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Massage Today
August, 2001, Vol. 01, Issue 08

Insurance Billing & Reimbursement Issues

By Vivian Madison-Mahoney, LMT

Here are a few pointers regarding insurance billing and reimbursement. Follow some of the guidelines below, take it slow and easy, and advance your way to success!

  1. Do not try to take on too many insurance cases at first. Take one at a time!
  2. Try to take a personal injury (i.e., auto accident) case first to get your feet wet. Do you work in a no-fault state? Call your insurance agent, call the insurance commissioner's office, or check the Web for insurance laws specific to your state.
  3. Keep in mind that not all insurance companies will pay, nor will you be paid on every case, every time, no matter what you are promised by others teaching insurance billing.
  4. Not all cases will be paid, even when submitted to the same insurance company that may have already paid several times before, on the same or different patients.
  5. Insurance companies will not always reimburse massage therapists. Variances exist from one state to the next. There may be reasonable and non-reasonable reasons why; find out by asking questions. Even in states where it is mandatory that insurance companies cover the services performed by a licensed massage therapist, such as in Florida, there are federal laws that override state laws. To my knowledge, Washington is the only state that has a Supreme Court ruling that counteracts such a law.
  6. Are you licensed? Are you certified? Are you in a state that absolutely will not allow reimbursement to an unlicensed, uncertified therapist, or by a massage therapist under any circumstances? Find answers by asking, by trying, and by waiting for responses. By refusing to take "no" for an answer until you have left no stone unturned and know that "no" is the only answer. Never be afraid to go above the adjuster or case manager to the supervisor or the vice president of the insurance company.
  7. Remember to be tactful and diplomatic at all times. Ask questions, but don't be demanding. Be firm in your quest to find out the reasons you are being denied. You may increase your chances of success just by asking questions.
  8. Each case, each area, each state, each insurance company and/or its adjuster(s) are different.
  9. Only individual insurance companies can actually guide you in the long run; there are no cut- and-dry rules across the board.
  10. Which insurance companies will pay; what they will or will not approve; why reimbursement has been reduced and/or denied; and how much will they reimburse; is contained in the explanation of benefits, (EOB). You may ask for all of this information up front, but that does not mean that you will always get the answers. If you do get an answer, there is no guarantee that the answer will always be the correct one. Only the check or the EOB is the explanation of fact for a particular submitted claim.
  11. Submit bills immediately, especially when a patient first comes to you. This way, you'll learn what the insurance company expects from you, or what you can expect from them. (In Florida, you must notify the carrier of treatment within 21 days of first visit of a PIP case or submit claim within 30 days. Otherwise, neither the carrier nor the patient are responsible for payment, and there is no recourse). Knowing the laws and rules creates confidence and power.
  12. Just because you are paid once does not mean you will be paid for each and every case. In fact, sometimes the adjuster may have made a "mistake."
  13. Don't let the bills pile up before you find out what's what as far as insurance reimbursement goes.
  14. Be willing to take chances until you learn the ropes, and be careful not to let the stakes get too high before you cut your losses. Just like with gambling or the stock market, don't risk any more than you are willing to lose.
  15. Call your State Department of Labor, Workers' Compensation Division or Board and ask if they have a "Provider Fee for Services Manual." When you obtain it, look it over for loopholes --you may be able to fit in the system to treat injured workers' in your state. Some states charge, some do not, some do not have a system at all -- but some are also fairly inexpensive. Texas is the only state where employers are not required to carry workers' compensation to cover their employees, however this does not mean that all employers do not have work comp coverage. However, Texas does have a Worker' Compensation Commission.
  16. If you do not try, you will never know! It is truly worthwhile once you get the hang of it and understand it is a numbers game. Yes, working with insurance is a game: you win some, you lose some, but if you don't learn the rules and play, you don't have a chance of being a winner. Many needy patients will also not have a chance to receive your care if you refuse to accept insurance for cases prescribed by physicians.

If you need phone numbers for the Divisions of Insurance or Workers' Comp in your state, call me at: 865-436-3573 or email at: and I will get back to you as soon as possible.

Regarding Discounted Fees for Services

Since so many of you ask my opinion on the subject of discounted fees for alternative care services to insurance companies, I will offer just that: my opinion, for what it's worth.

There is a lot of talk, both positive and negative, about CAM and insurance companies wanting to contract with massage therapists to give discounts for their services. There is much I could say on this topic, but briefly, let me tell you what I think. Insurance companies wish to have therapists give discounts for their subscribers, which in turn helps them sell policies or compete with other carriers to sell policies to employer groups, etc. This discount is given by providers most often in turn for the promise of the subscribers finding massage therapists or other alternative care providers in their directory of providers.

Just because you are in the directory is not a sign that you are a "provider" in the network in the usual sense. It is an agreement to be placed in the provider network booklet, directory or policy to inform the subscriber that you are willing to provide services at a discounted rate for a nonmedical, non-insurance related case.

I personally feel that therapists should be allowed to make their own decision as to if they desire to provide discounts in exchange for the listing -- just as it should be the decision of each massage therapist whether to accept medically referred cases and insurance reimbursement for such services.

I do not feel that anyone should be making the decisions or rules as to who should accept these types of cases. If the physician prescribes the treatment or therapy as medically necessary; if the therapy prescribed is within the therapist's scope of practice/licensure and/or certification; if the insurance companies are willing to reimburse you for your services; if the patient wishes to receive the therapy; and if the physician and the therapist decide that it is in the best interest of the patient, themselves, and their office, then it should then be the therapist's decision and only theirs.

For anyone else to make rules and regulations to limit ones income potential is unmerited. The same goes if rules were put into effect requiring a therapist to have to accept insurance cases. I feel it should be each individual's personal decision.

Here are some questions I would like you to ask insurance carriers and/or credentialing companies who submit applications to you, offering discounted fees to their subscribers for your services:

  1. If I am willing to provide discounts for services to your subscribers, does this preclude me from receiving payment under the policy or plan's insurance coverage for medically necessary prescribed treatment?
  2. Does the "preset" discounted fees preclude me from receiving usual, customary and reasonable (UCR) fees for prescribed, medically necessary services under the policy or certificate coverage?
  3. Does the contract provide for increases in discounted rates?
  4. Are there provisions for me to increase my rates to subscribers who ask for therapies or treatments other than that for which I am willing to discount my fees under the agreement?

There are many more questions to consider, but these should serve as food for thought for now.


Click here for more information about Vivian Madison-Mahoney, LMT.

 

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