Insurance for Alternative Care?
Lack of Industry Standards Part of the Problem

By David Luther and Margie Callahan

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Note: Because of the publication date, some of this information may be out of date.

There has been a rash of new provider organization networks (POs) popping up, each offering to credential and market massage therapists to managed care companies. Credentialing is supposed to be about accrediting a person's character through criminal background checks, competency by verifying education, special training and experience, and bonding against omissions and errors liability. Beware -- the credentialing system of many marketing organizations does not include criminal background checks, has no standard of education other than basic certification, and offers no insurance against liability for omissions or errors in the system's own credentialing process.

To join these particular POs, massage therapists are paying about $100. In exchange, they are told their name will be available to a great number of managed care organizations. Besides receiving money from massage therapists they sign up, these POs also receive 8 cents to 20 cents per member, per month, from the managed care organizations (MCOs), according to Adrian Langford of Alternative Health Solutions Inc., whose HMO company is pushing for more stringent standards in the integration of Complementary Alternative Medicine (CAM).

Langford says many of these POs making offers to CAM providers "do not avail themselves to the stringent requirements the MCOs use to credential managed care physicians. Many states do not have licensure for...CAM practitioners. States which do regulate these providers usually have only minimal requirements in order to practice. CAM networks [such as the POs we are talking about] which parallel state requirements as credentialing guidelines are focused less on quality and more on market development...Health plans must not lose sight of the importance of protecting their members from providers who have minimal experience or minimal commitment to raising the standards of their own profession."1

We cannot agree with Langford more, but our problems are these: These CAM networks (POs) are not utilizing the same standards for qualifying massage therapists as they do for mainstream health care providers. The National Council of Quality Assurance (NCQA) provides for credentialing standards that must be met by managed care physicians. Apparently the POs are not required to assure the credentials of CAM practitioners because, as Langford puts it, the HMOs contract with POs to simply "provide access to these providers. Typically the access is in the form of a patient-pay, non-benefit discount." This system turns a "benefit" into "access" and seems not to require the same credentialing of a physician providing procedures and services which are paid benefits.

Secondly, the HMOs are not willing to pay massage therapists for advanced massage techniques. If a patient who is in an HMO comes in need of medically necessary rehabilitative massage for soft tissue injury or chronic pain, the managed care companies often will not pay you to provide advanced rehabilitative, manipulative techniques - only wellness massage. To top it off, they usually will pay a doctor or physical therapist to provide advanced massage techniques. Luckily for the HMOs, physical therapists and doctors are either not trained in advanced massage techniques, or they simply will not do them because of opportunity cost (they can make more money doing something else). The HMO that operates this way can avoid paying anyone for advanced massage techniques which incur greater charges than wellness/relaxation massage.

If massage therapy is to be delivered by providers who have extensive education, experience, track record of efficacy, and obvious commitment to raising standards as Langford proposes, why, then, are these POs and MCOs promoting us as providers of wellness massage and not medical massage? Why do they want to offer their subscribers only relaxation and stress reduction and not rehabilitation of injury and chronic pain?

If a doctor prescribes massage for the treatment of soft tissue injury and/or chronic pain, the doctor does not intend for the patient to receive wellness/relaxation massage. What happens in this scenario is that medical massage therapists are not joining the POs or MCOs after considering the pay, and patients who need advanced rehabilitative massage are being provided with stress reduction. This gives a false impression of the efficacy of medical massage therapy in treating injury and chronic pain.

Another problem we see with the PO offers is if one of these people were already a cash client of yours, you would have to reduce your fee by 20 percent to 25 percent for them. If they were not already a client, would that small of a fee reduction (example: you charge $50 for a massage, 20 percent reduction brings you down to $40) motivate them to become a client? From all the feedback we have gotten from therapists who have already done this, they have yet to see any return for the money they paid to join a provider organization. As a matter of fact, they told us that it has only caused grief in that, when they explained to the client that $40 is to be paid by them, not insurance, they either hung up or got angry.

We believe there are two reasons the MCOs want massage therapists to be limited to providing wellness massage:

1. Last year 50 percent of all the patients in the HMOs went outside of their network to get alternative health care, and had to pay out of their own pockets for the care they thought should be covered on their policy, but wasn't. The public wants alternative medicine and is pressuring employers to get group plans that include it. The HMOs think that getting massage at a reduced rate for their clients might appease this demand and get the monkey off their backs.

