Insurance and Massage Therapy

WA State is one of two states that allow massage therapists to bill health insurance for massage therapy. In 1993, the Every Category Provider Law was created that states:

(1) Issuers must not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice for services covered as essential health benefits, as defined in WAC 284-43-5640 and 284-43-5642 and RCW 48.43.715, for individual and small group plans; and as covered by the basic health plan, as defined in RCW 48.43.005(4), for plans other than individual and small group.

For individual and small group plans, the issuer must not exclude a category of provider who is licensed to provide services for a covered condition, and is acting within the scope of practice, unless such services would not meet the issuer’s standards pursuant to RCW 48.43.045 (1)(a). For example, if the issuer covers outpatient treatment of lower back pain as part of the essential health benefits, any category of provider that provides cost-effective and clinically efficacious outpatient treatment for lower back pain within its scope of practice and otherwise abides by standards pursuant to RCW 48.43.045 (1)(a) must not be excluded from the network.

Medically Necessary. In order for your massage therapy to be covered, it must be medically necessary. Your insurance plan will define medically necessary. Here are some definitions from popular insurance companies.

Health Insurance does not cover massage therapy for regular maintenance or for wellness massage. You must pay cash for those services.

Prescription Required. All massage therapy requires a prescription in order for a massage therapist to bill and get paid by a health insurance company. Some carriers will tell you on the phone that a prescription is NOT required. This is NOT true. If you ask them does the massage need to be medically necessary and if a diagnosis code is needed, the will say yes. Let me know if you ever find one that says NO. To be medically necessary, a prescription is required. A massage therapist can not make a diagnosis about an injury or condition as it is not in their scope of practice. A doctor needs to make the diagnosis and provide the diagnosis code to the massage therapist in the form of a prescription. The prescription must also contain the number of sessions prescribed within what time frame.

Prior Authorizations. Some insurance companies such as Premera Blue Cross and Regence Blue Shield require and extra step of having your sessions prior authorized before they will pay for your sessions. They have hired a third party company – eviCore – to perform that service. The massage therapist will have to contact them and follow the steps which include using your account number, diagnosis code to get approval. It can be done online on their website or the therapist can call in. eviCore will then allow 4 sessions – no matter if you fell down a ski slope or just pulled a hamstring running….whatever the injury… the results are the same – 4 sessions. The massage therapist can then request more sessions if needed. They will usually approve 2-4 more sessions. After than, the massage therapist will usually have to do much more paperwork to get more sessions approved.

For more information on how to bill insurance see my book: Massage Insurance Billing Manual on my other site www.massagepracticebuilder.com