This One's For You "Doc"

"Doc" was a dying man, whose disease prevented him from speaking and moving, but his mind was still there.  He could see us and hear us and follow us with his eyes.  Until the end he could force out a smile or even a grimace if he really needed to get a message across.  He was dying from ALS, also known as amyotrophic lateral sclerosis or Lou Gehrig's disease, and chose to live out the rest of his life in the comforts of his own home.  His muscles slowly ceased to function and it spread throughout his entire body eventually getting to his heart, and what a heart it was.  I miss that man.
I was introduced to Doc -- who was not a doctor at all -- about a year ago.  I was eventually asked to provide massage to this man who was confined to a bed with life support systems all around him.  When someone is bed-bound many complications can arise and some of them can be prevented with or treated with massage therapy.  He had excellent medical care and an excellent team caring for him.  Still, I was asked to help.
Doc had his own way of telling me when he was uncomfortable and it didn't take me long to understand the different expressions he made with his face to communicate with me.  One day I noticed he had some swelling in his hands, called edema.  This happened because he was unable to move his body and the lymphatic fluid in his body was unable to move well because of it.  This caused the fluid to build up in his extremities, starting with his hands.  Common practices to care for edema are to raise the extremity to aid in the fluid flow and continue to watch the body part for signs of improvement.  What I did was take Doc's hand and ask him for permission to try something I have been trained to do.  I explained to him what lymphatic drainage massage was and how it might help and his facial expression gave me the permission I needed to continue.  Within five minutes his swelling was gone and he was smiling.  He could feel the difference even though he was unable to see the difference.  I had thought ahead though, and had shown him his hand both before and after the massage.  His eyes were wide, he looked confused, and then he smiled a big smile.  He was clearly impressed.
Some may say this was not a "need".  That this was not "medically necessary".  Let me ask you, if his nurse had given him a pill for his swelling would that have been a "need" or a "medically necessary" step to take? Sure it would have been, because it would have provided him with relief and would have decreased his chances of developing further complications.  It would have helped make sure the condition was under control.  It would have provided an effective way of treating the problem.  That's all medical necessity is: an effective way of treating a problem.  Why then, is massage considered NOT to be medically necessary?  Why do some doctors and home care agencies turn the other cheek on massage therapists when we can be of help?  I've tried to bring help into homes by approaching the very people who can make it happen and the doors keep closing in my face.
I've helped others besides Doc but I'm choosing to share my story of Doc because there's more to his story than there is to others.  I was told not to help Doc.  I was told I could not help Doc or I would lose my job.  I was told my massage services were not needed by the health care company I worked for.  Not needed, really?  Right there was the person who was paying them for Doc's care ASKING me to help.  Tell me that I'm not needed and I will show you someone in need of relief and a distraught family member who just wants them to feel better -- dying or not!  Not needed my behind!  Relief IS needed and by many people!  Time and time again I helped Doc on my own and provided him with relief with the permission of his primary care provider.
So when I advocate for home care patients to have access to massage it really bothers me when someone says it's not needed, or they don't provide luxuries or gifts to their patients.  I have a number assigned to me that allows me to bill insurance.  This means I am recognized as a health care provider.  I am not providing gifts or luxuries.  I am providing all natural therapy.  I am providing relief.  I am providing comfort.  I CAN HELP and help IS needed.
I studied lymphatic drainage massage because of  Doc.  I knew there was such a therapy & I knew it could help him but I didn't know how to do it so I learned how and I managed to do it before he passed so I was able to help him get through his situation with as little discomfort as possible.  Although Doc has passed I continue to advocate for something that I know brought him a lot of relief and that I believe others should be able to benefit from as well.
As I said, Doc wasn't actually a doctor.  There was a joke in his family about how he and his wife checked into a hotel one time and he had told them he was a doctor.  The hotel welcomed him so nicely and addressed him as "Dr. [enter last name here]".  They got the royal treatment!  So from then on he was known as, "Dr." even though he wasn't one.  He was quite the comic though, and he is missed.  This fight is for you Doc, that my efforts will help more than one person get through a difficult time, because I know it would have made you happy to see others cared for the way you were.  See you on the other side.

