What Benefit Does Insurance Reimbursement Afford Therapists?
Business Side

By Howard Nemerov

Originally published in Massage Bodywork magazine, December/January 2000.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.

Note: Because of the publication date, some of this information may no longer be applicable.

There are some serious concerns over having bodywork included in managed care. These concerns have to do with practitioners' experiences, including mine, being involved with a secondary provider here in California.

This provider started a listing service that was supposed to give us "free" access to subscribers. In exchange, we were required to provide our services at a 25 percent discount.

On the surface, it sounded great. We would get access to thousands of potential clients. The 25% drop in income from the treatment could be considered an advertising expense. Unfortunately, reality proved otherwise. After some of us withdrew from the program, we compared notes on our experiences. We each had come to similar conclusions ranging from uncomfortable to downright scary.

The types of potential clients who were calling seemed to be simply bargain hunters. They were preoccupied with cost, not benefits. They came across as greedy and grabby over the phone, like they were raiding the bargain rack at an outlet mall. They evidenced no sense of respect toward us as skilled health professionals. In short, they were not people who would enter into a professional/client relationship with us. Most importantly, they were not people we felt comfortable putting our hands on.

We shared a concern that because of the makeup of this program, we were actually subsidizing Blue Shield. Our strength lies in the fact that we are skilled at treating conditions not being addressed by conventional allopathic medicine. Thus, if we resolve a problem, there is no reimbursement by Blue Shield. When we resolve a problem before it leads to more serious pathologies requiring expensive medical procedures, Blue Shield realizes an increase in long-term profitability, which we pay for via our reduced fees. As one practitioner told me: "They are preying on the desperation of bodyworkers whose business is less than optimal, and benefiting from the preventative care we give by avoiding medical procedures that may have come later had the subscriber not seen us for treatment. In the end, they come out ahead." Other comments held this tone: "(The secondary provider) merely adds another layer of administrative and bureaucratic expenses to consume subscriber dollars. Blue Shield gets a free marketing advantage by offering (the complementary provider program) at minimal cost or risk to the company. It was a brilliant marketing maneuver."

There is an even more serious concern. By creating a large database of many types of practitioners, the secondary provider has built up a comprehensive list of all types of treatment modalities and their pricing structures. This can be exploited by the managed care industry. It also sets a precedent that no matter what we charge, we can be forced to take a much lesser amount in exchange for the promise of free marketing and magically increased referrals by being included in the managed care network.

The insurance industry compiles and distributes reimbursement schedules to all providers in the network. These list the various treatment modalities and the "reasonable and customary" price for each. We just gave Blue Shield a big bargaining chip in deciding how much we are worth.

Finally, add in administrative costs for billing and the waiting period for reimbursement, and we would be and are earning far less per hour under the managed care program.

Given these findings, if I was an insurance executive, I would be thinking that these massage people are ripe for exploitation. I would offer them inclusion in managed care, with the stipulation that they follow the fee schedule I dictate. I would act quickly, knowing that it is best to prey upon practitioners when they are in a weakened bargaining position.

I get complaints from my physical therapy associates expressing concern about how much of their business net worth is tied up in receivables, while they must spend money on staff to handle insurance billing and tracking delinquent payments, thus further driving down their profitability. When you include the fact that there is no guarantee that the bill will be paid at 100%, it is no wonder that these therapists prefer cash customers, to the point that they offer discounts for their fee-for-service clients.

Managed care insists on "licensed" professionals, meaning physical therapists. Yet, this is how those professionals are treated. How can we possibly think massage therapists and bodyworkers would be treated any better? To the contrary, I believe we would be treated worse, because in the medical hierarchy, physical therapists definitely pull rank over massage therapists.

Here is an example of what I mean. While I have worked with some very talented and ethical physical therapists, the following describes a very busy and large clinic where I observed treatment of multiple patients in a common room. The patients lie on a table for much of the session, perhaps icing, while the physical therapist is off working with somebody else. The clinic then charged insurance $98 an hour for largely ignoring the patient. This goes on twice a week for two or more months. The clinic ends up with a total insurance billing of a few hundred dollars an hour per therapist, since that therapist can juggle multiple patients this way.

This same physical therapy clinic offered me $10-$15 per hour as a physical therapy aide. I was already an established teacher by this time, and have had physical therapists for students, so this shows you what many PTs think about our profession. It's the trickle down theory of economics - the insurance company trickles down on the medical doctor, the medical doctor upon the physical therapists and the physical therapist upon the certified massage therapist. Meanwhile, the insurance executive buys another multi-million-dollar estate.

If we try for inclusion in the insurance industry from a position of weakness, we will surely be exploited. And make no mistake -- we are not strong enough to take on the American Medical Association, the American Physical Therapy Association or the insurance industry, neither politically or financially.

We have yet to define exactly what it means to be a clinical massage therapist, and how to certify or register such a person. It is my belief that insurance money should be spent for specific therapeutic purposes, and I am sure the industry would agree. I get a limited number of visits authorized to treat a condition, so I had better know what needs to happen. Referring doctors expect a summary of findings and treatment plan, and they like it to be professionally organized, just like the work of a physical therapist. These skills are over and above what is expected from a person who is trained to perform relaxing, salon-type massage.

This is not a cut on anybody's skill or professionalism. It's simply different tools for different applications, and what my own experience in insurance work indicates. Referring doctors want to know how you are going to complement or enhance upon the physical therapy regimens they already prescribe. If you want to compete with physical therapists for insurance dollars, you should have the proper assessment and manual therapy skills, as well as excellent anatomy, charting and technical writing skills.

Some folks talk about the national certification, but in fact each state insists on its own rules, just like they do with the licensing of doctors and physical therapists. We have no comprehensive organizational plan to deal with the legal and professional requirements for resolving this issue. As long as we do not know who we are and what we are talking about, we have no cohesive plan to present to the gatekeepers (the doctors who refer, and the insurance executives who decide where premium money is best spent).

In the meantime, if you want to get your feet wet with insurance billing, most states allow massage therapists to bill for Workmans' Compensation and Personal Injury. The network you build with referring doctors in these areas will be a good start for private insurance referrals, if and when the time comes. Occasionally, even private insurance will pay for your services now.

As things stand today, inclusion in insurance would be a disaster for massage therapists. At this time, it would ensure that lower pay and second-class status becomes a permanent institution for bodyworkers. It would be better for us to wait until we are ready financially, politically and logistically.

Howard Nemerov, CMT has taught and maintained a clinical practice for eight years, specializing in injury rehabilitation. He has many years of experience in personal injury and workmans' compensation claims, and providing Rolfing Structural Integration treatment for one of the largest high-tech firms in the San Francisco Bay area. He consults regularly on insurance billing with fellow practitioners. Nemerov can be reached at 415/459-4206 or by e-mail at

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