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Forum tackles insurance fraud in massage therapy

“Do massage therapists have standard fees and billing practices?” “Do
massage therapists receive training in ethics and preventing fraud?”
“Are record-keeping requirements upheld in non-regulated provinces?” “If
a massage therapy treatment plan is submitted for ‘maintenance’ or
‘wellness’ how do I, as an insurance adjudicator, determine if it’s
reasonable and medically necessary?”

The Canadian Massage Therapist Alliance wants to work with the insurance industry to address insurance claims fraud. CMTA representatives at the CHCAA conference include: (L-R) Julianne Heagy, past-president Massage Therapist Association of Saskatchewan (MTAS); Lori Green, executive director, MTAS; and Brenda Locke, executive director, Massage Therapist Association of British Columbia.

These were some of the
questions insurance industry representatives posed in a session titled,
Massage Therapy in the Canadian Health Care System, at the Canadian
Health Care Anti-fraud Association (CHCAA) conference. The session, led
by Lori Green and Brenda Locke, representatives from the Canadian
Massage Therapist Alliance (CMTA), provided opportunity to educate
insurers on the role and culture of massage therapy in Canada, and for
insurers to ask questions.

According to the U.S. National Health
Care Anti-fraud Association, health-care fraud and waste cost the
insurance industry nearly $70 billion each year, and fraud may account
for at least 10 per cent of all health-care costs. As a result, claims
for massage therapy in employee benefit plans, auto insurance and
workers’ compensation are under increasing scrutiny, with many
practitioners reportedly experiencing higher claim denial rates.

In
their presentation, Green and Locke outlined the goals of the CMTA,
which include promoting research and evidence-informed massage therapy
practice, encouraging regulation in all provinces and collaborating with
partners – such as the insurance industry – to better Canadian
health-care delivery.

The CMTA advocates for national
professional standards, continuing education competency and an
accreditation program, knowledge transfer of research, and for RMT
associations “to work with the insurance industry to establish and
maintain protocols that ensure Canadians receive bona-fide
medically-required massage therapy treatments.”

Further, the
CMTA wants to position RMTs as “primary health-care providers working in
both public and private sectors of health-care.”

Green and Locke
stressed massage therapy is not a “singular modality,” and includes
manual technique for muscles, connective tissues and joints, remedial
exercise, hydrotherapy and postural and movement rehabilitation. Massage
therapists are “educated and trained to accurately assess,
differentially diagnose and provide treatment… formulate and incorporate
an individualized evidence-informed treatment plan.”

The CMTA
representatives admit fraud in massage therapy claims is a real issue
for the massage therapy profession. They have attended CHCAA conferences
for several years, and shared concerns with the insurance industry over
misrepresented and undertrained practitioners, or legitimate
practitioners issuing fraudulent receipts. They said the CMTA is
supportive of a national practitioner registry to reduce fraud and the
risk of harm to the public, and encouraged the need for third-party
claim oversight, asking the insurance assembly to diligently review
massage therapy claim submissions.

In a 2013 white paper released
by the CHCAA titled, Non-therapeutic Massage, the organization cited
the prevalence of fraudulent claims on employee benefits for massage.
“CHCAA members have identified cases indicating massage therapy but
where the actual services provided were sexual services or were spa
services. Sexual services and spa services would not be considered
massage therapy under the contractual terms of a group benefit plan
which generally massage therapy services that are for medically required
therapeutic purposes recognized by standard medical practices.”  

The
paper also indicated that in many of these questionable cases, receipts
were issued in the name of registered massage therapists. “CHCAA
members had identified cases where it is apparent that the massage
therapist was knowingly providing the receipts, and other cases where
the receipts were being issued in the name of the massage therapist
without his or her knowledge.” The white paper included a list of
recommendations for massage therapists to help prevent fraud in their
practices.

The
CMTA has developed a standard RMT receipt that was presented at the
forum. Insurers at the conference responded favourably to the standard
receipt, and the CMTA encouraged all its member provinces to use it.
CMTA members include British Columbia, Alberta, Saskatchewan, Nova
Scotia, New Brunswick, Newfoundland/Labrador and Prince Edward Island,
as well as the Northwest Territories.

During question period, an
audience member asked, “Is the Ontario RMT association not a member?” 
Green and Locke confirmed the Registered Massage Therapists’ Association
of Ontario (RMTAO) is not currently a member of the CMTA. The RMTAO was
not present at the conference and were unable to respond to this
question directly.

Green and Locke spoke of “pretenders” –
individuals and organizations that dismiss the need for regulation and
accredited training.

“Like with all testing, fail rates are the
measure of rigor in a profession,” the CMTA presenters said. They said
both British Columbia and Saskatchewan have entry-to-practice fail rates
of approximately 25 per cent. However, it was noted in unregulated
provinces that some practitioners failing entrance exams may sign up
with an alternate association with lower standards, receive a billing
number and begin practice before successfully completing the exam. The
CMTA asked insurers to recognize this and exercise due diligence in
approving claims from members of these associations.

In a private
conversation with a representative from a large insurance company, an
insurer stated some frustration with massage therapy receipts that list
various techniques and modalities rather than “massage therapy
treatment.” She described having to check the scope of practice in the
province where the receipt was issued to ensure the practitioner was
working within approved scope and that the claim was valid. In effect,
the inability to transfer the massage profession’s nomenclature and
culture to the claims process makes unnecessary work for insurance
adjudicators.

During the session, Green and Locke stressed, “the
CMTA firmly believes that the CLHIA (Canadian Life and Health Insurance
Association) should only provide insurance coverage for bona fide
massage therapy that meets the definition of ‘medically necessary’
treatments.”  

In its document entitled, Medically Necessary
Services and Massage Therapy , the CMTA defines the terms, “medically
necessary” or “medical necessity,” as “health-care services that a
therapist, exercising prudent clinical judgment, would provide to a
patient for the purpose of evaluating or treating an illness, injury,
dysfunction, disease and/or its symptoms.”  

When
asked about wellness massage or massage prescribed post-acute injury to
maintain the body, Green stated, “we’re not saying relaxation is a bad
thing,” but affirmed massage therapy should be medically necessary.

During
the conference insurance industry representatives expressed other
concerns with the massage therapy profession and practice: they’re
unaware of how to access standard RMT fee schedules; claims for
treatment are not necessarily based on established treatment guidelines
or evidence-based practice; receipts are confusing and in a variety of
formats; and relating to fraud, practitioners are not consistently
reliable or properly trained in ethics.  

Insurers, however,
expressed willingness to work with the massage therapy profession — but
they want credibility, accountability and a unified voice they can
communicate with.

Donald Quinn Dillon is a registered massage
therapist, author and speaker. You can contact him through his website,
MassageTherapistPractice.com.