Massage Practice Builder

Billing Insurance for massage services has been one of the ways I have been able to stay in the massage profession for 23 years. Right from the start of my career after a 250 training class in massage (which at the time in 1987 was the basic education requirement for me to get my massage license), I was able to work with people with injuries from car accidents and injuries at work.  It took a bit to figure out on my own at that time because there wasn’t any internet and there was only one book on billing (Chris Rosches – Insurance Reimbursement for Bodywork Professionals) but it was enough to get started.  Along with the help from my friends who were also learning to bill, we were able to put it all together and get auto insurance and Labor and Industries (workers comp.) to pay for massage.

There are many things you need to know in order to work with insurance companies.  In some ways with technology, it is getting easier to get bill and get paid but with insurance companies bottom line of making a profit, they are reducing massage benefits and allowable fees making it challenging to get paid.

Some of the things you will need to know are:

• How to find out if massage will be covered and what you need to do to get paid
• How to do a thorough intake with clients
• How to fill out the billing form
• What CPT codes you can use
• What to charge for your services
• What the prescription will need to say
• How to do SOAP charts that show improvement for clients and track their progress
• How to do progress reports
• How to track bills and payments
• What to do if you don’t get paid
• How to get referrals from doctors or other health care professionals

To make it all even more confusing, each insurance plan will be different.  You can have two people on the same plan and one may pay and one won’t.  Each state is different.  Each plan is different.  Each client is different.  What you will need to know is what questions you will need to ask to each involved party – the client/patient, the insurance company, the lawyers and the doctors – in order to get paid.

At first, billing insurance will be a challenging process to learn.  You will be learning as you go but eventually you can learn what cases to take and which ones to stay away from.  You will be able to decide what cases you want to take which will make getting paid a little easier although not totally foolproof.  Even with all that, you may still have challenges in billing insurance.

That is why I have created a section for it on my website and have written an Ebook/book on the topic – Insurance Billing 101 for Massage Therapists -  to get you started in understanding the process of billing.  With the many challenges with insurance companies, I think that the more people involved, the more we will be able to really show what massage can do.  Part of what insurance companies don’t understand is that massage can actually save them money in the long run.  When it was first proposed that the insurance companies in WA State would be required to let massage therapists be contracted providers and bill health insurance, the insurance companies thought that they would be having to pay $10,oo0 for the carpal tunnel surgery and then another $1,000-$2000 to the massage therapist.  They didn’t (and still don’t totally) understand that it would save them the 10k!

The more people who stand up and start billing insurance, writing accurate and informative chart notes, the more insurance companies and doctors will start understanding what we are really doing as massage therapists.

Billing Insurance for massage services is one way of setting yourself aside from other massage therapists and also helping to build your massage business.  Each state and each insurance plan actually can be different making it a maze of paperwork and frustration.   Learning about what is needed in your state to bill insurance companies and get paid within a reasonable time is a process.

As far as I know, every state can bill for injuries on the job (workman’s compensation, labor and industries or whatever it is called in your state and for motor vehicle accidents.  I did hear that PA was having some issues around being able to bill for those so maybe someone could chime in.  I am also looking to create a list of states in which you are able to bill HMO’s and PPO’s and other resources for taking classes and finding a mentor to help you learn to bill in your state.

The first thing to do though before you do go out billing insurance companies is to take the time to figure out if doing this will be profitable for your business.   Figure out your cost per client using the simple formula that I have on the main site.

Learning everything you can about insurance billing before you start will help you prepare the proper forms and have an understanding of what to do.  Getting a mentor or finding a class in your area is really one of the best ways to learn.  Once you learn the basics then it is a matter of keeping up to date with the latest forms and codes that you need to know.

After you have decided that you do want to bill insurance companies here are some other things you will need to look into?

