the US, various organizations are calling for the inclusion of massage therapy in healthcare to help combat the Opioid epidemic and more.

Massage Therapy can help with pain relief and management, and can be a big part of resolving many musculoskeletal injuries and conditions. Many organizations are calling for alternative options for pain such as massage therapy among other therapies.

Meanwhile in WA State, massage therapists have been able to bill health insurance for the many pain related injuries and conditions because of a law that was created in 1993 called the Every Category Law (WAC 284-170-270) that states:

“(1) Issuers must not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice for services covered as essential health benefits, as defined in WAC 284-43-5640 and 284-43-5642 and RCW 48.43.715, for individual and small group plans; and as covered by the basic health plan, as defined in RCW 48.43.005(4), for plans other than individual and small group.

For individual and small group plans, the issuer must not exclude a category of provider who is licensed to provide services for a covered condition, and is acting within the scope of practice, unless such services would not meet the issuer’s standards pursuant to RCW 48.43.045 (1)(a). For example, if the issuer covers outpatient treatment of lower back pain as part of the essential health benefits, any category of provider that provides cost-effective and clinically efficacious outpatient treatment for lower back pain within its scope of practice and otherwise abides by standards pursuant to RCW 48.43.045 (1)(a) must not be excluded from the network.”

The Every Category Law was fought by the insurance companies for about 5 years and guess what…. the Every Category Law won and won big. A Supreme Court decision ended the battle with the Every category law moving forward.See the time line of events in implementing the Every Category Law in WA State – Report of the Clinician Workgroup on the Integration of Complementary and Alternative Medicine January 2000. Washington State.

The insurance companies in WA State also require that there be a loss of function AND pain in order for massage therapy to be covered by health insurance. That means massage therapy is used to help with many conditions such as carpal tunnel, herniated discs, headaches and much more than just pain issues.

The Call for Massage Therapy

In 2010, The Affordable Care Act opened the doors with Section 2706 that said insurance companies “shall not discriminate”against any health provider with a state-recognized license. Section 5101 includes licensed complementary and alternative medicine providers and integrative health practitioners in its definition of health professionals in the“health care workforce.” Yet nothing was done by any of the massage therapy associations.

In 2011, Relieving Pan in America:(PDF) A Blueprint for Transforming Prevention, Care, Education, and Research said reviews of research on acupuncture, massage, and chiropractic spinal manipulation for chronic low back pain suggest these therapies may be beneficial.

In 2016, the CDC even said: “Although there are perceptions that opioid therapy for chronic pain is less expensive than more time-intensive nonpharmacologic management approaches, many pain treatments, including acetaminophen, NSAIDs, tricyclic antidepressants, and massage therapy, are associated with lower mean and median annual costs compared with opioid therapy. CDC Guideline for Prescribing Opioids for Chronic Pain “— United States, 2016

In Feb 2017, the National Association of Attorney Generals, issued this letter (PDF), asking for alternatives to Opioids be considered to help end the epidemic.“When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care. “

In Jan 2018, the Academy of Integrative Pain Management (AIPM) and the US Pain Foundation, wrote a letter to the U.S. Senate Committee on Finance (the Committee with jurisdiction over the Centers for Medicare and Medicaid Services, or CMS), asking them to cover massage therapy.

The Joint Commission has also previously called for coverage of massage therapy in 2015 (PDF) “Revised Rationale for PC.01.02.07 (New for Ambulatory Care and Office-Based Surgery Practice)

“The identification and management of pain is an important component of [patient]-centered care. [Patients] can expect that their health care providers will involve them in their assessment and management of pain. Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. The following examples are not exhaustive, but strategies may include the following: Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy”and again in 2017 ”

“When a patient’s preference for a safe nonpharmacologic therapy cannot be provided, hospitals should educate the patient on where the treatment may be accessed post-discharge. Nonpharmacologic strategies include, but are not limited to: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment,massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.”

