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Provider Networks: A shot in the arm, or a shot in the dark?
Editor's Note

By Karrie Mowen (Osborn)

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Note: Because of the publication date, some of this information may be out of date.


Managed care organizations. Provider organization networks. Affinity programs. Non-benefit discounts. It's the lingo of health care today and it may well be the lingo of more and more massage therapists tomorrow.

Creating relationships with managed care organizations can be a step forward for massage therapists into a world of acknowledged efficacy and legitimacy. In some cases, however, creating provider/network relationships can forever diminish one's outlook on the process. The view of massage therapists is all over the board when it comes to insurance, massage therapy and reimbursement and, unfortunately, there's no indication common ground will be found any time soon. Still, as consumers continue wanting alternative health care options and insurance companies are forced to meet those demands, massage therapists will inevitably find themselves in the middle.

In this brief look at provider networks, we offer a peek into a managed care organization and one of its successful providers. We follow that with a perspective piece from authors Margie Callahan and David Luther on the implications of insurance to the profession and a layman's look at the downside of this relationship for massage therapists and bodyworkers. We recognize that there are good and bad stories on both sides of the coin, and we realize that not all views will be properly disseminated in this short discussion. Still, we feel this "peek" is an important beginning for therapists to come up with their own answers to the question: Are these relationships a potential shot in the arm for my business, or a shot in the dark?


Consensus Health -- Doing it Right
With 83 million Americans1 spending $16 billion on complementary and alternative medicine (CAM) therapies in 19972 and approximately 90 percent of the money they spent on these therapies being non-reimbursable3, it's evident health care alternatives are gaining credibility in the American consumer's eye. Not only are these alternatives gaining credibility, they're driving the market. In fact, in a 1997 study, almost 70 percent of consumers polled said availability of alternative health care options was a top factor in choosing a health plan.4 Taking notice of these facts are managed care organizations eager to keep those customers who are clamoring for alternative therapies appeased as well as create an edge in a terribly competitive market.

Today, approximately 70 percent of managed care programs in the United States offer CAM services and/or discounts for those services. And that number is expected to grow significantly. Look at Washington State. Legislation there has mandated health plans to offer, in the form of a benefit, access to CAM practitioners; Hawaii and New York have already forged the way. We can assume that other states will have similar legislation presented in the future.

Consensus Health, founded in San Francisco in 1996, was the first organization to provide discount multi-specialty CAM-credentialed networks and services to major health plans, which today includes Blue Shield of California, Blue Cross Blue Shield of North Carolina and major health plans in New York and Maryland. Instead of offering reimbursement options, Consensus offers 6 million-plus members access to a network of multi-specialty CAM providers who've agreed to discount their fees up to 25 percent (a practice common in the world of managed care and CAM therapies). The Consensus program must be working, at least for the consumer -- since introducing the program in 1997, Blue Shield of California's HMO membership has grown 35 percent annually.

Secondly, Ina said it's hard to differentiate between massage practitioners. "When they are working with a managed care program, there is recognition that they are a quality practitioner." But, Ina said, it goes beyond public perception. "When you have a massage therapist being recognized and referred to, their services will be tracked and communicated to other health care programs. Doctors will look and see outcomes, albeit anecdotal, but the point is there is awareness that's happening." The big picture, she continued, is that the information is being shared with more traditional providers within a health plan.

Ina said opportunity is the third piece to the "why" question. "This is never going to take over their entire business, yet a vast majority of massage therapists will get these clients as a small part of their business. It will give them the opportunity to have another source of revenue come into their business, and they can control that," she said. "Unlike a physician, the massage therapist can pull out of managed care at any time. It's simply another source of revenue...and an opportunity to be included with quality practitioners."

Consensus Health contracts with massage therapists, then credentials and qualifies them. In exchange for the therapist being advertised and marketed through Consensus, they must give a 25 percent discount to customers who are part of the program. "Therapists do not pay anything to us directly," Ina said. This type of program eliminates the paperwork hassle, the late payment hassle and all of the other customary disadvantages of being involved with a managed care program. Similar discounting programs are eliminating typical insurance reimbursement "hassles" for massage therapists around the country.


Credentialing
One of the most controversial aspects of managed care organizations offering CAM providers is the promise of qualified, credentialed practitioners. Some believe the standards are not high enough in this credentialing process, while others believe the credentialing process itself is flawed.

Ina said Consensus credentials massage therapists just as they would physicians. "We have credentialing standards for all modalities," she said. Where standards exist, providers are credentialed using measures which meet or exceed those required by the National Council for Quality Assurance (NCQA). Where criteria don't exist for certain alternative specialties, Consensus has created them to parallel the exacting standards of the NCQA. The process of credentialing begins with a primary source verification. Consensus verifies that practitioners have malpractice insurance, business licenses if required, proper educational requirements and no malpractice suits against them. Then comes a site evaluation where the facility and their standards are also scrutinized. Finally, the potential provider's qualifications are discussed before a peer review committee. If accepted, providers must be recredentialed every two years.

