Insurance Adjudicators Assume Gatekeeper Position: Providers, Employers and Claimants Beware!

Recent discussion on Facebook suggests massage therapist claims are facing increasing scrutiny by adjudicators of employee workplace benefits.  Paid for by the employer, employee health benefits are considered part of the employee’s salary and accountability for presenting and defending suggested treatment plans and intended health outcomes falls to the massage therapist.  It’s the employee and employer…not the insurance adjudicator, who should decide whether to seek massage therapy and proceed with a treatment plan.

funnyinsurance Massage therapists – and indeed all providers who bill for compensation against these plans – should feel extremely uncomfortable about non-medical administrators approving or denying claims from plans financed not by the insurance company, but by employers and their employees.  Insurance adjudicators are largely not medically trained and cannot make judgments about necessary care.  There’s a conflict of interest – insurance companies are motivated primarily by profit…the more claims denied or reduced the higher profit margin to the insurance company for administering the plan.

Insurance is pervasive – home insurance, mortgage insurance, life insurance, disability insurance, auto insurance, health and dental insurance, commercial and professional liability insurance…there’s even insurance to ensure you can pay your credit card, or if your big screen TV dies.  Insurance was created to mitigate risk – to spread risk of loss over a large number of clients and pay out claims against some form of loss.  The insurance company brokers this transaction and receives a commission for administering the plan.  Logically, the fewer claims the insurance company has to pay out, the more profit it makes.

Government appears to favour auto insurers and WSIB (worker’s compensation) over providers, sympathizing with the insurance industry’s complaints of fraud and escalating costs.  Insurers are increasingly concerned with fraud – as we all should be – and have taken great steps to prevent it.  It appears, however, insurers are pushing beyond plan administration towards a decision-maker or gatekeeper role.  This means adjudicators not trained in health science are determining whether a claimant will receive care, what type of care and how much.  Insurance companies post record profits while providers experience increasing downward pressure on their fees.

Here’s a recent post by a massage therapist on Facebook,  ”I treat clients at a software company 1-2 times per month and now my work there is on hold because almost all of my clients at that office are currently being audited….One employee (shared) his submissions were declined for massage and chiropractic at another office… The employees are very frustrated right now, (they experience) crazy deadlines, work overtime constantly and sit at computer 8-12 hours per day… They all need treatment just to maintain work productivity.” –  H.C., RMT.

This RMT went on further to say the company’s human resource manager is having difficulty getting her calls to the insurance claims adjudicator returned.  How have we allowed insurance companies to demand premiums up front, then arbitrarily decide to pay claims or not?  What other product or service can you purchase that you’re not guaranteed to receive the benefit of that product/service?  What are corporations, businesses, employees and consumers not shouting loudly against such practices?

I’ve written previously on initial steps the insurance industry has taken to preclude massage therapy claims, on the reports of massage therapy claim fraud and how I suggest the insurance industry’s practices are intentional and deplorable  You may also appreciate my particularly frank criticism of the insurance industry’s practices

No question, the massage therapy profession contributes to the problem.  We lack treatment guidelines and evidence-based practice showing efficacy and effectiveness in treating a variety of common problems experienced by workers.  We’re small and disorganized, lacking a consistent public and media relations platform to spread news of the benefits of massage therapy.  We need to correct these things, and to create solid relationships with the insurance industry so employers and their workers can receive the health benefits they’ve paid for.

There’s no question that the insidious attempts by the insurance industry to deny claims and exclude massage therapy service coverage is one of the most serious threats facing the massage therapy profession today.

I encourage you to get on the phone, right now, with the executive director or president of your massage therapy professional association.  Tell them you’re very concerned about this problem and ask them what concrete steps they are taking to meet this challenge.

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