In April 2017, the American College of Physicians did a study to systematically review the current evidence on nonpharmacologic therapies for acute or chronic nonradicular or radicular low back pain and here is their recommendation: “Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate- quality evidence),massage, acupuncture, or spinal manipulation (low-quality evidence).” https://www.ncbi.nlm.nih.gov/pubmed/28192793

In April 2017, Federation of State Medical Boards April 2017 adopted their policy on Chronic use of Opioids and recommended: “The treatment plan may contain information supporting the selection of therapies, both pharmacologic (medications other than opioids to include anti-inflammatories, acetaminophen, and selected antidepressants and anticonvulsants) interventional, and non-pharmacologic therapies such as cognitive behavioral therapy,massage, exercise, multimodal pain treatment, and osteopathic manipulative treatment. The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered to the extent they are available.

In Oct 2017, the first Integrative Pain Policy Conference was held in San Diego. The AMTA was invited and was supposedly there according to the report from the Academy of Integrative Pain Management, but to date I have not heard any report from the AMTA. The Congressional Integrative Health and Wellness Caucus held on March 15, 2015 calls for:

The mission: “Amidst Opioid Crisis: New Caucus Will Focus on Integrative Health Solutions.

Make sure you contact your legislative representative and ask them to JOIN. Medicare Managed Care Manual Chapter 4 – Benefits and Beneficiary Protections. Revised for 2019 coverage Year also calls for more massage therapy as an alternative to Opioids.

“Medically-Approved Non-Opioid Pain Management (PBP B13d, e, or f ): Medically-approved non-opioid pain treatment alternatives, including therapeutic massage furnished by a state licensed massage therapist . “Massage” should not be singled out as a particular aspect of other coverage (e.g., chiropractic care or occupational therapy) and must be ordered by a physician or medical professional in order to be considered primarily health related and not primarily for the comfort or relaxation of the enrollee. The non-opioid pain management item or service must treat or ameliorate the impact of an injury or illness (e.g., pain, stiffness, loss of range of motion).” https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf

Massage Therapists are licensed as Health Care Providers in over 20 states. This is the list that I have so far, collected from various Facebook Groups so check the sources and let me know of any corrections.AL, CO, CT, FL, GA, LA, MI, MD (LMTs only) MO, NC, NM, NY, OH, OR, TN, VI, WA, Wa DC, WI, WV, WY.In most states, massage therapists can bill for car accident related injuries and for work related injuries.With so much interest and backing from prominent organizations calling for massage therapy to become part of the answer to the Opioid Epidemic, where is the Massage Therapy Profession?

How to get massage therapy covered by health insurance in your state.

Find out if you are licensed as a health care professional. Please find the link to a page in your laws that show that massage is licensed as a health care profession in your state and share in the comments.
Look at what has been done in WA State in this arena. They have been able to bill health insurance since about 1996 because of a law called the Every Category Law http://apps.leg.wa.gov/wac/default.aspx?cite=284-170-270 that was put into place after a long battle with the insurance companies that wanted to stop it. There is even a supreme court decision making it into law. See time line of events in implementing the Every Category Law in WA State – Report of the Clinician Workgroup on the Integration of Complementary and Alternative Medicine January 2000. Washington State
Join Healthcare Integration for Massage Therapists Facebook group
Find out what is happening in your state on creating a different law that would make health insurance companies cover massage.
Find out what your AMTA chapter is doing. Here is a list of them on Facebook. https://www.facebook.com/lists/10151631915757567 Here is a list of them on the AMTA website: http://www.amtamassage.org/chapters/index.html Many of the AMTA Chapters are not currently doing anything but a few are. OH, WI, WV are working on getting laws passed that include coverage for massage therapy.
If your AMTA Chapter is not working on anything and they are not interested in working on anything – Join them and tell them you want to be on the Government Relations Committee. You will need them to get a lobbyist to help you. A lobbyist costs about $40,00-$100,000 a year. AMTA should be paying for the lobbyist in your state.
If you can’t get anywhere with AMTA, start your own separate state organization – like WA did – WA State Massage Therapy Association. . No one has been at the table for us and in the past 6 years or so – the insurance companies have been constantly reducing our allowable fees making it more difficult to make a living billing health insurance. This will be a much slower process as you will need to have enough members and make enough to pay a lobbyist. Keep working on AMTA Chapters until they let you do this or want to be involved.
Find out what your Insurance commissioner needs and start the conversation with them about getting massage integrated into healthcare. http://www.naic.org/state_web_map.htm
Write a letter to be sent to the OIC in your state. You will need this info for the OIC and use the above requests for massage therapy to be incorporated into healthcare along with these papers: MASSAGE THERAPY IN INTEGRATIVE CARE & PAIN MANAGEMENT (PDF) Published by the American Massage Therapy Association The Value and Efficacy of Massage therapy. Published by the American Massage Therapy Association Summary of Evidence (PDF) – How massage fits into the Essential Health Benefits (Created by AMTA-WA).
Write a letter that clients can send to their insurance company asking for massage therapy to be covered.
Write a letter that clients can use to send to the OIC.
See also: www.covermycare.org http://www.covermycare.org/cmc/the-cmc-toolkit/
You will also need a Political Action Committee. WA State has one that was started in about 2005 to help support candidates who support massage therapy – WA Massage Alliance for Health (www.wamah.org) Our Every Category Law constantly needs protection and to get anywhere with healthcare, you need a PAC. Oh and why don’t we have a National PAC???

