A Regional Analysis of U.S. Insurance Reimbursement Guidelines for Massage Therapy.

INTRODUCTION: Massage techniques fall within the scope of many different health care providers. Physical therapists, occupational therapists, and chiropractors receive insurance reimbursement for health care services, including massage. Although many patients pay out of pocket for massage services, it is unclear how the insurance company reimbursement policies factor provider qualifications into coverage. This project examined regional insurance reimbursement guidelines for massage therapy in relation to the role of the provider of massage services.
METHODS: A qualitative content analysis was used to explore guidelines for 26 health insurance policies across seven US companies providing coverage in the northeastern United States. Publicly available information relevant to massage was obtained from insurance company websites and extracted into a dataset for thematic analysis. Data obtained included practice guidelines, techniques, and provider requirements. Information from the dataset was coded and analyzed using descriptive statistics.
RESULTS: Of the policies reviewed, 23% explicitly stated massage treatments were limited to 15-minute increments, 19% covered massage as one part of a comprehensive rehabilitation plan, and 27% required physician prescription. Massage techniques mentioned as qualifying for reimbursement included: Swedish, manual lymphatic drainage, mobilization/manipulation, myofascial release, and traction. Chiropractors, physical therapists, and occupational therapists could directly bill for massage. Massage therapists were specifically excluded as covered providers for seven (27%) policies.
CONCLUSION: Although research supports massage for the treatment of a variety of conditions, the provider type has not been separately addressed. The reviewed policies that served the Northeastern states explicitly stated massage therapists could not bill insurance companies directly. The same insurance companies examined reimbursement for massage therapists in their western U.S. state policies. Other health care providers were able to bill directly for massage services to companies that did not accept direct billing by massage therapists. The specific exclusion of massage therapists as eligible providers violates the Affordable Care Act's non-discriminatory provision. Massage therapists should continue to advocate for reimbursement privileges to spur wider acceptance of massage therapy in health care.

INTRODUCTION

Massage therapy, the application of massage by an educated professional,( is a popular form of complementary and alternative medicine (CAM) and many providers may employ it in their practice. Patient interest in CAM gives rise to its steady integration into mainstream health care and health insurance companies have begun to reimburse some treatments.( Acupuncture and chiropractic manipulation are the most widely covered CAM services, possibly due to their profession’s high education standards, enactment of licensure, established efficacy research, and legislative efforts to promote reimbursement across states.( Although most patients pay out of pocket for massage therapy,( massage therapy remains one of the more widely used CAM treatments in the USA.( Renewed interest among physicians in referring patients for massage may arise out of the new physician board certification in Integrative Medicine and patient demand.( Despite the expectation of an upsurge in massage referral rates, acceptance of massage therapists within organized medicine, especially in regard to reimbursement, remains unclear.(

Although massage therapy when practiced alone is viewed as CAM, massage techniques can be used by osteopaths, chiropractors, occupational therapists, and physical therapists.( Published studies evaluating massage’s effectiveness have employed a wide range of treatment providers, from parents or nursing staff to trained massage therapists. Since manual training varies greatly across professions, this raises the question of whether the provider’s professional scope may influence massage outcomes. Studies have found that the degrees of massage therapists’ manual training, competence, and experience does, in fact, have significant affects on research outcomes.( Although other health professionals may use massage techniques and receive insurance reimbursement for services, they may have little or no formal training in massage.( Licensed/ certified massage therapists receive specialized training in massage theory and application of massage techniques, but they are underutilized in the medical setting. Currently the majority of massage therapists operate within private practices serving those who pay out of pocket;( however, there is an increasing interest by massage therapists to gain visibility in medical contexts. Accessibility to massage in the medical setting greatly depends upon health insurance coverage;( therefore, coverage guidelines are of interest to the profession.

United States’ health care delivery relies on insurance reimbursement to secure patient access to a variety of treatments; patients who purchase insurance plans do not pay the full cost of medical care or treatment. Insurance companies evaluate safety and efficacy of treatments, clinical practice guidelines, and patient demand to determine the extent to which care or treatment should be covered. These companies may offer many plans with a variety of coverage and reimbursement requirements.( When companies consider coverage for treatment procedures, they tend to allow coverage for specific provider types (professions) that are capped at a set annual dollar amount.( However, it is unclear how provider professions are factored into insurance company guidelines for reimbursement.

