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Massage Today
June 14, 2004

Teaching Unethical Business Practices Must Stop

By Ed Denning, MEd, LMT

It is time to stop teaching unethical business practices to massage therapists. Those who teach the unethical business practices outlined below do so to capitalize on the greed of massage therapists who do not think about the consequences of their behavior.

Those consequences are now beginning to exact a price, which all massage therapists will pay.

Unethical Teaching of Code Selection

One of the teaching practices I am talking about is the inclusion of highly questionable Current Procedural Terminology (CPT) Codes. Many more codes than is appropriate are presented in literature and seminars. These folks carefully point out that the massage therapist is responsible for selecting the correct code (which means that the authors or seminar prenseters are not liable for what they teach), then list a large number of codes, most of which no massage therapist is qualified to use.

Those they teach are encouraged to interpret for themselves the meanings of the codes and whether they are qualified to use them. In most cases, the selection of a code is driven not by the meaning of the code and the massage therapists' qualifications, but rather by the fee that code pays.

The result of that kind of teaching is significantly higher fees and much greater income for the massage therapist, which is what drives the massage therapist to resort to questionable coding decisions. Did you know that an indentation of wording in the CPT coding manual carries with it an addition to the definition listed?

Did you know that a semicolon has a meaning, which is different than a comma when reading the codes? If you do not know those things, then you are incapable of using the American Medical Association's (AMA) CPT coding manual correctly. Stay out of it.

Certain insurances in Colorado are now restricting the number of CPT codes that a massage therapist may use to one code. They are also setting a specific maximum amount that can be claimed for that code. This is occurring because 95 different codes had been used by massage therapists making claims to their company. There are only three codes that the vast majority of massage therapists are able to use. That is not opinion, that is fact. The insurance companies are protecting themselves from unprincipled abuse on the part of the massage therapists. The massage therapists have abused those companies because of what they were taught.

Unethical Teaching of Fee Setting

Fee setting is a complicated and imprecise subject. One of the ways some teachers abuse this imprecision is to not include some very important information in their teaching. There are books that list every CPT code. They include information on usual and customary fees for service. The one I have organizes information in this way:

Name of code Medicare/Medicade 50% 75% 90%
Code 97124 $24 $40 $65 $84

Except for Medicare/Medicaid, there is no set fee for 97124; each fee is for a unit of 15 minutes.

  • The 50% column means that 50% of the physicians who charge for that service charge $40 or less.
  • The 75% column means that 75% of the physicians charge $65 or less.
  • The 90% column means that 90% of the physicians charge $84 or less.

When you take into account the number of years of training, the overhead of the professional office, insurance to practice, and other miscellaneous costs of doing business, the physician has a right to charge a fee significantly higher than the massage therapist. And yet some who teach about fees would choose the $84 fee as though that ought to represent the usual and customary fee.

Realistically, a physician's usual and customary is higher than that of a massage therapists. Fifty percent of the physicians charge less than $40 for that service; therefore, a massage therapist's fee most certainly ought to be below $40.

Another small problem: If I tell you what the fee is for a service, then I have committed price fixing; that is i1llegal anywhere. We must each set our fees according to our own set of values and conditions. There is no legally correct fee. You could charge $150 per unit, and it would be legal to do so. So, why not choose the higher numbers?

Unethical Teaching of Business Practices

Consistency is the principle by which you can judge whether your business practices are within an ethical framework. Do you always charge the same fee for the same service? Please note: the amount charged is not the issue, it is the application that counts.

Which of the following should be charged a different fee than the others?

Factory worker
Sales clerk

The answer, of course, is that they should all be charged the same fee. Can you make exceptions? Of course. I was a former teacher. Perhaps I wish to provide a special discount to teachers. I need only be up front regarding my prejudicial behavior toward teachers. My fee differential ought to be readily available for all to question.

What about insurances? An insurance company's client is an individual. Individuals all ought to be treated the same according to the example above. But there are additional expenses to billing insurance. Shouldn't we be able to charge a higher fee due to the higher expenses? The answer is "Yes".

However, there is no CPT Code for that expense by a massage therapist; therefore, it is not now possible to charge insurances for that work. Be patient. Such codes will be forthcoming.

There can be a large difference between legal and ethical. Helping to place that gap in perspective is the concept of "usual and customary." When trying to determine what is the usual and customary fee for a massage therapy service, you would want to know what a particular service would cost the average customer. Not the discounted price or special price, but the amount which the customer parts with before going out the door.

Earlier I asked a question: Why not choose the larger number? This had to do with the fee schedules that are published by the AMA.

The reason you don't charge the higher number is because it does not represent your "usual and customary" fee honestly and accurately. You choose a number that represents the reality of your behavior. No tricks with wording or fancy ways to sidestep an honest appraisal. If a cash customer would always pay $55 for a service then that is the "usual and customary" fee. Apply the "usual and customary" concept to the figures from the AMA and live with it.

Acceptable Ethical Models To Command Higher Fees

How can you earn a higher fee and avoid all of the previously mentioned problems? Actually for some it is quite easy.

  • Become so good at what you do that those in pain flock to you for relief. You can demand a higher price due to the demands placed upon your business. Their fees are higher for cash customers and for insurances.
  • Build a better mousetrap. There are average massage therapists who are making fees well above the average due to their great business skills. They have a knack for making good business decisions and attract more customers because of those skills. They get to charge more because they have greater demands placed on their businesses. Their fees are higher for cash customers and for insurances.
  • Specialize. Find a niche that others have not filled. Become skillful in that area and demand a higher fee for your specialized service. Their fees are higher for cash customers and for insurances.

There are many more ways to earn substantial incomes as a massage therapist. All of them require dedication, perseverance, education, good judgment, personal growth and hard work.

Ending Unethical Teaching

  • Stop buying into pie-in-the-sky schemes. Ask questions of your teachers. Insist on documentation of their opinions, then have it read by any accountant or lawyer.
  • If a business practice being taught has to be defended as being legal, you can usually know that it is unethical.
  • Let your fellow massage therapists who are using unethical business practices know you disapprove and that you believe that they are damaging your business and future income. Be ready to explain to them what is wrong with their practices.
  • Join a professional organization. Most have Codes of Ethics and Standards of Practice documents that help us all to know which are good business practices and which are not. Meeting others and discussing business practices will help you know the positions you want to support.

Ed Denning is a licensed massage therapist in Ohio. He is coordinator of the massage therapy program at Stark State College of Technology, and also serves on the Massage Therapy Advisory Committee of the Ohio State Medical Board.


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