Forum tackles insurance fraud in massage therapy

RMTs, insurers agree better collaboration needed to curb problem
Don Dillon
October 07, 2013
By Don Dillon
Oct. 7, 2013 — Representatives from the Canadian massage therapy profession and the insurance industry gathered in Toronto recently in a forum discussing health-care insurance fraud aimed at providing guidance and clarity on issues affecting both sides of the controversy — massage therapists and insurers.
“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?”

fraudforum.jpg   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.

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