Health insurance companies are increasingly covering some type of CAM.( After companies examine the evidence of treatment efficacy and safety by reviewing research literature, they develop evidence-based practice guidelines for insurance coverage. These guidelines, including methods for the review and research cited, are posted in a publicly available area of the company websites. Insurance reimbursement guidelines vary by company, plan, and region, but many public and private payers cover some form of manual therapy under specified circumstances.( Massage therapy is gaining more recognition in health care. It is promising to find that insurance companies are now covering massage services; however, it is important that massage therapists are considered viable providers.

To date, little research has been done to examine massage insurance coverage guidelines, specifically as it pertains to the provider’s profession—and inclusion of massage therapists as providers. The purpose of this analysis was to conduct a critical examination of insurance company guidelines for massage therapy in a region of the US.

METHODS

Most health care professionals are aware that massage therapy services are covered under a variety of plans, yet the details of “who, what, when, where and how” remain unknown. In order to gain an understanding of this complex phenomenon, a qualitative research approach is necessary. Using an exploratory process sets the foundation for more specific hypotheses and explanations for future studies. A content analysis was used to analyze publicly available information of insurance policies and coverage. The research investigator initially telephoned insurance companies to acquire detailed information on coverage parameters; however, personnel were reluctant to share such guidelines to non-policy holders. The company’s websites offered enough information on general coverage policy to conduct this study. Furthermore, this policy analysis approach provides an objective extraction of information, whereas a survey may introduce potential bias of the person answering on behalf of the company. The study took place at Rutgers University Biomedical and Health Sciences. To permit a detailed analysis, the eastern region of the United States was selected centering in the state of New Jersey. Given the states in the overlapping metropolitan areas in the region (Newark/New York City, Philadelphia, and Wilmington), the core area for analysis was identified as New Jersey, New York, Delaware, and Pennsylvania. This was initially done to gain a more thorough understanding of coverage in eastern states, yet eventually expanded to the other states for which these companies offered policies. Reimbursement policies were included if they were made available through employers or individuals. Excluded from this analysis were therapies that fall outside of the scope of massage therapy practice, such as spinal manipulation, therapeutic modalities used in rehabilitation (e.g., ultrasound, muscle stimulation), and corrective exercise.

This study examined the general coverage publically advertised by insurance companies. However, it should be noted that special provisions to coverage, including adding services, may be available for policy holders under a special contract. All publicly available areas of the website (i.e., not requiring a login or password) were searched for information relevant to massage, and policy information for consumers and companies were explored. Additionally, each website’s search feature was used to identify links to “massage therapy” and “manual therapy.” Any page containing the word “massage” or information relevant to massage was reviewed for details related to massage reimbursement. Sources of information included practice guidelines, techniques, covered providers, reimbursement/billing, insurance policy coverage, and specific information referencing massage or manual therapy were extracted into a dataset and qualitatively assessed by one research rater. The written guidelines and respective codes were cross-checked by the second author to confirm codes were valid and reliable. The initial rater explored patterns within the contents of the dataset and quantified techniques, providers, conditions for which massage treatment was covered, specific practice guidelines, and payment/coverage. Only explicit wording was coded. For example, when a policy guideline stated, “massage therapists are not eligible providers,” it was coded as such. Coding of the data permitted quantitative analysis of the extracted information. Because the project used publicly available information and did not use any humans as subjects in the research, review by a Human Subjects Institutional Review Board was not required. This study took place when both authors were affiliated with the Rutgers University School of Health Professions.

RESULTS

A total of 26 insurance policies offered through seven insurance companies were included in this analysis. These policies included coverage in one of the four primary eastern states and at least one additional U.S. state. In total, policies in the core four eastern states (New Jersey, New York, Delaware, and Pennsylvania), 11 additional eastern states (Maryland, Connecticut, Maine, Rhode Island, Vermont, Massachusetts, New Hampshire, Virginia, West Virginia, Florida, and Georgia), and one federal district, the District of Columbia, were included in the analysis. Although the analysis was intended to be regional, these companies offered additional policies in 13 Midwestern and Western states: Ohio, Illinois, Missouri, Texas, California, Colorado, Kentucky, Alaska, Louisiana, Nebraska, Kansas, Oregon, and Hawaii (Table 1). Thus the regional analysis provided information about insurance reimbursement and coverage in 29 US states with an emphasis on the northeastern US. Insurance companies represented in this analysis were: Aetna, AmeriHealth, Cigna, Oxford/United Health Care, Blue Cross and Blue Shield, Coventry, and Kaiser Foundation.

