Massage therapy and PT

Since well before the Affordable Care Act, massage therapists have been struggling for recognition in the medical community. Alternative care in general suffered from a pretty low opinion, but massage was often lower still. So many insurance policies covered chiropractic and acupuncture treatments without covering massage. Somehow the fact that a massage made you “feel good”, as opposed to having your joints forcibly popped or getting needles stuck into your back, disqualified it from being a part of Serious Medical Care.

And so we fought with insurers and lawmakers about how massage should be treated like the CAM service it already was. The professions already went hand-in-hand, with so many massage therapists working in chiropractic offices, and with LMTs, LAcs, LCs, and NDs so often found under the same roof. Complementary and alternative care in general has such a broad variety of uses, and no single modality should be excluded.

Even though I knew that the changes would not happen immediately, when the Affordable Care Act took effect I assumed that before too long massage would gain its proper place alongside other CAM treatments. Alternative care of all kinds for everyone!

What’s happening with more and more insurance plans, however, is that massage is being thrown in an entirely different category than its CAM brethren. Massage is considered by these insurers to be a type of rehabilitative care, akin to physical therapy.

On the one hand, that’s pretty cool. Physical therapy is undeniably a medical treatment. If massage is like PT, that means massage has earned recognition as a medical treatment. Nice!

On the other hand, being a “rehabilitative therapy” instead of a “CAM therapy” means that massage is not as accessible as its companion modalities. In these insurance plans, chiropractic care and acupuncture treatments are available without needing to meet any deductible first, making them perfect for wellness and preventative care. Massage, however, is trapped behind (sometimes unreachable) deductibles, forcing the client to pay out of pocket for treatment or forego treatment entirely.

I get why they’ve done this, I suppose. The code I use to bill for massage (CPT 97140) is identical to one of the codes that physical therapists use. It’s actually considered a PT code by many insurance companies. And since Section 2706 mandates that insurers cover services based on the type of treatment as opposed to the type of practitioner, this is, in a way, less discriminatory.

But it still leaves me with a very bad taste in my mouth. Because by treating massage therapists in this way, insurers have declared that massage has no place in wellness or preventative care. We shouldn’t be giving massages that feel good (and help prevent future issues); we should only give massages that solve immediate problems.

If that’s the case, then where does rehabilitation end and relaxation begin? What a loaded question.

More and more – and this is true for providers in all physical medicine modalities – I have had to justify to insurers why my treatments are medically necessary. I find myself constantly trying to convince insurance companies that my massages are rehabilitative and purposeful even if the treatment has gone on “too long” (their words) and my client should be completely healed by now.

I was denied coverage for a treatment last week because the insurance company didn’t understand why I haven’t fixed all of my client’s muscle problems completely and forever such that he’ll never be in pain ever again. When I say it like that, it’s easy to see why this is foolish.

You know what should define a medical need? A doctor’s referral. If a doctor writes that his or her client needs massages, those massages are – almost by definition – a medical necessity. And yet, in practice, they don’t make a difference. Somehow insurance companies have convinced themselves (and the public) that they know best, even through they’re driven by profit over anything else.

Going back to my original point, I can’t say that I can see a clear resolution for this mess. The two billing codes* that massage therapists use are considered to be physical therapy codes, and therefore subject to physical therapy reimbursement requirements. It’s not just LMTs – if a chiropractor gives a pre-adjustment massage, this is also treated as rehabilitative treatment. The difference, of course, is that a spinal adjustment is a chiropractic code, and covered like a CAM treatment.

Should CPT 97124 and 97140 be considered the domain of LMTs, and covered in the same way that other CAM care is covered? Or maybe physical therapy should be available without a deductible? Some insurance companies already do that, and I’d be interested to see if it makes a difference in spending. If the insurance companies are all about the money, that might be our only chance of getting the point across.

* Depending on the insurer, sometimes both CPT 97140 and 97124 are considered PT codes, and sometimes only 97140 is. In the latter case, 97124 is either not covered at all or reimbursed at a lower rate.

EHB Discrimination

As I wrote about last week, insurance companies have been doing a great deal of “creative interpretation” in order to make the ACA guarantee only what insurers intend to cover. We see this very clearly with Section 2706: the broad, umbrella coverage of “any health care provider” has been reinterpreted to mean… well, nothing.

In the state of Oregon where I work, I’ve been in contact with the Insurance Division through filing complaints regarding discrimination. It hasn’t been fun.

The process has gone something like this:

  1. I send a list of complaints/denials to the analyst.
  2. The analyst forwards each complaint to the insurance company in question and asks them to explain their actions.
  3. The insurance company replies to the analyst with some reason as to why they denied coverage for this claim.
  4. The analyst forwards the reply to me and tells me that my denial is not, in fact, discrimination under Section 2706.

What’s missing from this chain of events? Something pretty important, actually: Any critical analysis at all of what the insurance companies say. Of course insurance companies are going to defend their actions! It’s the state’s job to tell them when they’re breaking the law. Instead, the excuses are being taken at face value.

After some back-and-forth exchanges, I’ve landed on the overarching reason as to why my massage services keep getting denied: Massage is not considered an Essential Health Benefit.

Way back when Oregon came up with their benchmark plan – that is, a plan that covers all of the Essential Health Benefits outlined in the Affordable Care Act – they did not choose a plan that covered CAM services. Acupuncture, chiropractic, and naturopathic could be added to the plan for an extra fee, but massage was nowhere to be found.