2. The HMOs know that alternative medicine is going to happen but they don't want to add more health care, because they are afraid it will increase their costs. But if they are going to have to accept us eventually, they want to make sure they get us as cheaply as possible. Ergo, if they can get us to sign up now for wellness massage at reduced rates, they can establish our worth as being at that level. When we finally do get accepted and go to negotiate contracts as a providers of medical massage with all the additional education, experience, responsibilities, cost and time involved in medical massage, they will say, "Well, you have been doing it for the past few years at $35-$40 and it is not legal to raise your prices just because you are billing insurance." This is what happened in the state of Washington.

Personally, we think we are lambs on the way to slaughter. The POs often claim that we still need to prove the efficacy of our work. The efficacy of both wellness and medical massage has long been known, and this ploy is designed to stall and set our prices at a level not applicable to the standards of medical massage. Why, if we need to prove the efficacy of medical massage therapy, are MCOs willing to pay physical therapists and doctors to provide it?

Because of the pay being offered, the majority of massage therapists who will sign up will be those practicing wellness/relaxation massage, and the efficacy in treating injury and chronic pain with massage will not be that of medical massage. Then the MCOs will come back and say we don't know what we're doing and we are not worth more than $35-$40. If these plans were designed to serve the public well, therapists with the most training and experience in pathologies and protocols would be motivated to sign up. However, therapists who could best prove the efficacy of medical massage have no incentive to do so for $40 per hour, considering the level of service they provide, plus all the additional responsibilities.

We believe that in the future, massage therapy will be a major part of the health care delivery system. We believe these companies that are trying to set us up as providers could be invaluable to us, but not when they limit their provider pools to wellness massage for low prices.

Langford's recommendation to MCOs for quality management and quality assurance of CAM providers includes, among other things, "A minimum of two years practice experience...along with verification of continuing education and a site review of each practitioner's place of practice." Also, "there should be a strong focus on both physician and member education."2

It seems what our industry lacks are qualification standards which would define the two types of massage: wellness and medical. Until we do, we are game for those who want only wellness massage therapists to provide health care, so it can be done at rates which will keep the medical massage therapists out of exactly the realm in which they are the true specialists. This system allows the HMOs to keep rehabilitative/medical massage from the general public as a means of, what they appear to presume, saving money.

This is not to say that wellness and relaxation massage does not deserve its place in the health care delivery system. We all know preventative medicine is very important. Besides a current willingness to pay for wellness massage, HMOs regularly pay for wellness care provided by mainstream medicine. The problem with not having the two types of massage defined is the resulting misallocation of the two types of service, which presents a damning image in regard to efficacy and affects the entire industry of therapeutic massage.

David Luther and Margie Callahan, are the co-authors of The Medical Massage Office Manual. Together they have created a beginner-to-advanced system for the medical massage therapist that includes free counseling, the manual, seminars, billing services and billing software. Both Luther and Callahan are NCBTMB Category A providers of seminars. For more information, call Luther at 561/697-8414 (for those east of the Mississippi), or Callahan at 888/322-5520 (for those west of the Mississippi).

1. Langford, Adrian, a memo
2. Ibid.

10 Questions to Ask Before Joining
1. Which MCOs are currently contracted for my specialty?
2. Why am I paying you if you use my name to help build and market your network product?
3. May I have copies of grievance procedures?
4. May I have copies of credentialing procedures?
5. Do you provide insurance against errors and omissions in your credentialing process?
6. What are your educational and experience requirements?
7. Are patients aware that they will be provided with only wellness massage, which is beneficial in relaxation and stress reduction only?
8. Am I bound to treat the patient specifically according to the doctor's prescription? (What if I am not qualified to treat what is diagnosed, or to use procedures that are part of the doctor's treatment plan?)
9. Will I be expected to accept the responsibilities and liabilities of documentation, claims submission, communication with physicians, attorneys, and insurance personnel, or any other responsibilities outside of simply treating the patient?
10. Are patients aware they have to pay out-of-pocket? May I see the information that makes them aware of it?

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