Yes Doctor, Massage IS Medically Necessary, Part II

UPDATE: Since my press release (Yes Doctor, Massage IS Medically Necessary, Part I) I have been informed by two organizations that they suspect the reason massage is not offered through home care agencies may be 1) home care services have to be "medically necessary" in order to be covered and massage doesn't fit into that category, 2) they run the risk of massage being considered an illegal gift used to lure patients toward one company vs. another, 3) it would be an "add-on" expense to the patient with no reimbursement option, 4) that Medicare and Medicaid do not cover massage therapy & the majority of home care clients utilize Medicare & Medicaid as their payment method, 5) there's not a "need" for it,  and 6) there would likely need to be laws changed in order to get Medicare & Medicaid to cover massage.  On all six accounts, once again, massage is misunderstood.  Grab a cup of your favorite source of relief and have a seat, this one is a long one!

1-- (Home care services have to be "medically necessary" in order to be covered and massage doesn't fit into that category.)  Wrong, massage DOES fit into that category.  It falls under "rehabilitation" on a medical bill.  Massage is no less medically necessary than an aide going into a client's home and helping them to pay bills, run errands, do housecleaning, cook a simple meal, remind them to take their medication, bathe, get dressed, etc.  Insurance pays for those services.  What deemed those services medically necessary?  Either the client was incapable, it was unsafe, OR it was uncomfortable due to illness or injury.  Providing those services offered them either with something they are incapable of doing themselves, a safer environment for them, or RELIEF in having to do it.  Massage, over time, can actually help people do things they haven't been able to do in a long time.  It can provide a better conditioned body which is safer for the patient who has to move.  It can provide a safer environment for the bed-bound patient by reducing the risks of edema and/or limited range of motion or blood clots.  It also offers RELIEF -- relief to the frayed, tense, or torn soft tissues of the body that bear down on nerves and cause pain, discomfort, or limited ability to move.  It also has the potential to lower blood pressure and high blood glucose levels.  Yes, it IS medically necessary and I have the paycheck stubs from insurance bills to prove it.

2 -- (They run the risk of massage being considered an illegal gift used to lure patients toward one company vs. another.)  I had to read this one several times to be sure my eyes were not playing tricks on me and if it weren't such a serious issue I'd have found it humorous.  Amusing as it is, this statement is wrong.  As far as massage services being a gift is concerned, we're not talking about an in-home spa here, we're talking about a health care service that comes with a prescription.  Yes, doctors CAN write a prescription for massage!  Yes, some massage therapists are recognized as health care providers and yes some of them can bill insurance (but WHICH  insurances recognize it varies).   A prescription is not a luxury, that's a medical necessity.  I've never heard of a home care service being considered a gift either.  A gift is something someone receives without paying for it or agreeing for the responsibility of its expense in one way or another.  Offering a service is not the same as offering a gift.  As far as legalities go, in my experience working in the home care industry I can tell you that the only thing illegal about gifts and home care is when a caregiver takes advantage of a home care client by accepting gifts from them or by giving them gifts in order to manipulate them.  There would be nothing of the sort here.  For a fee they would be receiving a LEGITIMATE HEALTH CARE SERVICE that follows a doctor's prescription -- either private pay or through their insurance, just like all the other health care services that are available to them.  There's no hint of a "gift" in that anywhere.  I'm pretty sure that when you pay for something or your insurance pays for something you're not receiving a gift, you're receiving a service.  The only thing illegal about offering massage is that if it's illegal it's NOT professional massage!  That is something else entirely!  Taking into consideration the idea that by offering a service other agencies may not offer an agency may be breaking a law is something I can't even wrap my head around.  Here's why:  first of all, massage, when offered by a licensed properly trained professional, is a legitimate health care service billable to some insurance companies and recognized by health and medical facilities nationwide.  Additionally, some home care agencies don't offer medical services and some do.  Does that mean those that offer certain services that others do not are somehow illegally or unethically pursuing patients?  No, I don't believe so.  Does it make the health care services those agencies offer a "gift" and not a "service"?  No, I don't believe so on that one either.  Does it make people want to choose one company over the other?  Probably, depending on their needs.  Is it illegal for people to have those choices available to them?  No.  Is it illegal for one home care company to offer a legitimate service that another does not?  Last time I checked, no.  So why, then, would offering legitimate health-based massage as part of rehabilitation or pain management or other health care reasons be an illegal way of pursuing health care clients?  No clue where that one came from!

