Explanation of Prices and Services for Insurance Billing

This is a repost from a collegue’s website.  I (Beau Miakinkoff) did not write it.  I am providing this as a service for other LMT’s and LMP’s as well as for my clients that are interested in knowing why medical massage prices are different from self-referral prices.  (please make a note that the fees listed are from 2009 and do not reflect the allowable rates  that White Dragon Therapies bills for the current year.)

To LMTs: Oregon Clinical Massage is an educating facility. We went through a great deal of trial & error, and spent large amounts of money and time in our search for the information contained on this page. We offer it to you in the hopes that you do not have to do nearly as much work to put all these pieces together.

Medical Massage Services Fee Schedule – The Short Story:

Massage Therapy (Effleurage, Petrissage and Tapotement Only)
97124 – $40.00 per 15 minute unit

Manual Therapy (Myofascial Release, Trigger Point Therapy, Muscle-Energy Techniques…)
97140 – $46.50 per 15 minute unit

Initial Evaluation
97001 – $120.00

Re-Evaluation
97002 – $65.00

Moist Heat, Ice, or Topical Pain Relief Preparations
97010 – $8.50

The 90 Second Story:

Oregon Clinical Massage bills UCR (Usual, Customary and Reasonable) fees for Massage Therapy (97124 – 40.00/unit), and Manual Therapy (97140 – $46.50/unit) as defined by Ingenix in their National Fee Analyzer database. These fees have been adjusted for the Portland metropolitan region for 2009. Fees are based on actual time spent on behalf of the patient, as significant non-treament time is required for each prescription visit.

The fee for an initital evaluation (97001) is $120.00 and Re-Evaluation (97002) is $65.00. The completed, typed evaluation is an essential aid in our treatment, and we present a copy to each referring physician for their approval. This report allows us to know our starting point, and points to the individual treatments necessary for the patient. There is currently no code for Licensed Massage Therapists specifically in the AMA’s Current Procedural Terminology (CPT) Code Book, but the AMA states in their book that each provider should use the code which most accurately describes the services rendered. Until Massage Therapists are assigned an industry-specific code for evaluations and re-evaluations, the closest codes are the Physical Therapy evaluation codes. An initial intake of some kind is legally required in Oregon for each new case. We like to be sure we are giving the best care possible to each person who comes to see us by doing as complete an evaluation as our scope of practice allows.

Ingenix states that UCR fees for Application of Topical Pain Relief Preparations/Use of Hot and Cold Therapies (97010) is in the $25.00 range for the Portland area. We bill $8.50 for this service.

If you would like to download a PDF copy of an example of a  Billing Policy and an explanation of the differences in fees and Therapist time spent between Medical and Wellness massage, please click here.

 

The Long Story:

Very rarely, an insurance company will attempt to reduce our fees or deny payment entirely. This happens in any industry. Following is a letter written by Ariana Orton from Alliance Clinic to an insurer who was attempting to reduce payment. It is placed here for informational purposes. Ariana Orton is a co-founder of Alliance Clinic, and was the CEO at the time this letter was written.

Dear (Claims Representative),

We have received a copy of the billing/coding review which you forwarded to us from (online independent medical billing review company). Please note that Alliance Clinic is a Medical Massage clinic, specializing in automobile accident cases, which involves dealing with insurance companies, physicians, attorneys, courts, and medical examiners. Every therapist at our clinic is either a Nationally Certified Medical Massage Therapist, or is qualified to sit for the board exam and awaiting an exam date. We will hire no therapist who does not meet this level of expertise.

The requirements for this exam and certification involve at least twice the educational requirements of an entry-level massage therapist. The three therapists at this clinic have over 4000 combined hours of training in massage and manual therapy, and 21 years of experience dealing with injury cases. A portion of (independent reviewer’s) justification in recommending reduction of payment is based on what the Integretics site had posted, and comparing it to what other, perhaps entry level LMTs, charge in the Portland area. There are fewer than ten Nationally Certified Medical Massage Therapists in Portland. Are his findings based on what this population is billing, the injuries they are treating under physician supervision, and the results they are seeing? Has he done any research on this issue? Is (independent reviewer) aware of the difference between LMT certification and NCMMT certification, and the difference in the qualifications and level of service that each is providing?

Our rates are based on and derived from Ingenix Database’s National Fee Analyzer for 2003, and calculated according to the Portland area’s adjustment factors. We bill $37.50 per unit for 97124 and $42.50 per unit for 97140. The owners of Alliance Clinic have been billing and getting paid UCR (Usual, Customary, and Reasonable) fees since 2002. Our rates fall within the mid-range of UCR for the Portland area. They are comfortably within the industry standard for the level and quality of service we provide.

It is absolutely true that fees should not be more expensive based on who is being asked to pay the bill. Everyone at Alliance Clinic is charged the same for each service, regardless of whether or not it is being covered by insurance. It is legal, ethical, and common practice to provide a discount for payment at time of service, which negates the need to spend hours billing for, tracking down, and collecting payment for services. Alliance Clinic offers a discount per physical medicine unit for payment at the time of service. This is a common practice in primary care medical offices as well as massage therapy offices.

Massage Therapists in Oregon are also not required by law to keep or provide chart notes. However, well documented records and chart notes are required for insurance billing purposes. Therefore, Alliance Clinic offers a discount if typewritten records and chart notes are not required. This is also legal, and common practice among medical massage therapists.

The prices posted on the Integretics site reflect these discounts, without this explanation, because Integretics did not take cases where billing was required, and it was therefore confusing to most people when this explanation was present on the site. Integretics’ bodywork practice was merged with Alliance Clinic in December of 2005. It is clear that the differences in the levels of service required between clients and patients are still not well understood by insurance companies and others. Perhaps the following will help.