So there you have enough to get yourself started. These are just my suggestions after seeing what has happened in WA State and being on the Board of a few organizations.

Join my closed Facebook Group : Health Care Integration for Massage Therapists to
continue the discussions and start creating plans.

Overcoming the Objections to getting massage covered by health insurance.

My goal here is to get massage therapists to the table with the powers that be – insurance commissioners, health insurance carriers and legislators before they just jump in and make massage therapy covered by health insurance. From what I have been seeing, so many things are pointing us in that direction (see above), but we are not ready. We need to be part of the process of setting this up so we can have more of a say in what is set up.

The health care system is broken. Yes it is, but it is what it is. What will it be like if/when it moves to a one-payer system?

It takes too much time to bill and get paid. Billing health insurance is all done electronically and once you are credentialed with a carrier, the payment times are about two to four weeks.

You have to do too much paperwork. Paperwork is really minimal and not much more then you need to be doing already. SOAP charting and filling out the CMS 1500 billing form are all done online.

You won’t be able to work in the way you want and your massage will be dictated by the insurance. Not really. You won’t be able to do full body relaxation massage. It will be specific area massage therapy for rehabilitation of conditions like carpal tunnel syndrome, herniated discs, headaches and more. If you can support your massage work through charting, you can do it.

It is coming folks…whether we/you want it or not. The clients/patients want massage therapy covered by health insurance.

Why not be on the forefront of making it happen and have our voices heard from the start?

Learn to bill health insurance and be involved in
getting massage therapy covered by health insurance.

Billing Health Insurance in WA State

November 4, 2018 By Julie Onofrio Leave a Comment

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.

RCW 48.43.016 Prior authorization standards and criteria—Health carrier requirements—Definitions.

(2) A health carrier may not require prior authorization for an initial evaluation and management visit and up to six consecutive treatment visits with a contracting provider in a new episode of care of chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan. Notwithstanding RCW 48.43.515(5) this section may not be interpreted to limit the ability of a health plan to require a referral or prescription for the therapies listed in this section.

(6) For purposes of this section:

(a) “New episode of care” means treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment.

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?

Coming Soon! New Edition of Massage Insurance Billing Manual

September 22, 2018 By Julie Onofrio Leave a Comment

I have been working on the new edition of the Massage Insurance Billing 101 Manual this summer and will continue to work on it this Fall 2018 and hopefully it will be done before the end of the year.

The new expanded and updated version will have much more information

how to build a business billing insurance
how to get referrals from doctors
how to set up a hospital based massage business
EHR and how to choose the best system
Negotiating Contracts
How to get massage covered by health insurance in YOUR State.

Purchase the 2015 PDF version now and get the new Edition too when it comes out soon! (No guarantee on the timeline but hopefully Jan 2019!)