Chiropractic Management and Supervision of the Medical Massage Therapist

Working with a massage therapist (MT) in a chiropractic clinic is an interesting challenge when massage therapy is not a licensed profession in your state. In addition, some chiropractors practice in states where there is a very limited interpretation of chiropractic scope of practice. There is a strong state-by-state trend toward the establishment of massage licensure, to the point where about 25 states now license massage therapy. With the growth of massage therapy, it is expected that it will be licensed in most of the remaining nonlicensed states within the next decade. If national association membership statistics are reliable, there are approximately 50,000 MTs in the United States within national orgainzations alone, and massage therapy schools report a significant and steady increase in student enrollment and graduation.

The combination of chiropractic and massage therapy nationwide is very common, and some DCs have learned that this is a very effective and profitable alliance. Some of the benefits to the DC include:

• multiplication of clinical office services;
• clinical support;
• an increased number of patients treated per day;
• increased revenue;
• decreased clinical workload;
• the ability to treat patients through the massage therapist;
• the ability to supervise one or several massage therapists who carry out the clinical treatment plan;
• utilizing the MT as a CA;
• freeing the DC from "one-on-one" therapy and income limitations;
• an effective team approach to care;
• attracting and retaining more patients; and
• attracting and retaining "adjustment phobic" patients.

If this is so good - why aren't more DCs doing it? There are multiple reasons:

1. Awareness of the benefits of a combined practice is just beginning.
2. There is a lack of information and knowledge about how to legally work with a massage therapist.
3. Attitudes are outdated regarding massage therapy.
4. MTs lack the clinical training needed to work in a chiropractic office.
5. Struggling DCs cannot afford to hire MTs at what the massage therapist can earn in private practice.
6. There is misinformation regarding the legal requirements of working with an MT.
7. There are practice conflicts between DCs and MTs.

Regardless of these hurdles, this type of practice is extremely beneficial to both parties. Benefits to the massage therapist include:

1. the opportunity to work in a professional environment;
2. exposure to the clinical concepts of chiropractic health care;
3. legal supervision;
4. employment opportunities; and
5. access to insurance billing.

Is the MT an employee or an independent contractor? Can I bill for services performed by an MT? I will elaborate on these later, but ultimately both depend on the relationship between the DC and the MT. Unless the MT is simply renting square footage in the chiropractic office and has a totally independent practice, most likely he or she would be considered an employee if an Internal Revenue Service audit were performed. The DC and the MT can develop an independent contractor relationship, but there are, however, key issues determined by the DC's scope of practice and state licensure law, including a physician's right under that law to supervise or to delegate responsibilities to a layperson.

Scope of Practice Issues

The limited scope of practice in some states continues to define chiropractic solely as the treatment of spinal subluxation and does not allow, in some states, treatment of extremity subluxations. This interpretation is certainly debatable and subject to future legal challenge.
However, the prudent practitioner may choose to limit scope of practice to the spine, and not treat extremity conditions in states that impose this narrow scope. This definition does, however, allow the DC to treat the numerous conditions and disorders related to spinal subluxation. MTs, not limited by a license and a defined scope of practice in nonlicensed states, are not restricted regarding the anatomical regions that they treat. However - and this is important - when an MT works under the supervision of a chiropractor, he or she must work within the scope of practice of the chiropractor. The MT will assist in treating spinal conditions related to vertebral subluxation by providing soft tissue therapy to the connective tissues of the spine, where chiropractic is limited to spinal therapy.

Massage Therapist Supervision and Delegation of Duties

Just as DCs will delegate certain responsibilities and duties to CAs, they can supervise and delegate clinical and therapeutic procedures to MTs. The following is a checklist that DCs working with an MT should adopt as office and clinic policy. I suggest this information be reviewed by an attorney who specializes in state health care and chiropractic practice law:

1. The purpose of therapy in the combined chiropractic and massage therapy practice is the correction and treatment of the chiropractic subluxation.
2. The primary mode of treatment of the chiropractic patient is the chiropractic adjustment.
3. The DC is the "primary care physician" of the chiropractic/massage therapy team.
4. The DC provides chiropractic evaluation and diagnosis.
5. The DC assumes responsibility for patient rehabilitation.
6. The DC determines the patient's treatment program to include chiropractic adjustment, massage therapy and approved therapeutic modalities.
7. The DC provides chiropractic spinal adjustments.
8. The DC re-evaluates and modifies treatment as necessary for patient recovery.
9. The DC remains available at all times to answer questions and address therapy issues.