Overall, Ina said the response from CAM providers has been positive; turnover has remained low. She guessed that approximately 500 massage therapists are part of the Consensus CAM program today. Helping them stay successful is the mission of Consensus which sends therapists "encounter books" filled with receipts and various documentation in preparation for their managed care initiation.


Fees
While other service providers may wait months for insurance reimbursement and be lost in a sea of paperwork, Ina insists the discount program creates a more "hassle-free" environment. "They're still paid on time, there's no paperwork, no intervention of anyone else. If we were creating a massage therapy program that was going to be in managed care, we would try to get them the usual and customary fee, with the understanding that they would have a delay in payment, more paperwork, etc."

Still, even with the discount program, Ina reminds us that this is a self-referral program complete with its own set of headaches. "They will have some hassle factors, but the good part is, unlike a physician, massage therapists will never be reliant on a health care payment to survive." A therapist can also leave the program if it's not proving beneficial.


Education
Just as education of the general public is important in building respect for the bodywork community, educating the administrators of health care programs and the primary care physicians is just as important. Ina said Consensus provides educational programs for physicians as a key part of its approach, as well as encouraging the education of health plan administrators. It's hard for someone to make crucial business and health decisions when they don't even understand the work being done, she said.


So Is It Working?
Julia Zarcone, certified massage therapist out of California, has been a provider for Consensus Health since mid-1997, as well as acting as a consultant to the company. "I was really interested in the whole managed care environment and what it's doing to medicine," said Zarcone of her entry into managed care. Why Consensus? "I believe the intention of Consensus is to guide somatic and manual therapies into the managed care arena so that therapists benefit. They're not taking advantage of therapists or undermining their practices." Zarcone went on to say that aligning forces with groups like Consensus has the potential to help the profession as a whole.

Believing that managed care will be the future for massage therapists, whether they like it or not, Zarcone said she chose to be one of the "early adopters" and put in her two cents when it counted most. By getting involved early and expressing opinions, Zarcone believes massage therapists will be afforded a more favorable outcome in the future.

Zarcone said even though she believes that massage therapy will increasingly move into managed care programs, it doesn't make her necessarily any happier about all the discount programs cropping up. "I would like to see us move steadily and more quickly toward reimbursement programs. I'm not thrilled that all these networks are discount programs. I think the problem is there's not a lot of agreement among practitioners what structure that might be (for credentialing and inclusion). Just creating codes for reimbursement will be really hard to do. But that's a whole other issue."

As to the fee structures and discounting issues massage therapists worry about, this therapist is not disheartened. Zarcone said it's up to therapists to take responsibility. "We need to look carefully at our fee structures. Therapists need to really assess what they charge and make sure they're really charging what their work is worth." Before joining any kind of managed care program, Zarcone recommends this kind of self-assessment to avoid major problems down the road. "What do you charge? Do you need to charge more? Is it worth it? Do you want to take a 25 percent pay cut? If the practice won't handle it, don't join."

Even though Zarcone hasn't seen significant increases in business because of this insurance relationship, she said she would join all over again. She does admit, however, that the client brought in through network referrals is a "different kind of client," a message repeated by many. But Zarcone doesn't see that as a bad thing. "I certainly have clients who are easier to work with than others. At the base of it, though, is that everyone can respond to bodywork. Everyone likes touch." She said the client referral from the network is a client who needs more education about bodywork, who may have never seen a massage therapist before, and who may think the therapist can "fix them up quickly." Still, Zarcone said she enjoys seeing people from a broader spectrum of backgrounds.

Zarcone's advice to other massage therapists thinking of joining a managed care organization is simple: "Find out as much as you can about the network you're joining. What are their values? Who are they aligned with? What are their track records? Practitioners should get as much information about the network as the network gets about them."

Other Advice
Ina also offers advice for massage therapists and bodyworkers to be careful when entering into a new agreement with a managed care program. Like Zarcone, Ina reiterates that research is paramount in developing the relationship, just as it should be with any new business venture. Here are her recommendations on what to look for with a managed care organization which offers or promises reimbursement:

1. Evaluate their fee reimbursement. Is it fair?
2. Look at their turnaround time. What is their contractual time to pay you?
3. What are your "out" clauses? Make sure you have the ability to get out.
4. What is the product design they're going to be a part of? How are they going to get referrals? What is the protocol for getting reimbursed?
5. Understand what the billing process will be in order for reimbursement (special forms, etc.).
6. Ask about up-front fees. "It's not appropriate to pay for yourself to be qualified. There's no reason to be paying for this service," Ina said.

Karrie Mowen (Osborn) is former editor and current contributing editor of Massage Bodywork magazine.

References
1. David M. Eisenberg, M.D., "Trends in alternative medicine use in the United States, 1990-1997." Journal of the American Medical Association. Nov. 11, 1998.
2. Ibid
3. 1995 California Benchmark Compensation and Benefits Trend Survey.
4. Landmark Telephone Survey of 1,500 households, 1998.








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