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Massage Today
January, 2001, Vol. 01, Issue 01

Medically Necessary and/or Insurance-Related Cases for Therapists

By Vivian Madison-Mahoney, LMT

I would like to express my excitement and appreciation for this wonderful opportunity to be able to communicate and share with you my most passionate subject: physician-referred, medically necessary insurance cases.

My goal will be to inform, guide, and assist you in this sometimes complicated yet ever-rewarding adventure.

The following are some of the many issues we will cover in future articles in Massage Today:

  • medically necessary, prescribed cases vs. other clients
  • charting
  • documentation
  • patient intake
  • prescription content
  • confidentiality issues
  • release of records
  • authorization
  • verification of coverage
  • payment agreements
  • assignment of benefits
  • insurance billing procedures, techniques and guidelines
  • pros and cons of insurance cases
  • professional fees
  • types of insurance-related cases
  • collection procedures
  • protecting yourself from losses
  • dealing with other professionals
  • legalities
  • preparation for court cases
  • ethical considerations
  • tax issues and deductions
  • independent contractors vs. employees
  • tools of the trade for getting started on the right foot
  • and so much more!

In this our first issue, I will discuss what determines a medically necessary case, and help you understand the importance of physician-referred cases (whether or not you have intentions to or are able to accept insurance cases for payment in your region). I will also discuss how and when to make reference to a "patient" vs. a "client."

Medically Necessary Cases

To be classified as a medically necessary case to be eligible for insurance coverage, a physician must determine that the patient has a specific diagnosis. A professional examination and history of the patient is needed to determine a diagnosis. This must be obtained by one trained and licensed to practice medicine for which the diagnosis is given.

Definition of "Medically Necessary"

Medicare and most insurance companies define "medically necessary" as: "Services or supplies that:

  • are proper and needed for the diagnosis or treatment of your medical condition;
  • are provided for the diagnosis, direct care, and treatment of your medical condition;
  • meet the standards of good medical practice in the medical community of your local area; and
  • are not mainly for the convenience of you or your doctor."

Legalities of Medically Necessary Cases

Medically necessary cases need to be viewed as legal cases. Documentation must be maintained, accurate and in order for possible legal purposes in the future.

Physician-Referred Cases May Not Necessarily Be Insurance-Related Cases

A case that is medically necessary or referred for therapy by a physician is not necessarily an insurance-related case. One may have been diagnosed with a disease or injury and referred to you by a physician, but not have any type of insurance coverage. When treating a physician-referred case, you must keep accurate documentation, regardless of whether the case is covered by insurance.

You cannot bill an insurance company for any treatment that has not been determined by a physician's diagnosis to be medically necessary. This does not mean you cannot treat medically necessary cases referred by physicians.

Whether or not you are allowed to bill for insurance cases will be determined by many factors. Licensure or certification, insurance company requirements, and your state and local laws or rules may come into play.

There were no laws or rules in Florida that pertained to insurance billing for a massage therapist when I began in 1984. Therapists set the pace, and insurance companies paid for therapies performed and billed by a licensed massage therapist. You also may have to set the pace in your area.

Patient vs. Client

Physicians like to claim the title "patient." Attorneys like to claim the title "client." When a physician refers a case to you, this person is referred to as a "patient."

What has worked well for us the past 15 years is to always refer to the patient as the "physician's patient," and not claim them as "my patient." As one who works under the authority of a physician, by way of a prescription, we are acting as an extension of the physician, so to speak.

If you realize this, it will:

  1. help you to remember your position, and maintain humility; and
  2. gain respect from physicians, thereby increasing referrals.


No information given within these articles is meant to override your licensing or state and local laws or requirements, or to take the place of legal counsel. It will always be your ultimate responsibility to know the laws and rules of your state and locale, and those of your licensure or certification boards.

Click here for previous articles by Vivian Madison-Mahoney, LMT.


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