• Do I need a National Provider Number (NPI)?  You can sign up for one easily at NPPES
• Get the proper forms in order.  You will need an intake form that asks the same questions that are on the required billing form the CMS 1500.   You can see what a form looks like here.
• You will need to know how to do chart notes and progress reports.  Efficient documentation is one of the keys to getting paid.
• Learn what questions you need to ask the client and the insurance company.  You can start with some of the questions I use and then figure other questions that will be necessary in your state or for various insurance companies.
• Learn how to work with doctors and create a marketing plan to contact doctors and create a referral network.

The thing to remember is that the information I am providing is based on my experiences and work in WA State.  Some of it may or may not apply to your situation and state.  You will have to find out for yourself what YOU need to bill effectively!

I am also starting a group at a ning.com community (free to join and use) of massage professionals to hopefully connect more people with others in their state and get more help with learning to bill insurance companies more effectively.

Through the years massage insurance billing to me has been such a mixed blessing.  I am constantly challenged by the ethical dilemmas in billing insurance companies.   Last month an insurance company told me to just make up a code to put on the bill.  They were telling the patient that no script was needed but it is in every case.

In WA we have the unique status of being able to be a contracted provider with HMO’s and PPO’s.  To me that means we do the same work and more work and get paid less!  You do get to see clients more often than you would for the most part if they were paying cash but it is as such a price.

Some of the other problems are:

• clients often no show more often because they think the insurance company is paying.  This requires having a cancellation policy and enforcing it.  I have gotten more grief from clients with insurance when I try to enforce my policy for some reason.  They just don’t respect their sessions as much it seems.  (of course there are also many who do.)
• Clients will often think that they can just get massage for anything because they have coverage.  It doesn’t cover wellness massage.  Insurance companies have a medical necessity clause that usually says something like “to rehabilitate or restore function of an acute condition. It does not cover maintenance massage”.  Of course there is no list  of what is maintenance massage or what conditions it does cover.  Doctors seem to be prescribing massage for their patients without realizing that it is not usually covered if they just have an ache without loss of function.  There are also many massage therapists out there who will do maintenance massage and also make up diagnosis codes so it can be challenging when you have to turn a client away only to be taken up by someone who will ‘let it slide’ as one guy said through the system.
• Delays in payment – having to call multiple times to get paid
• Stop payments – companies are now requesting chart notes and it seems that no matter what I write they are denied.  I have taken classes in chart noting.  They do not have any reason other than they just think everything is maintenance massage.
• It is more difficult to get clients to continue their treatments after they are better and pay cash.
• Talking to insurance companies is like talking to a wall -literally.  I had to be on a 3 way phone conversation with the patient, the patient customer service rep and me and I actually could not speak to the patient rep as a provider.  It just wasn’t allowed.
• Each year our allowable fees are reduced along with patient benefits.   While I used to get paid well over $100 for one company they now pay less than $70.  They do not raise their allowable fees very often.  Last year I got a raise of about .02 from one company.  One company used to allow over 45 sessions a year and now are down to 16 sessions a year.  They are constantly decreasing everything

The thing is that it is really difficult to change anything with the insurance companies since they have such power.  I have heard from many other massage therapists in other states wanting to know how to get on a provider list in their state.  Some companies in other states are now allowing that but it is really such a mixed blessing – How do we as  a profession gain the strength to stand up to insurance companies?  How can other states go into credentialled contracts with insurance companies with more open eyes and make better decisions about accepting insurance for massage services?

How can we get out of managed care and create our own system of health insurance or health care that will have the patients benefits in mind?  Or is there a way to participate in managed care and work to change the system?

What if the big associations had commercials on TV and radio for massage to promote massage and help massage therapists build cash businesses?  I could see it now  – an announcer about to talk really fast about the side effects of massage and they start very slowly saying something like ‘ well you will just feel better’.

To help other massage therapists understand and do massage insurance billing I do have quite a bit of information on how to do it on my website.  I leave that info up with mixed feelings also but I think massage therapists need to know how to bill so they can see just what it is like  so we can begin to make changes in the system.