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”.

© Copyright 2009
www.whymassagetherapy.com
All Rights Reserved.

How Often Should I Get a Massage – Frequency Guideline

Following my initial blog post on this subject How Often Should I Get a Massage, here is my treatment frequency guideline, for massage therapists and their clients.

Remember, this is just a very generic guide, and will have to be adapted for individual situations.

Here are my general guidelines for treatment frequency:

Relaxation – once a month for an hour, unless you want to come more often.

Acute injury – more frequent treatments of shorter duration should help – for example, 2 times a week for 30 – 45 minutes. This should help relieve pain and congestion in the area, then after a few weeks, switch to deeper, muscular work for longer periods of time. At this point your injury may have moved into a subacute or chronic stage of healing, depending on the severity of the injury, 1-2 times a week for an hour, over a period of 3-4 weeks should get you on the road to recovery.

Treatment for chronic conditions (i.e. headaches or back pain) – one hour twice a week for 4 treatments, then try once a week for 3 or 4 weeks, and try to decrease to 1x in 14 days for 2 treatments. You will then go into maintenance mode. Once again, very individual, and the longer the condition has been an issue for the client, the more treatments will usually be needed to make consistent gains.

Some more general guidelines:

Follow remedial exercise and homecare advice – passive treatments such as massage therapy can only take you so far, it is YOUR responsibility to be proactive in your own health care. This means follow exercise, stress management, nutrition and lifestyle advice. Record what you do and how you feel, try to make a correlation between various factors. If you have a team of health care providers who are willing to work together, use them!

Don’t go too long between treatments! Progress made during a treatment is building on the progress made in a prior treatment. This means that if I’ve treated a client for chronic back pain for a month and we’re seeing some results, if he stretches out the length of time between appointments to 8 weeks instead of my recommended 2 – 4 weeks, it may be like starting all over again. What a waste of money for the client!

Remember, though, that if you start to feel consistently better (and consistent is key), you have the right to say “I’d like to stretch out the time between treatments a few more days, can we try that?” Your therapist can only give you advice and guidance, you have to figure things out what works for your situation.

If the treatment is not helping – find another therapist! Sometimes people feel awkward about ditching their therapist, especially if you have a good relationship with him or her. BUT, it’s your time and money, and you should see results. Sometimes massage therapy is not the be-all-end-all of treatments, I personally find a combination of therapies to be the most effective.

Knowing your rights as a client will prevent you from getting expensive, unnecessary or ineffective treatments, and will enable you to receive treatment that suits your needs.

© Copyright 2009
www.whymassagetherapy.com
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How often should I get a massage?

Without fail this is one of the most common questions I receive as a massage therapist. The truth is, though, how often you should get a massage treatment is very individual and doesn’t follow a set formula.

As a massage therapist, I am asked this question by every 9 clients out of 10.  There are several factors that I take into consideration, and these factors include, but aren’t limited to, the following:

1. Why are you coming for treatment?  For example, is this for a specific issue, or is it for relaxation?

-       treatments which focus on specific issues are usually more frequent, though I rarely have treated a client more than 2 times a week for more than 3 or 4 weeks.

-         for relaxation and general health purposes, more than once a month is not necessary unless you have the time and financial resources to get treated.

2. What is the tissue presentation?

-         if you have a chronic, long-standing issue, and the tissue is very “dense” or “hard”, then you may need several treatments over a few weeks to make progress. Once your tissue has loosened up a bit, you should start feeling better. After a few weeks, your therapist should see how you are progressing, and you should be given the option of reducing treatment frequency.

-         tissue that is inflamed from injury cannot be treated directly with massage therapy, however, surrounding and compensating structures can and should be addressed to prevent pain and muscle imbalance.

-         tissue that is inflamed from injury can be treated with Manual Lymph Drainage (also known as lymphatic drainage or mld). Frequent treatments of this nature are recommended as this therapy facilitates the removal of metabolic waste from the injury and relieves pain and congestion.