Wellness Massage and self-referred Orthopedic Massage are very different services than billed Medical Massage. The first visit by a self-referred client, if it is a one hour visit, requires about 1.5 hours of time for the therapist. This visit costs the payer $70.00 for a massage and $90.00 for corrective treatments, after the discounts are offered. This averages to $46.00 – $60.00 per hour of actual time spent. Subsequent visits require about 1.33 hours, which average to $50.00 – $67.00 per hour of work and time spent.

Medical Massage services require a great deal of extra time tracking and handling paperwork. For visit one, assuming a one hour treatment is prescribed, anywhere from 3.5 to 5.5 hours are spent. A minimum of 30 minutes is spent in an evaluation with the patient present, due to the usual presence of multiple injuries and greater care required to protect the patient, and an additional 60 minutes are required for preparing a detailed written evaluation, for which we charge $90.00. UCR for this service was $125.00 in 2003, however we do recognize that our scope of practice limits us from some services that this code usually includes, and therefore we charge a reduced rate for this code. This averages to about $47.00 per actual hour spent with or on behalf of the patient for a first Medical Massage visit. For subsequent visits, total time spent is 2.5 to 3.0 hours, which averages to roughly $30.00 – $56.00 per hour.

Please see our standard forms: Patient Understanding of Medical Fees, which compares wellness vs. medical massage, and the Billing Policy, which outlines the UCR fees we charge. Both are included with this mailing. (Clicking here will download both forms as one PDF.)

In the case of wellness massage the therapist is only responsible to the client, themselves, and the Board of Massage. However, in the case of medical massage, the therapist is responsible not only to themselves, the patient, and the Board of Massage, but also to the referring physician, the patient’s lawyer, the courts, independent medical examiners, and insurance companies as well. Billed prices are based on the assumption that the standard amount of time outside the treatment room will be spent, and that no reminders, re-billing, or collection actions need to be taken. If such becomes the case, much more time is spent, making the average earned per hour, if payment is actually collected, much less than the above averages.

It is, therefore, more lucrative for us to handle self-referred, prompt pay clients, rather than prescribed patients. For this reason, many massage therapists will not handle insurance cases. We feel that it is important to make high quality massage and manual therapy services accessible to those whose physicians feel that they need such treatment.

The Worker’s Compensation Fee Schedule for 97010 allows for $7.89. It does not state that each provider should adjust their 97010 billable based on what they charge for 97124 or 97140. It simply allows for $7.89. That is what we bill. It is legal, ethical, and common practice. Many clinics still bill $25.00 per use of hydrocollated heat, which is more in line with the Ingenix database UCR. $7.89 for 97010 is very reasonable, and will not be reduced.

Please note that the Inspector General’s Advisory Opinion 98-8 re: Discounts states: “If the higher costs are due to ‘unusual circumstances or medical complications requiring additional time, effort, expense, or other good cause,’ due to claims processing, documentation… and delays/denials in medicare payment, then [medical providers] are allowed to charge Medicare more than their ‘usual charge’.” Because insurance industry standards are very often derived from Medicare standards, the IG’s opinion is applicable to all medical insurance claims.

Alliance Clinic offers individualized care for each patient. We keep our case loads small so that each patient can have personalized attention and focused work. We discuss these cases, within HIPAA guidelines, sometimes moving patients between specialists in our office to make sure that their recovery is as quick and complete as possible. Alliance Clinic’s patients very often reach MMI (maximum medical improvement) before their prescriptions run out. Ethical and legal practices are very important to Alliance Clinic, as we are also a teaching and mentoring facility for other therapists who wish to become informed about Medical Massage.

Concentra, a widely recognized and trusted medical billing review corporation, has recommended full payment of these charges. Alliance Clinic is working to raise the bar for a specific class of massage therapists by encouraging higher education and greater skill in dealing, especially, with insurance cases. It is our intention to decrease the overall costs of medical care paid in auto accident cases by improving the aggregate manual therapy care that such patients are receiving. We wish to do this by ensuring that practices of Medical Massage Therapists are uniform, legal, ethical, accessible, and highly qualified.

As referenced above, the Inspector General has agreed with massage therapists and other medical providers on this issue. The level of service provided in the case of medically necessary treatment is higher and more time consuming than could reasonably be compensated if collecting the same amount as for prompt pay clients. Please reconsider (independent reviewer’s) findings in a timely fashion. If we do not receive the past due portions of (patient’s) payments within 14 days of this letter, we will refer this issue to the Insurance Division at the Department of Consumer and Business Services on grounds of claim delays, denials, and poor service. We will also be recommending that (patient) acquire the services of an attorney at that time.

Finally, (insurance company) has an opportunity to decrease overall costs now and for the future of the industry by recognizing this higher level of service, and supporting it. Join Aetna and become among the first insurance companies across the nation to recognize Nationally Certified Medical Massage Therapists. Recommend this treatment to your insured clients when they have soft tissue injuries.Your insured clients will likely heal faster, require less surgery, and their medical bills will likely be much less costly when you do.

Sincerely,

Ariana Orton, CEO
Alliance Clinic

cc: (patient), (independent reviewer)


2 Responses to "Explanation of Prices and Services for Insurance Billing"

  • Thank you for this article. It is well-written and informative. I am a PA massage therapist working on billing for an auto accident.

    1 Kathe Sodeinde said this (February 6, 2013 at 11:14 am)


  • This is an excellent explanation of a question many PI clients have. I have reposted it on my website (with credit to you, of course). Thank you and best wishes.

    2 Victoria Kingsbury said this (May 10, 2013 at 1:03 pm)


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