However, just because you say something doesn’t make it true. Massage has been proven to fulfill several of the EHBs in multiple ways. Mental health services. Rehabilitative services. Preventative and wellness services, including chronic disease management. There are documented medical benefits to massage therapy.

But because Oregon decided, however erroneously, that massage therapy did not meet any EHB requirements, LMTs were removed from the (not actually existent) list of “any health care provider” covered by Section 2706.

Most insurance companies aren’t fully denying the service of massage, though. That would effect other provider types who do meet the EHB requirements. Some insurers have placed massage in a category with physical therapy, which means that massage clients need to meet a large deductible before the service is covered, even though other CAM services are available without this hurdle.

Other companies have decided that massage is covered, but only in conjunction with another treatment, such as an chiropractic adjustment or a naturopathic visit. Since LMTs are, by their license, only allowed to perform massage, the only massage therapists who can take advantage of this are those who work under a DC or ND and don’t do their own billing.

…And just like that, we’re back to where we started: CAM coverage for everyone except LMTs. Massage coverage when performed by anyone except an LMT. In what world is a massage necessarily more effective when given by someone who doesn’t have 600+ hours of exclusive training? How can insurance companies claim not to discriminate when they refuse to accept a massage CPT code on its own, but cover the same exact code when it’s coupled with an adjustment or office visit code?

I pointed this out to the analyst, and he just shrugged.

I don’t know if Oregon has drafted a state-specific bill intended to reiterate the aims of Section 2706 (as a few other states have done), but I haven’t heard anything about one. The only reassurance I can find is that the Insurance Division just created a committee to talk about EHB coverage for a new benchmark plan for 2017 and beyond. I wasn’t chosen to be on the committee, but you can bet that I’ll be sharing my opinion.

State Non-Discrimination Laws

There’s a good bit of linguistic gymnastics going on when it comes to interpreting Section 2706:

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.

What kind of health care provider does Section 2706 apply to? Any kind. By not specifying provider types, the ACA intended to create an all-inclusive umbrella of coverage, so that no provider type would be unintentionally left out. Sounds nice, right? Unfortunately, this non-specific language is allowing insurance companies to continue its discrimination.

That’s what makes the most recent news out of Hawaii so frustrating. Some background: This state is one of a few states (also including New Mexico and Rhode Island) that has been drafting their own version of Section 2706. By making the language of Section 2706 into state law, these states are telling insurance companies that this section of the ACA is important and must be followed.

Last month in Hawaii, the state senate reviewed the language of the bill and decided to rework it to focus support specifically on naturopathic doctors.

Why just naturopaths? Hawaii already has strong insurance coverage for chiropractic and acupuncture; naturopathic medicine needs more protection against discrimination. And so, by specifying that insurance companies cannot discriminate against “naturopathic physicians acting within their scope of practice”, the law gets done what Section 2706 has had trouble doing, albeit for just one provider type. But one provider type is certainly better than none.

Recent news, however, shows just how tight of a grip the insurance companies have on lawmakers. The bill that had been reformulated to protect naturopaths has been amended yet again back to its original focus, the more general protection of “all licensed care providers”.

And, sure, that might sound great – everyone gets covered, right? Not just naturopaths, but also massage therapists. A win for us, surely?

But protection for “any health care provider” is already the exact language of Section 2706, and insurance companies are fighting hand-over-fist to allow continued discrimination. And considering that this change was in part due to requests by Kaiser Permanente, I think the insurance companies know exactly what they’re doing.

Cover My Care’s Toolkit

Cover My Care – the new outreach program for IHPC – has recently released their 2706 Toolkit.

From the CMC Toolkit page:

Our 2706 Toolkit provides information and tools for anyone interested in advancing the purpose of Section 2706: educating officials in your states, insurance company management, the local media, and joining or forming groups of consumers, patients and providers who insist that full access to affordable licensed providers is important to health care choices now and for the future.

Whether you’re a CAM practitioner or a patient who utilizes integrative medicine, the Toolkit has plenty of material for you to share with friends and clients.

Stay tuned! Coming soon to CMC: A page where you can share your stories of insurance denial and read what other patients have been going through.

Cover My Care

IHPC has introduced the next phase in their mission: Cover My Care.

This grassroots program is designed to “create public advocacy for access to all healthcare providers who are licensed in the states.”

Cover My Care’s objectives include:

      • Telling stories from all across America where these therapies are bringing relief and restoration of health to people.
      • Telling how these therapies are finding their way into standard medical practice: in medical education, in everyday care and in programs of wellness and prevention: in cancer, pain management, chronic disease, and stress management.
      • Providing toolkits and connections that can help you make the case in your state.
      • Making known the substantial medical education and professional certifications that practitioners in these disciplines must obtain in order to win licensure in their state.

They already have a number of posts on topics such as government relations, uses for alternative care, and updates on state licensing. The website is still in its early phase, but new posts are added every week. Make sure you bookmark Cover My Care and continue to check back!

Cover My Care Website

Cover My Care Facebook Page

Cover My Care Twitter

Credentialing with Insurance Companies In Oregon

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

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

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

What you will need to submit to the insurance company:

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

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

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

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

What insurers are big in Oregon?

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

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

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