More than you care to know about Health Insurance

I have been billing claims to insurance companies for many years now and I still don’t know everything, but I will share with you what I do know.

The basic layout of a health insurance plan is benefits, deductible, copay or coinsurance. Most plans have a variety of benefits such as massage therapy, dental, prescription drugs, etc. This is the good part of a health insurance plan, where they cover part or sometimes all of your health expenses.

The next part is a deductible, all plans have one. A deductible is the upfront cost to you, the customer. In most cases this portion must be paid before insurance starts to contribute to ANY of your benefits. The bigger the deductible the cheaper the plan and vice versa. I’ve seen deductibles as low as $150 and a high as $5,000.

Copay and coinsurance is the other way insurance companies make money. First you pay for your deductible and when you use your benefits you still have to pay for part of them. When you come to our office for a massage and you have met your deductible you may still owe 35% of the massage visit. A copay is essentially the same, except it is a flat rate that doesn’t change bases on the amount billed to your insurance company.

-Amazon Plans: From my experience Amazon health plans typically circumvent the deductible owed for MASSAGE (I don’t know about other benefits). The good news is Amazon plans also pay for most if not all of the billed amount- leaving very little owed by the client (typically $14). The only issue of the Amazon plan is Premera only allows for 60min sessions. This means if you decide to get a 90min massage the additional 30min is your personal financial responsibility.

-Sound Transit Plans: Most health plans here have a higher deductible, however the company gives their employees an HRA account. This covers the client’s massages typically at 100%, until the deductible is met. After the HRA is depleted so is the deductible and Premera insurance coverage kicks in. So nothing is owed by the client. When Premera commences payment the reimbursement rate covers an hour long session with us here at Woosah. Again Premera only allows for 60min massages, additional time is the client’s responsibility (Refer to the out-of-network section below).

Prescriptions are required by some plans and not required by others. However if you wish to have your sessions submitted by Woosah or by any other independent massage therapist you will need to provide a prescription regardless of what your plan dictates. I have spoken to insurance companies about this debacle and every time they tell me to get a prescription even when the plan says otherwise. Here is why- as massage therapists we are not allowed to diagnose your symptoms. It is out of our scope of practice. We are not allowed to say you have “low back pain.” We need a physician to tell us what we are treating. We need a doctor to give us a code that tells the insurance company what is being treated and billed; ie “low back pain” equates to “M54.5.” Without this code your claim to your insurance company will not be paid.

Another issue with prescriptions and insurance companies is they do not like to pay for “chronic” issues. This means insurance will eventually stop paying for massage on your “low back pain” or “M54.5” if your pain and treatment persist for a continued amount of time. There is not a specific amount of time insurance companies allow, however if they choose to audit your file and see massage on the low back area for over a year they will most likely choose to deny further and/or past treatment. Insurance companies will argue that massage is not getting you better if your pain persists for months and years. They see massage as a medical treatment that gets you better, not as a preventative benefit for stress, wellness, etc. (Note- there is no diagnosis code for stress). This means you could be financially responsible for your sessions should the insurance company decide your treatment is not “medically necessary.” This is another reason why updated prescriptions with NEW and different diagnosis codes are necessary. We recommend obtaining a new prescription annually to avoid insurance interference.

Woosah Massage is contracted with Regence and is an In-network provider. This means we have accepted a standard rate of reimbursement for each massage sessions. In exchange we are exposed to a wide number of Regence customers who look for a provider. We are required to bill no more than our contracted rate. We are also required to collect coinsurance or copay from the client.

Woosah Massage is now Out-of-network with Premera Insurance Company. Being Out-of-network we are in charge of our billing rate and everything that stems from this point. This allows for more freedom and creates benefit for us as well as the client. We are not required to collect coinsurance payments and can pass along discounts to the client where we see fit.

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