3. Keeping in mind that everyone is individual and responds differently to treatment, you may notice that the effects of the treatment last only a day or so after the first treatment, with longer periods of feeling better as you progress – this is when your therapist should reduce treatment frequency.  After all, how are you going to know that you’re feeling better if you are still getting treatments twice a week? Exactly …

4. After 3 treatments, how are you feeling?

-         Personally, even with chronic issues such as upper back pain and tension, I feel that a client should notice an improvement by the end of the 3^rd treatment. This is my guideline which tells me I am on the right track, and it keeps me focused on what the client needs. I’m not saying there should be a huge or remarkable improvement, but some progress should have been made.

-         And just a side note for clients – if you aren’t seeing some improvement such as decreased pain, increased mobility etc by the end of the 3^rd treatment, then your issues aren’t being addressed. At this point your therapist should go over the treatment plan again (sometimes we miss things), and perhaps revamp it a bit.

-         If no progress has been made by treatment #5, ask to be referred to another therapist.  Beware the therapist who insists that you continue to book, and don’t be shy to say that you’re not feeling any different, after all, massage therapy is your investment in health.

If you are unable to come for the recommended frequency due to financial concerns, talk to your therapist. If he or she is aware of your financial limitations, she might be able to adjust the treatment plan so that you can maximum benefit for your restricted budget, or recommend things you can try at home to enhance and prolong the effect of the treatment.

For more information on Massage Therapy Treatment Frequency Guideline …

© Copyright 2009
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What is muscular atrophy, and what causes denervation and disuse atrophy?

What does atrophy mean, and what causes atrophy of a muscle?

The definition of Atrophy, according to Human Anatomy and Physiology (8th Edition) is “reduction in size or wasting away of an organ or cell resulting from disease or lack of use”. Atrophy is also referred to as “muscle wasting”.

Atrophy of a muscle can occur in 2 ways – from disuse or denervation.

Disuse atrophy will occur when a person is unable to use a muscle for any number of reasons. It is very common when a limb has been cast from a break or fracture, or a person has been on bed rest for a extended length of time. Once a person is mobile again, or a cast has been removed, the client should undergo a rehabilitation process designed to challenge and strengthen the involved structures. Assuming that the atrophy was only caused by lack of use, the patient will eventually regain strength and normal size of the muscle.

Denervation atrophy occurs when the nerve supply to a muscle is interrupted and the muscle no longer receives signals or stimulus from the nervous system. This type of atrophy can occur from injury to the central nervous system, as in a spinal cord injury, or in the peripheral nervous system, such as a broken bone which damages surrounding nerve. Damage doesn’t necessarily mean a complete severing of the nerve, in which case nerve tissue is not known to regenerate. Damage will occur in varying degrees of severity, and may be a result of compression (impingement), crushing or partial tearing. If this is the case, with proper care and rehabilitation the injury will heal and muscle strength can be regained.

Why is this important to a Massage Therapist?

Massage therapists are specialists in treating the dysfunctions of the musculoskeletal system, and understanding the anatomy of the involved structures is key to providing a successful treatment. Odds are that you will see quite a few conditions throughout your career that will either cause, or have the potential to cause, muscle atrophy. Conditions such as chronic Thoracic Outlet Syndrome or Carpal Tunnel Syndrome may cause denervation atrophy due to impingement or compression of the ulnar nerve root and median nerve respectively, and can be successfully resolved once the underlying cause of the compression has been addressed.

Atrophied tissue is very fragile, and deep techniques are contraindicated until the condition of the tissue improves. Initially, the primary goal of treatment for atrophied tissue is to increase circulation and to stimulate the nerves – this can be accomplished by gentle dry brushing, followed up by light stimulating techniques such as stroking, effleurage or c-scooping. Great care must be taken if there has been crushing or tearing of the nerve, as any local techniques which apply pressure or traction can disrupt the healing of the injury.

It is highly recommended that you consult with the client’s physician, physiotherapist or chiropractor to verify the cause of atrophy, and that you work under his or her supervision and guidance if the atrophy is caused by denervation.

© Copyright 2009
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Massage Therapy Client Rights

Question: At my first massage therapy appointment, I asked the therapist some questions concerning the treatment. I found her to be evasive, and a little impatient with me. As a client, don’t I have right to know what is going to happen?

Yes, you certainly do. Here is a list of some of the rights you have as a massage therapy client.

