Q: Insurance companies are tightening rules on rehabilitative therapy visits. What should consumers know?

It can certainly be frustrating if your insurance company denies claims for rehabilitative services, (like massage therapy). Many times these are the services that you feel that you need most. There is one key factor which will help you avoid problems with your insurance company. You need to ensure that your doctor’s office provides clear records to your insurance company. Specifically, your records must show that your rehabilitative therapy services are documented as medically necessary.

Why insurance companies might deny claims

Regence Blue Shield has been using a tight screening system on rehabilitative services in Washington State for decades. Our team at Rice brings direct experience with this via Laurel, our Group Benefits Supervisor who managed a chiropractic clinic several years ago. Rehabilitative services are certainly available to medical insurance plan members. However, the insurers are obligated to their members to make sure that all services are effective and are truly needed. This helps manage costs for the entire population of members enrolled in an insurance plan. If a member submits a claim to receive reimbursement for a massage service in a spa setting for comfort and relaxation – it should be denied. You wouldn’t want to share costs for someone else’s day at the spa, would you?

Service claims must be reviewed for medical necessity because this happens more often than you might think. MOST providers and their office staff will know the precise lingo that needs to be present on patient progress reports to get approval for additional visits, but those who have only dealt with older, more relaxed rules like those that Premera Blue Cross of Washington was using in the past might not have the experience yet. For this reason it is incredibly important for consumers to follow up with their doctors, and make sure that they hold their staff accountable for accurate reporting of their condition & progress, especially when a claim is denied.

What it means to be Medically Necessary

Rehabilitative services, as with any other service, must be medically necessary. Meeting this requirement means that you also must show improvement. Your body must be getting better due to the treatments, not just maintaining a current state. Maintenance rehabilitative therapy is not considered medically necessary.

The key things that need to be in a progress report are statistical and measurable – for example, “before the injury, Joe could carry 4 grocery bags from his car. Immediately following the injury, he couldn’t carry any. Now, after 8 PT visits, he’s able to carry 2. With an additional 8 visits, he could be back to carrying 4 again.” Or actual measurements – Chiropractors use devices that measure range of motion in certain directions and PTs and LMPs should be able to eyeball similar movements.

Activities of Daily Living (ADLs) are, like the grocery bag example, another measureable item that should be considered. How many hours of sleep has this service encouraged? Were people able to lift their kids more easily, dress themselves more easily, etc?

While it’s not an exact science and this may require your doctor to complete a bit more paperwork, that’s how systems work these days! This is because, unfortunately, it does occur where people take advantage of the system and abuse their benefits for purposes beyond healing. But be assured, by following the correct process and working with your providers- you can get to your own healing in no time!