An effort to improve the insurance billing process for massage therapy is underway in Washington State where the right to bill insurance is recognized for the profession. This is a collaborative effort being undertaken by eviCORE healthcare and representatives of the massage profession. There’s hope the work in the state will help national efforts and increase access to insurance billing for massage therapists who wish to participate nationwide.

Simply put, eviCore is a third-party that helps bridge gaps between health care providers and insurance companies in an effort to streamline insurance billing by developing and implementing clinical guidelines and trainings around what is and what is not covered.

Draft guidelines for 2022 focused on more tightly defining medical necessity around massage therapy, a key determinant for insurance coverage. These guidelines were reviewed and commented on by a committee of massage therapists.

Distinct from scope of practice, medically necessary care, as describe by eviCore, is “the care that the health plan has agreed to cover.”

What Are Clinical Guidelines?

Criteria for developing clinical guidelines include evaluating available evidence and translating evidence into structured recommendations.

First and foremost, to be considered medically necessary, there must be high-quality research supporting massage therapy as a specific and effective treatment. Levels of evidence range from systematic review, meta analysis and randomized control trial at the top to descriptive/qualitative study and opinion at the bottom.

Clinical guidelines are developed by professional organizations and regulatory entities, for example, and comprise systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.

Medical necessity, according to eviCore, informs policy definitions of terms and criteria for covered services and is determined by health insurance companies.

Developing Massage Therapy Clinical Guidelines

Indications and non-indications are the main criteria for general medical necessity. General medical necessity criteria include direct treatment of included condition, standardized and measurable assessments, and significant and measurable progress toward recovery.

These guidelines are applied only if  a health plan has designated eviCore for medical necessity review and when state/local law allow medical necessity review. eviCore then evaluates on a case-by-case basis with consideration for severity, chronicity, co-morbidities, re-injury and continuity of care.

Throughout the process, massage therapists are supported with peer-to-peer calls, dedicated provider engagement teams and other training resources as needed.

By collaborating with eviCORE in the state of Washington during the development of clinical guidelines and provider trainings, massage therapists are hopeful that this experience, including the relationships developed during the process, will help in similar efforts across the country.