1) Get some advice on how to find a licensed massage therapist – you have the right to know what qualifications your therapist holds. Ask where he or she went to school, to what professional association or college he or she belongs, and if they have any additional training. And remember, don’t discount a therapist just because he or she has recently graduated – there are some really fantastic new therapists who begin their careers every year.

2) You have the right to be informed about what to expect during and after a treatment. This is known as Informed Verbal Consent and is a set of statements designed to make the client aware of expectations concerning the treatment, as well as his or her rights as a client. Informed verbal consent goes above and beyond some typical quesitons, such as “do I have to take off all of my clothes” or “is it normal for the treatment to hurt?”. For any Canadian massage therapist who practices in compliance with the CMTO standards, informed verbal consent is mandatory before assessment or treatment begins and provides the client an opportunity to ask questions.

I have been disappointed to hear from clients who, when they’ve seen me for the first time, tell me that no
massage therapist has ever gone over informed consent with them. I cannot speak for students educated in the US, but Canadian massage therapists should really know better. We are obligated to advise clients what is going to happen. Period.

3) You have the right to receive treatment in a safe and hygienic setting. This is everything from the entryway of the clinic, to the bathroom and waiting facilities, and most certainly extends to the linens, towels etc that come into direct contact with the client. Linens should only be used with one client, and anything that comes into contact with the client’s skin needs to be washed after each use.

Equipment should also be safe, clean and in good repair, and there should be nothing on the floor on which a client could trip or lose footing. If the linen looks dirty, the equipment is wobbly or obviously broken or the
clinic is obviously unhygienic, you have every right to turn around and leave. (and I suggest you do)

4) You have the right to receive treatment from a massage therapist who is clean and hygienic herself. If there appears to be “hygiene” issues, you have the right to voice your concern and leave, you are not obligated to receive a treatment from someone who makes you uncomfortable or is unclean. I can pretty much guarantee that if a therapist doesn’t pay attention to his or her personal hygiene, that the linen and equipment will be lacking in this department as well.

5) You have the right to refuse treatment from a therapist who is ill. Your therapist should advise you in advance (preferably) or when you arrive if he or she isn’t feeling well or has a cold, and should not charge you if you decide to postpone treatment until he or she is feeling better.

6) You have the right to stop or modify the treatment at any time. If you are in a lot of pain, or for ANY reason you are uncomfortable, you do have the right to tell the therapist you want to stop. The therapist should respect your request and allow you to get off of the table and get dressed in privacy.

A massage therapists needs to receive informed verbal consent from you if he or she is going to be working in a “sensitive area” – for example, breast massage is not typically performed unless it is clinically indicated by your presentation or health history. Either way, it is always your choice whether or not to receive or refuse treatment.

If you feel that any inappropriate touching or remarks have been made, whether of a sexual nature or not, you have the right to report the therapist to his or her professional association. Please do so, as therapists who violate massage therapy professional standards and a position of trust do not deserve to call themselves massage therapists. In addition, therapists who engage in sexual misconduct commit a crime for which there should be repercussions.

7) You have the right to be advised of the massage treatment fees when you book your appointment. You also have the right to not be subjected to “upselling” or pressure sales tactics. The College of Massage Therapists of Ontario, and any provincial massage therapy association who follows their guidelines, require therapists and clinics to post their fees in a visible space for all clients to see. Anyone who doesn’t do this is in violation of the policy.

8 ) You have the right to know what products are being used on you. If you have a health issue such as an allergy, or an objection (for example) to products tested on animals, you need to ask this when you are booking your appointment. Remember, though, that a therapist also has the right to know of any issues in advance so he or she can be honest with you, whether or not he can accommodate your request.

9) You have the right to receive your treatment on time. Occasionally a therapist may run a little behind, for example, if the previous client was late; however, if this is habitual, then it shows an issue with your therapist’s time management. While the duration of the appointment will probably be reduced if YOU are late, if your therapist is late, you should receive your full treatment.

If the therapist is so late as to keep you from other commitments, you have the right to leave without incurring a charge. After all, you were ready at the agreed upon time.

The above points are some of your rights, but do realize that a therapeutic relationship between a massage therapist and client is based on mutual respect. If for any reason you don’t feel the situation is working out for you, please consider finding a therapist with whom you have a “good fit”.

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.