Table 1

Insurance Cases Reviewed

Insurance Carrier	State of Plan-Specific
Aetna	NYa, PAa, CT, DEa, MD, ME, OH, IL, GA, FL, MI, TX, CA, NJa
AmeriHealth	PAa
AmeriHealth	NJa
AmeriHealth	DEa
AmeriHealth	Medicare Advantage
Cigna	Multiple States
Cigna	NJa
Cigna	NYa
Oxford/UnitedHealth Group	Multiple States
Oxford/UnitedHealth Group	NYa
Oxford/UnitedHealth Group	RI
Oxford/UnitedHealth Group	CT
Oxford/UnitedHealth Group	NJa
Blue Cross Blue Shield (BCBS)	MA, RI, VT, IL
BCBS Horizon	NJa
BCBS Anthem	CT, ME, NH, VA
BCBS Highmark, Inc.	DEa, WV, PAa, CO, MA, KY, VA, MO
BCBS Empire	NYa
BCBS CareFirst	DC, MD, VA
BCBS Independence	PAa
Coventry	MO, DEa, FL, GA, IL, AL, KS, LA, NE, WV
Coventry	NE
Coventry	GA
Coventry	MO
Kaiser Foundation	MD, CO, GA, OR, GA, LA, FL, HI
Kaiser Foundation	OR

Primary Eastern States

Eighteen (69%) of the 26 policies reviewed implemented specific practice guidelines (Table 2). Seven of these policies (27%) required massage to be medically necessary with the requirement of a physician note or prescription. As described by one policy: “[Massage is] eligible only with Doctor’s certification identifying the physical nature of the medical condition and length of treatment program.” In general, massage was not considered medically necessary for prolonged periods of time, but rather “limited to the initial or acute phase of an injury or illness (i.e., an initial two-week period).” Another policy referred to massage as a “passive modality”, stating they such modalities are

Table 2

Descriptive Statistics of Insurance Reimbursement for Massage Therapy (n=26)

Variable	Number of Policies	Percentage of Total Policies
Explicitly Stated Covered Providers
Chiropractors	12	46.15%
Physical Therapists	11	42.30%
Occupational Therapists	7	26.92%
Naturopathic Doctors	5	19.23%
Medical Doctors	2	7.69%
Massage Therapists	2	7.69%
Doctors of Osteopathy	2	7.69%
Explicitly Stated Covered Techniques
Manipulation	14	53.84%
Traction	13	50.00%
Mobilization	12	46.15%
Manual Lymphatic Drainage	10	38.46%
Myofascial	5	19.23%
Craniosacral	1	3.84%
Active Release Technique	1	3.84%
Rolfing	0	0%
Hydrotherapy	0	0%
Massage Reimbursement Guidelines
Physician Prescription Required	7	26.92%
Limit of 15 minutes per region	6	23.07%
Massage therapy is a part of a comprehensive treatment plan	5	19.23%

“…most effective during the acute phase of treatment, since they are typically directed at reducing pain and swelling… Passive modalities are rarely beneficial alone and are most effective when performed as part of a comprehensive treatment approach. Improvement should be seen within the first or second visit… In some rare situations, passive modalities may be indicated for up to one or two months as part of comprehensive physical therapy program.”

Not all plans specifically stated the number of sessions permitted, although few did state that therapeutic manipulation was limited to 20 or 30 visits per year.

Among the 26 policies that reimbursed massage, 6 policies (23%) specifically noted that massage treatment was limited to 15 minutes on one area of the body. Massage was required to be a part of a comprehensive treatment plan that included other therapeutics under five policies (19%). As one policy described it, “Massage therapy is considered medically necessary as adjunctive treatment to another therapeutic procedure on the same day.” None of the policies covered massage as a stand-alone treatment.

Two billing codes specifically listed in the insurance guidelines covered massage techniques (97124—stroking, compression, percussion) and manual therapy techniques (97140: manipulation, traction, lymphatic drainage). Myofascial release was covered under five policies (19%). Manual lymphatic drainage (MLD) was reimbursable under 10 policies (38%) for lymphedema and required either a MLD-certified chiropractor or occupational therapist to perform the services. Massage techniques that were specifically mentioned as excluded from insurance coverage were Rolfing (three policies, 12%) and hydrotherapy (two policies, 7%).