3 -- (It would be an "add-on" expense to the patient with no reimbursement option.)  Right AND wrong, it would be a completely optional service and some insurance plans pay for it.  So in SOME cases it would be an additional expense IF THEY WANTED IT -- which does not make it an "add-on expense" because they're not being charged for it automatically.  It would be OPTIONAL as a service, not an automatic expense, just like under someone's insurance plan they have the OPTION of seeing a DC (chiropractor) or acupuncturist or not to.  They could also have the OPTION of seeing an LMT or not to.  In some cases yes, it would have to be private pay but in some cases, there is an option to have insurance cover the cost.  So yes, sometimes it would be an additional expense but only if the client CHOOSES it and only if their insurance does not cover it and they would go into it knowing whether it's even an option for them and in which way.  It's not like it would come as a surprise.

4 -- (That Medicare and Medicaid do not cover massage therapy & the majority of home care clients utilize Medicare & Medicaid as their payment method.)  Right and wrong.  It's correct that the two do not reimburse massage therapists but it is wrong that they do not cover massage therapy.  Also, to the best of my knowledge many home care clients use Medicare as their pay source so it would be reasonable to expect, then, that the profit margin to agencies would be small because it would mean that many of those in home care may not be able to utilize the service in their home if it's offered and have it paid for by their insurance; however, that doesn't mean it shouldn't be offered to all because of some not being able to cover the expense with their insurance or even because most are not able to cover it.  It can still be offered and some people will be able to use it like those who are using the services of a home care agency due to an injury at work, for example.  Workers' compensation will pay for massage so why isn't it offered when agencies DO accept workers' comp cases?  There's nothing unfair about offering massage, just like there's nothing unfair about the fact that some insurances will pay for Patient A to receive help with making a meal but the same insurance will not pay for Patient B to receive the same assistance -- still, assistance with making a meal IS still offered through the agency that both patients utilize.   Not all insurances that pay for home care cover the same expenses from one patient to another so why, then, would it matter whether massage would be a covered service from one patient to another as long as it is acceptable in some cases?  Of course it would be ideal if each case were more simple but my point is that it's not like that anyway.  Each case is already different.  Not all plans would cover massage but some would so why deny it?  That would be like me saying that because not everyone can pay cash I can't accept cash payments because there aren't enough of them to waste my time on.  It makes no sense to me.  Also, in some cases Medicare and Medicaid WILL cover the expense of a massage itself albeit there is a trick to it and this is where help from doctors comes in.  In order to be covered it has to either be provided by a doctor or under the direct supervision of  a doctor.  If there's a Medicare or Medicaid expert out there who believes otherwise please correct me but this is what I was told the numerous times I tried to get help for people who wanted it.  This is why I say it would really help if more doctors recognized us (massage therapists).  If we can't get into the homes of those who have Medicare or Medicaid due to their inability to pay we can see them in the doctor's office when they come for a visit where our work can be supervised and billed to their insurance -- if only we were allowed to.  Doctors are, after all, the first ones in line before a care plan is made.  Doctors hold the key to our being acknowledged by all these other players -- nurses, PTs, OTs, hospitals, assisted living, home care agencies.  In turn, though, home care agencies could hire LMTs on their own as well for those whose doctors DO acknowledge massage as an adjunct to their current plan of care.

  5 -- (There's not a "need" for it.)  This just made my blood boil.  It is wrong, SO SO WRONG!  I will be writing a separate blog about "need" (keep an eye out for "This One's For You 'Doc'") but until then I will just say that I have never heard of anyone in pain "not need" to find relief.  I've never heard of anyone with stiff muscles and limited range of motion "not need" to be able to move more freely.  Human touch is, in itself, a human need.  Babies can't thrive without it.  The elderly feel lonely without it.  We all need it.  Massage goes a step further and actually focuses on the problematic tissues to physically make someone feel and function better.  But no, there's no need for that!  Perhaps this statement is out of ignorance.  Perhaps because home care patients know massage is not an option they don't ask for it and that is somehow translated as a lack of demand.  Perhaps home care patients who are elderly are afraid to ask for more help.  Perhaps, like the people who gave me these reasons for not accepting massage, people don't realize it's a form of health care.  That doesn't mean they don't need the help!

