Massage Therapy and Insurance Fraud

An unfortunate trend seems to be rearing its ugly head in the massage therapy profession in Nova Scotia, Canada. Could fraudulent billing by businesses and massage therapists be the beginning of the end of insurance coverage for massage therapy services?

In most areas of North America, and Canada in particular, the massage therapy profession has long been promoting itself as a viable and legitimate health care modality. For several years massage therapists belonging to professional colleges and associations in Canada have been privileged to have our services covered by private and motor vehicle insurance, allowing us to build our practices upon an expanding base of savvy health care consumers.

In the recent months, however, it has come to the our attention as a profession that BlueCross insurance is rightfully investigating allegations of insurance fraud, and has gone so far to revoke direct billing rights of some businesses found to process fraudulent claims. BlueCross has also gone so far as to re-establish the direct billing Terms of Use agreement by massage therapists – but the general fear is that if this privilege continues to be abused it will eventually be revoked, leaving many of us out in the cold with a client base who will no longer be able to afford, or be willing to pay for, our services.

What is insurance fraud?

For our purposes, a simple definition of insurance fraud (please see my source FraudEducation.com) would be “criminal act requiring a material and intentional misrepresentation in order to obtain a benefit.”

This intentional misrepresentation regarding massage therapy services could possibly encompass:

1) Billing an insurance company for a therapeutic massage treatment that never happened (for example, a therapist or clinic bills insurance for a missed appointment)

As I have mentioned in my previous article Massage Therapy and Preventing Missed Appointment by Clients , I prefer to let one missed appointment go without penalty to the client, but in the event that it happens a second time, you need to be prepared to stand strong in case your client refuses to pay. Under no circumstance should the therapist allow these missed appointments to go by without bringing it to the client’s attention. Clients must understand that a therapist or clinic is unable to “just bill insurance” and you will not commit insurance fraud to let them off the hook. If a client won’t pay the fee, then it is better to discharge the patient from your care and document the events leading up to the dismissal.

In the case of a patient undergoing treatment in a motor vehicle insurance claim, it is necessary to document not only subjective and objective findings, but their compliance to your treatment plan and home care. If you find that a client is always late, misses appointments and doesn’t do suggested home care, you can discharge a patient for “non-compliance”. Clients should be informed up front that being discharged for non-compliance will not work in their favour, and that any further requests for treatment will not likely be granted, as the insurance company will not take the request seriously. After all, if a client is unable or unwilling to follow a previous treatment plan, then he or she is unlikely to be compliant in the future.

2) Performing treatments which are excessive and unnecessary.

There is a difference between what we think is necessary and what is considered excessive treatment – this is difficult, as a massage therapist working on MVA clients may identify a need for more treatments than the insurance tables deem appropriate. However, very few people need treatment more than a couple of times a week, unless you have specialized in a therapy such as Manual Lymph Drainage (aka MLD or Lymphatic Drainage), which is most effective initially in several treatments in a shorter time frame. I would have to say that if you can’t document objective findings which demonstrate an improvement in your client’s condition, or you can’t propose a reasonable treatment plan, you will probably find that your client will get limited treatments approved by insurance.

As massage therapists are not considered primary health care providers, our clinical impression is often trumped by a diagnosis of physician, chiropractor or physiotherapist. There’s not a lot we can do about that, but the reality is that in the past there have been therapists who have treated insurance coverage like a cash cow, instead of a tool to help their clients get needed treatment. (Not only is this fraudulent, but it is also unethical on the part of the therapist.).This quite rightfully has led insurance companies to view the profession with a bit of trepidation and suspicion, which is why a primary health care provider’s opinion will be taken over a massage therapist’s.

3) Billing an insurance company for a “massage therapy treatment” but performing another service (for example, a body treatment, such as a mud wrap. This has been alleged to be happening in Nova Scotia in spa settings.)

4) Using the billing number of a registered or licensed massage therapist by another party to perform services.

In the case of billing spa or esthetic treatments as “massage therapy”, or an unqualified practitioner using a therapists billing number, this is absolutely inexcusable. This practice has resulted in several spas being investigated. To my knowledge, there is at least one spa in Halifax that has had BlueCross direct billing privileges revoked, with several more under investigation.

Unfortunately for some of the therapists involved, this fraudulent billing has happened without their knowledge, and while I know this may seem little suspect, I really believe that a lot of therapists have been put in a no-win situation. In most spas and some clinics, therapists do not have access to the system which allows them to process the charges, so they sign a waiver allowing the business to do this admin work on their behalf. If a greedy business owner wants his or her cut of the action, they may instruct admin staff to bill a mud wrap or pedicure as massage therapy. If a client is aware that this is happening, then the client is every bit at fault as the therapist. I would also like to point out that a therapist signing a waiver does not imply that they are in agreement with fraudulent billing practices, and many are not offered a choice of refusing to sign.

Does Fraudulent Billing = Professional Misconduct?

Any one of the above mentioned situations is not only considered fraudulent, but may also be considered professional misconduct by a professional college or association. Part of required client records according to the CMTO is a financial record – this includes not only the date and time of the treatment, but also of the treating therapist, duration, the fee, and how it was paid. Any falsification of client records is considered professional misconduct.

If a therapist’s billing number is fraudulently used, should the therapist have to reimburse the insurance company? Or should it be the spa or business’s responsibility? Who is culpable of fraud?

I have discussed this at length with several friends and colleagues of mine. While I do agree that it is a therapist’s responsibility to oversee his or her account with the insurance company, I do not necessarily agree that a therapist should be held responsible for reimbursing the insurance company if the spa or clinic fraudulently billed it on his or her behalf and the therapist did not receive the money. This places many therapists in a very difficult situation as they often don’t have access to the company system to review the billing. It will be interesting to see how this all unfolds and if it results in criminal charges of fraud for spas and businesses, and professional misconduct of therapists.

For further reading, please go to the post “Massage Therapists – Prevent Insurance Fraud”.

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