Physicians, chiropractors, physical therapists, and occupational therapists were eligible for reimbursement in almost all policies. As cited from one policy, “Services that do not require the performance of a PT and/or OT are not skilled and are not medically necessary services, even if they are performed by a qualified professional.” A few policies restricted massage therapists from billing unless employed or supervised by a physician, physical therapist, or chiropractic doctor. Seven policies (27%) specifically deemed massage therapists ineligible providers. One policy stated, “The Company does not provide reimbursement for services that are performed by someone other than an eligible health care provider (i.e., within their scope of practice) for either constant attendance modalities or therapeutic procedures. This includes massage therapists.” Of the policies that reimbursed massage therapists, those specific to reimbursement in western states, such as Oregon and Colorado, permitted massage therapists to bill directly. Massage is more prevalent in western US states; the percentage of people visiting massage therapists is greater there than in the rest of the nation.( Four of the 26 policies (15%) that reimbursed massage required all massage providers to receive preauthorization before billing. It was not specifically stated that any other profession needed preauthorization to bill for massage.

The type of massage coverage varied across the seven insurance companies, yet all of the companies offered massage services through a discounted rate program “not guaranteed under [the] health plan contract and could be discontinued at any time.” These services were provided to policy holders willing to pay reduced out-of-pocket costs directly to the provider, without filing an insurance claim for the massage services. These reduced rate services were offered as part of an employee wellness plan or onsite chair massage.

DISCUSSION

Although there is a growing body of research on massage efficacy, the findings of this analysis suggests limits on general insurance reimbursement for massage. These limits include requirements for prescriptions and lack of recognition of massage therapists as covered providers. The use of 15-minute billing increments is typical across the medical field, but this differs from the 60-minute massage treatment that is more commonly associated with massage therapy. Discount programs providing lower cost massage for patients did not reference reimbursement for the massage therapists, suggesting that the therapists associated with these plans are simply getting a lower fee in return for their affiliation with the insurance company. Reimbursement requiring physician supervision differs from the autonomy in massage practice that is addressed in state licensing acts. This difference suggests a lack of recognition of the legal scope of practice for massage by the insurance companies.

Limitations of this study include the inaccessibility of specific plan information, as insurance companies refused to provide detailed explanation of coverage to the research investigator, a non-policy holder. Amendments to insurance plans may cover massage in a broader capacity; however, this information could not be captured and research was limited to analysis of publicly available information only. Future survey of insurance company personnel might potentially uncover rationale behind the policies set forth by the companies. In order to conduct a thorough analysis, this project was started with a focus on insurance companies within a region of the US; western states were later considered where the targeted companies offered additional policies.

Future research should explore massage coverage across all regions of the US. Further investigation of the potential barriers to wider acceptance of massage therapists in mainstream health care delivery is necessary for the profession to overcome such obstacles. Massage Therapists should continue to collaborate with and educate allopathic medicine providers about the efficacy of massage therapy treatment.

As it stands, many CAM practitioners are unable to receive reimbursement for the very treatments they are trained in and thus cannot practice to their full scope.( This violates the Affordable Care Act (ACA)’s non-discriminatory provision, Section 2706(a), also known as the Harkin Amendment, which states that health insurance companies cannot exclude a group of providers who are practicing within his/her scope of license or certification.( Although there are no studies comparing the amount of massage technique training across health professions, the prevalent standard of 500-hour education for massage therapists in the US is the equivalent of one year of college. Future research should compare how educational standards for providers of massage techniques are related to insurance coverage for services. The findings from this study should empower the massage profession to continue to advocate for reimbursement privileges. Massage Therapy organizations should persist in their progression of the Current Procedural Terminology (CPT) codes to secure massage therapists’ ability to bill or become credentialed as in-network providers for health plans. Massage therapists should reference the Harkin Amendment as they campaign for coverage and direct their efforts to their state’s insurance commissioner. If inclined, massage therapists should start to bill for their services. Even those uninterested in billing should understand that insurance coverage spurs wider acceptance of the massage therapy profession within health care.

CONCLUSION

The topic of insurance coverage for massage is relevant to a range of stakeholders beyond the massage profession. Insurance company policy-makers and state legislators should be aware of potential discrimination against insurance coverage when massage is performed by a licensed massage therapist in states where massage therapists are licensed health care providers. Employers who negotiate for insurance plan rates and services may be unaware that there are potential differences in coverage for massage techniques by health care professionals. Consumers may not be aware of how the relationship between research evidence, insurance company policies, and employer negotiation for insurance plan components impacts potential access to massage as a covered benefit. Ongoing exploration of issues related to the relationship of the massage therapy profession to the conventional health care system, insurance coverage, and access to massage are warranted.