The chiropractor that decides to establish a combined practice in his or her office must create an office policy manual available for inspection that includes the above responsibilities, along with the following massage therapy responsibilities:

1. The MT will provide massage therapy to chiropractic patients under the direct supervision of the DC.
2. The MT will provide massage therapy as indicated by the patient treatment plan, which will be determined by the DC.
3. The MT will provide the following procedures as directed by the DC:
1. massage therapy;
2. therapeutic exercise; and
3. therapeutic modalities.
4. The MT will report all treatment procedures to the DC in the form of case notes and chiropractic treatment reports.
5. The MT will immediately contact the DC with any questions or problems pertaining to a patient's treatment.
6. The MT will work within the boundaries of his or her education and certification, and the scope of practice of the DC.

Also included in the office policy manual should be a description of the MT's training and certification and copies of his or her training certificate and liability insurance policy. The manual should also contain the exact office procedure for contacting the DC by telephone or paging service.

Issues Regarding Insurance Billing

The DC can bill for services provided by an MT working under his or her direct supervision, provided that these services are within the scope of practice of the DC and within the education background of the MT. The DC can bill for services provided within his or her evaluation and treatment plan, whether he or she was present at the time the services were provided, as long as the DC was "available" to the MT. This is an important concept, in that it means that the DC may design a therapy program and determine the treatment plan, but does not have to be physically present during each and every treatment. Both adjustment and massage therapy can be billed during the same office visit, along with evaluation codes, therapeutic modalities and other appropriate procedure codes. In the course of a patient's treatment plan, the time may come when adjustment procedures are not performed at every visit. The chiropractor does not have to perform an adjustment at every office visit and may still bill for other services provided by the massage therapist.

A Team Approach

Successful chiropractic practices are built on a "unified-team" approach that combines care with education and business practices. The well-trained MT will become a part of the team and work in maximizing patient care and practice growth. In the course of the combined therapy, some patients may prefer treatment by the MT to high-velocity, high-force adjustment technique. This situation can cause problems in a practice where the DC has failed to maintain patient control by clearly defining within the practice his or her authority and legal responsibilities for patient care; where the MT does not respect the authority of the DC; and where the DC may allow personal ego to override his or her professional behavior. The DC wins in a combined practice when patients are happy, with increased visits and improvement, and when revenue is increased. The DC should take credit for the decision, foresight and success in establishing and managing the combined practice.

As just noted, some patients prefer massage and are "adjustment-phobic." In these cases the DC, in the evaluation of the chiropractic patient, may choose a low-velocity/low-force adjustment technique that is better physically and psychologically for these patients in overcoming their therapy objections.

Evaluating the MT as a Potential Partner

Comparing different MTs is not unlike comparing apples and oranges: not all have the same background or training. The DC should consider the following when choosing an MT:

• Many MTs are only trained in relaxation and spa massage, and do not have clinical skills.
• MTs should be willing to become part of your chiropractic team.
• MTs should be graduates of approved, state-licensed schools.
• Medical MTs have training that is specific to clinical, medical and chiropractic offices and clinics.
• The average minimal level of massage therapy training in massage schools is 600 hours; therapists with 1,200 hours of this or chiropractic assistant training are good choices for your office.
• Members of the American Medical Massage Association and the American Manual Medicine Association are nationally board-certified and have specific training for clinical therapy environments.
• These members carry liability insurance that covers the higher level of therapy techniques and procedures that are performed in a chiropractic office; relaxation massage therapists usually do not have adequate coverage.

Professional Liability

The majority of MTs practice therapeutic massage, belong to therapeutic massage associations and carry therapeutic massage liability insurance. They are usually not trained in clinical rehabilitation techniques or medical massage, and usually practice relaxation or spa massage. This type of massage therapy is normally not a good adjunct to the specific clinical benefits and objectives of chiropractic care or to the promotion of a proactive chiropractic team approach to patient management and treatment. Medical MTs who are members of the American Medical Massage Association carry professional liability insurance that covers advanced medical massage techniques and manual therapy techniques. In addition, the chiropractor should consult with his or her insurance carrier to make sure that professional liability policies cover the addition of a massage therapist in the office.

Paying the Massage Therapist

If possible, MTs should be hired and paid as employees. If your chiropractic office cannot justify a massage therapist's salary, you should not guide your practice in that direction. However, there are a variety of payment plans for the massage therapist. He or she:

1. rents space in your office and there is no other financial agreement;
2. receives 60 percent of the agreed-upon massage therapy fee or money collected;
3. is paid between $25 and $36 per hour; or
4. is paid an hourly wage for CA duties and another agreed-upon fee or percentage for massage therapy.

If you are attempting to develop an independent contractor relationship with an MT, he or she may be paid under a corporation and payment may be made to it. An attorney should assist in the process of writing an independent contractor agreement and a certified public accountant should review the provisions to make certain that the agreement complies with federal tax law.

Conclusion

The combined practice can provide significant benefits to the DC when properly approached and managed. This article is intended to assist in developing a combined practice, and is not intended to provide or replace the advice and direction of an attorney or certified public accountant.

Gregory T. Lawton,DC
Founder, Blue Heron Academy of Healing Arts and Sciences
Grand Rapids, Michigan