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therapy is covered by your health insurance in WA State because of a law called
the Every Category Law. We are the only
state that allows massage therapists to bill health insurance. Massage therapy
is only covered if you have a medical condition that massage therapy could help
improve or relieve altogether. It is
not for maintenance massage or stress.
It does not cover relaxation or wellness massage therapy. There are no plans that are preventative
plans. All sessions require a prescription
from a doctor that state the diagnosis, treatment plan (how many sessions over
what duration of time) and are good for 3 months. New prescriptions are required if you have a
new condition. Massage therapy works best for things like headaches, carpal tunnel syndrome, strained muscles, recovery from surgeries, fibromyalgia and other diseases and conditions. According to the plan benefits Massage therapy is for conditions where there is Pain AND a loss of function as described in their guidelines listed below. (Patient should have at least one (1) Functional Limitation as follows:Sitting, Standing, Walking,Stair climbing, Lifting, Working, Personal care (washing, dressing,etc.), Driving,Sleeping Patient should have at least one Subjective Complaint, as follows:Neck pain, Shoulder pain, Upper arm pain, Forearm pain,Wrist/hand pain, Upper/mid back pain, Low back pain,Hip pain, Upper leg pain, Lower leg pain, Ankle/foot pain).
A prescription is needed for all services that are billed to Regence Blue Shield to show medical necessity. Some carriers will tell you that you do not need a prescription. That is incorrect. Many will say you don't need a referral. A referral is different than a prescription. If you also ask: Does this need to be medically necessary -- the insurance customer service representative will say YES. Also ask if a Diagnosis Code is required. They will also say YES and that means a prescription is required as massage therapists are not allowed to diagnose!
Your sessions will address the issues you are having most effectively when you come in once a week or every other week depending on scheduling allowances to treat the condition. We should see some improvement within the first 2-4 sessions. If your condition starts to improve we continue with treatment until you have a significant reduction in pain and function is restored. If there is no improvement or if there is some improvement but the condition keeps reoccuring, I will send you back to your doctor for other treatment as per their guidelines.
Refer patient when:
No benefit is attained from treatment
Treatment provides only temporary relief, without leading to a resolution of the condition
Improvement with massage therapy has reached a plateau but residual symptoms still exist
If the condition has not progressed towards resolution, refer the patient to an appropriate health care provider to explore other treatment alternatives.
If you do not meet the definition of medical necessity, I am unable bill your insurance. You can see me and pay cash for your sessions.
Medically necessary services: Medically necessary services are defined as a health care service or supply that a physician or other health care professional exercising prudent clinical judgment would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. They are:
-In accordance with generally accepted standards of medical practice
-Clinically appropriate in terms of type, frequency, extent, site and duration
-Considered effective for the patient’s illness, injury or disease
-Not primarily for the convenience of the patient, facility or provider
-Not more costly than an alternative service or sequence of services or supplies at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease
Taken from their website on December 15,2019. (Regence Prior Authorization for Providers PDF)
Regence defines Maintenance Massage therapy as:
"Maintenance therapy means a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. Once the maximum therapeutic benefit has been achieved for a given condition, any additional therapy provided is considered maintenance therapy." Regence Blue Shield Administrative Manual
Regence Blue Shield uses a third party company to provide their prior authorization services (see more below). After your initial 6 sessions of massage therapy, a prior authorization is required. They further define Medical Necessity as follows (from https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/musculoskeletal-therapies/regence-massage-therapy_guidelines_v102019_eff03012019.pdf ):
Massage Therapy is considered medically necessary when all of the following circumstances have been met:
All plans require that a prescription be written by a doctor.
As of June 7, 2018, the prior authorization requirements have changed. Regence plans that formerly required prior authorization are now allowed to have 6 sessions of massage therapy without any prior authorization. Here is the new law in full. Sections 2) and 6) are most pertinent to massage therapy.
Prior authorization standards and criteria—Health carrier requirements—Definitions.
(1) A health carrier that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall inform an enrollee which tier an individual provider or group of providers is in by posting the information on its web site in a manner accessible to both enrollees and providers.
(2) A health carrier may not require prior authorization for an initial evaluation and management visit and up to six consecutive treatment visits with a contracting provider in a new episode of care of chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan. Notwithstanding RCW 48.43.515(5) this section may not be interpreted to limit the ability of a health plan to require a referral or prescription for the therapies listed in this section.
(3) A health carrier shall post on its web site and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions.
(4) A health care provider with whom a health carrier consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed or of a specialty whose practice entails the same or similar covered health care service.
(5) A health carrier may not require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party.
(6) For purposes of this section:(a) "New episode of care" means treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment.(b) "Contracting provider" does not include providers employed within an integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW.
After the initial 6 sessions are done, more sessions may be requested through prior authorization. The prior authorization is done through a 3rd party hired by Regence called eviCore. I take care of this process. What it means is that I take the prescription and your plan details and plug them into eviCore's website and they will tell me how many sessions you can get for your massage therapy. This ignores your plan benefits and the doctor's prescription. What usually happens is that they allow 2 or 3 more sessions no matter what your condition is.
What this means is that even though your insurance may allow 16 sessions and your doctor prescribes say 10 sessions or even the full 16 sessions, you get 6 sessions.
All plans require a prescription but Regence Uniform plans are exempt from prior authorizations along with a few other companies who are self insured which means they can set their own rules. They are just using Regence to manage their own plans and are exempt from the usual rules insurance companies must follow.
This other companies that are currently excluded are:
(This list is subject to change and plans may vary. You and I will still need to confirm this with your insurance plan to be sure.)
What this means is that when the physician prescribes massage for a condition, it must now clearly be a condition where there is a loss of function (can't sit for X amount of time or Walk for X amount of time) AND a pain syndrome.
It also means that the pre-authorization process limits the number of sessions that you can get to 4-6 sessions no matter what your benefits are and no matter what the injury/condition is. It does not matter if the doctor prescribes more sessions and it does not matter how many sessions your plan allows.
Currently the physical therapists have initiated legislation that would stop this behavior which would also make it apply to massage therapists.
I suggest that you contact your insurance plan, your company's benefits co-coordinator and tell them what is happening. Contact the Office of the Insurance Commissioner (they already know but the more complaints the more they will pay attention!)