6 -- (There would likely need to be laws changed in order to get Medicare & Medicaid to cover massage.)  I'm not sure about that, that one may be right, but again as far as I know they do cover it in certain situations but it has to be done by a doctor or under the direct supervision of a doctor.  Still, changing the rules of Medicare may be necessary indeed in order to have the service covered in the home by Medicare.  But again I will say, not all home care patients are Medicare patients.  What I'm asking is for those in positions of power to help out.  The need IS there.  Let's come together and make this happen for those to whom it is already possible and go from there.

Yes Doctor, Massage IS Medically Necessary, Part I

On Monday, October 17, 2011, I delivered the following press release.  Please see "Yes Doctor, Massage IS Medically Necessary, Part II" when you're finished reading.

NATIONAL HOME CARE & HOSPICE MONTH TO BEGIN NOVEMBER 1ST 

LOCAL HOME CARE AIDE SHEDS NEW LIGHT ON MISSING LINK IN SERVICES FOR HOME CARE PATIENTS

Saco, ME, October 17, 2011  - Home care agency services often include patient access to nurses, occupational therapists, physical therapists, home health aides, CNAs, and PSS caregivers but many patients, who are often elderly, still voice concerns about their current treatments not helping them enough with chronic pain, poor circulation, high blood pressure, or limited range of motion.   Unfortunately, there is one group of professionals that could help this population but that, unlike many hospices, no home care agency in the southern Maine area acknowledges: massage therapists.  Access to professional massage therapists could help many home care patients by relieving some of their common complaints that other professionals do not have time for or are not licensed to provide, but many home care patients don’t realize it’s an option because it's not offered to them through their doctor or their home care agency for comfort or for rehabilitation.  

Massage therapists interested in health care often have to overcome barriers when attempting to be recognized as part of a health care team.  [A local home care aide] and a licensed massage therapist says, "Massage is still a misunderstood profession in some circles and massage therapists are still not often taken seriously in the health care field.  There's not always a cure for what ails us but sometimes relief is the only cure people really need to get them through the day.  Massage can do that; unfortunately, it doesn’t seem to be given much consideration when a diagnosis or care plan is made despite the fact that it can be a very effective form of treatment.” 

[She] has studied therapeutic massage at Spa Tech in Westbrook, is certified through the Institute for Integrative Healthcare Studies in New York in lymphatic drainage massage and massage for hospitalized and medically frail clients, and is certified in adult and child CPR/First Aid/AED through the American Heart Association.  She has worked as an aide through a local home care agency for the past year and earned her PSS certification in March, 2011.

Insurance -- Does it Pay?

I actually wrote this over the summer but I apparently saved it as a draft and never published it so it's appearing as a recent blog; it actually isn't very new but I hope you find it somewhat informative.

I am often asked,  "Do you take insurance?"  Some insurance plans do pay for massage but WHO they pay is what it comes down to. 

Before I begin let me just say that I do accept insurance for auto accident claims, pending verification.  If you're injured in an accident and your insurance will cover massage I can probably bill them for you.  I had to put the "probably" in there because even when some plans pay for it they are particular about how they do it.  You do have to have specific forms completed by your primary care provider that they don't have in their office -- I have to send them, steps need to be taken with your insurance company before I can begin, and you will need to be willing to have a credit card on file in case for some reason your insurance company fails to reimburse me.  It can happen.

Most auto insurance companies recognize massage as a health care service and many health/medical insurance companies recognize it also, but they differ when it comes to whether they recognize a massage therapist as a provider for that service.  Yes, apparently massage therapists are not always considered legitimate providers of massage therapy.  So what it comes down to is not whether the massage therapist will take your insurance, but who will reimburse a massage therapist and who won't -- most auto insurances will, most health/medical insurances will not.  That is, unless, you live in Florida or Washington state.  In those states, the same health care companies that deny direct reimbursement to licensed massage therapists in 48 other states WILL directly reimburse licensed massage therapists. In Maine, the insurance companies will reimburse doctors' offices and hospitals and they, in turn, can pay their employees but many health/medical insurances will not knowingly reimburse a massage therapist directly.  As a matter of fact, more and more insurance companies have been demanding reimbursement from massage therapists who were not authorized to receive payments from them.  Perhaps some do reimburse directly but many do not.  They will, however, consider directly reimbursing YOU, their customer.  What you do is pay for the massage yourself and then submit a "superbill" for your reimbursement.

Now, you may be a bit confused because you'll hear of other massage therapists "accepting" your insurance directly, nevermind this doctor stuff.  To the best of my knowledge -- and someone in Maine PLEASE let me know if I'm mistaken -- they are not "accepting" your insurance at all.  What has been done in the past and what some insurance companies have stopped doing is that the massage therapist will sign an agreement with the insurance company that allows the therapist to be included in their list of providers; HOWEVER, the insurance company has absolutely nothing to do with the massage therapist.  They never see a bill from the therapist.  They don't even know that you've seen the therapist.  They never pay the therapist (and if they did they will at some point come back to collect their money when they find out the practitioner is not a doctor and guess who that therapist might then turn to in order to collect payment?  That would be you, my friend.  You, the client.).  What really happens is that the massage therapist agrees to provide you, the insurance company's customer, with a discount in exchange for being listed in that book/pamphlet.  That's it.  It's an advertisement.  Rather than the therapist paying the insurance company for an ad in their provider listing -- which is probably unlawful -- the therapist takes a cut in pay for the ad, with the hope of receiving a kickback in the form of paying customers.  As well intentioned as it may be it can be misleading to the consumer who thinks the therapist is somehow associated with the insurance company.  I have seen ads where massage therapists say they can directly bill your insurance but aside from auto coverage or workers' compensation I don't know how this is, when I've spoken with most insurance companies and they all have said the same thing, "We do not contract with massage therapists".  If someone out there has managed to get a different response I'd love to know.

Here's the potential problem with directly billing insurance.  Insurance is great when you have a medical issue that needs to be addressed.  For example, if you have an injury and want or need massage as part of your rehabilitation, insurance that covers massage is a WONDERFUL thing to have.  But if you're coming in for a massage as part of your wellness routine with no specific health or medical goal in mind that your doctor has recommended for you, you might want to think again about whether you want all massage services to be covered by insurance.  If the other 48 states followed suit with the first two, there's a big debate about whether it's actually beneficial.  Why?  Because insurance companies are a business.  A business is concerned with its bottom line.  Insurance will dictate every little detail about your sessions -- how many you can have, how much they'll actually pay the therapist (and when they don't pay it all & the therapist loses the dispute, the therapist will charge you for the difference; if it's rejected the therapist will charge you in full), how many minutes long it can be, where on your body you can receive massage, and which parts of your body are covered as an option for therapy at all (You know that little muscle there in your eyelid that keeps driving you crazy and you're afraid that sometimes people think you're winking at them because it won't stop flipping out?  It might not be covered, that's all I'm saying.).  It's all in the medical coding used to write the bill, which has to be done on a special piece of paper in a very special way so the person who looks at the bill can decipher every little aspect of your visit and decide which part is reimbursable and which part is not.  For example, if you had a headache and the massage therapist found the source of the muscle tension (causing your headache) to be near your shoulder blade, the insurance company may very well deny payment for massage to anywhere other than the head -- because it was a "head" ache, not a "shoulder blade" ache.  

I do have to say that some companies WILL reimburse YOU  if you get a massage and it often has to accompany a prescription from your doctor with a legitimate reason for you to receive the therapy.  This is absolutely WONDERFUL!  Don't confuse this as your therapist "accepting" insurance though.  The therapist has nothing to do with your insurance here either.  This is only between you and your insurance company but by far, in my opinion, the best way to go.  Yes, your claim can still be denied and no, you can not get your money back from the massage therapist if that happens but this is why you call the company in advance and get the authorization yourself.  If you can get your hands on a plan that will give you this option YIPPEE! It's great for everyone involved!  This is a roundabout way for companies to FULLY cover the cost of your massages without having to mess around with all those strings attached.  Who benefits here?  The massage therapist gets paid in full.  The cost of business stays low because there's no need for an increase in overhead.  You pay up front but get fully reimbursed by the company after sending them a receipt.  They have a happy customer and work within their budget.  Seems to me everyone benefits from that plan.