According to a recent survey, massage therapy is the most frequently integrated service in chiropractic practices. But how do you integrate massage therapy profitably? In this two-part series, let's answer that question by outlining how to hire and pay massage therapists; cash and insurance coding procedures, including the most effective time increments and pricing strategies for delivering massage therapy; the best ways to market your massage therapy practice; and how to convert massage patients into chiropractic patients.
Insurance or Not?
Whether to bill insurance or have a cash practice for massage therapy varies by state. In a number of states, massage therapy is covered by insurance, 97124, massage therapy, but only under certain types of cases, specifically, personal injury and worker's compensation. Most private payers have reduced or eliminated their coverage for massage therapy. Some states and insurance carriers allow massage therapists to use 97140, manual therapy, based upon their scope-of-practice laws and by provider contract.
If you are billing 97140, you must be specific with your documentation. Manual therapy is not massage therapy. Your notes must document the components included in the description of manual therapy: manual trigger-point therapy, myofascial release and manual traction. This differs from the description of 97124, which includes effleurage, petrissage and/or tapotement (stroking, compression, percussion).
What about billing units? In an insurance setting, I've heard of chiropractors billing up to four units of 97140. In my experience, this is a red flag. It is difficult to establish medical necessity for three and certainly four units. I encourage providers, if they're going to do insurance-based massage therapy in their office, to bill a maximum of one or two units of therapy and, if a patient wants additional time, to charge the patient cash separately from the insurance-based units.
What About Time Frame?
It's tempting to use massage as a compliance tool because of how enjoyable it is for the patient to receive. Realize that third-party payers require the documentation of medical necessity. This will vary; however, somewhere between a three- to six-week time frame, most carriers are going to say, "Enough is enough." If you're going to do insurance-based massage, you'd better have specific goals you are working toward and objectively document improvement. If not, you won't establish medical necessity.
In an insurance-based practice, I recommend region-specific, 15-minute increments associated with the diagnosis you're working under. It is also important to remember that manual therapy, 97140, must be performed on a separate region from the chiropractic adjustment. For example, if you are adjusting the cervical region, you might apply the 97140 to either the upper extremity region or thoracic region, as many muscles have origins and insertions that span multiple regions.
15- or 60-Minute Massage?
In my experience, 15-minute, region-specific, sports-style massages have a higher rate of patient compliance. It is not unusual that when scheduling massage in 60-minute, spa-style blocks of time, if the massage therapist isn't available, the patient will cancel their chiropractic visit. With proper scheduling and coordination between the massage therapist and the front desk, it is possible to offer a range of times including 15-, 30-, 45- and 60-minute massages without creating a bottleneck. Note that 60-minute massages are actually 50 minutes because you must build in break time for the massage therapist.
The front desk must know how to cluster-book massage therapy appointments. If a patient wants a 60-minute massage, the front desk should schedule the massage during points in the daily schedule when there is less volume and demand. For example, the front desk could lead a patient who wants a 60-minute massage to the 10:00 or 10:30 time slot, because you know you can fill the time from 9:00 to 10:00 with 15-minute therapy massages. Book prime time when you can turn over 15-minute spots easily and schedule hour-long massages out of prime time.
What About Pricing?
In a cash-based practice, it's appropriate to charge more for the shorter-term massages. You can generate more revenue per hour if you sell four 15-minute blocks than one 60-minute block. It's not unusual to charge around $25 cash for a 15-minute unit, which generates approximately $100 per hour, whereas if one patient purchases a single full-hour massage, it's going to be in the range of $75 to $80 per hour.
What happens when a massage franchise comes to town and patients can drop in for a $39, 50-minute massage? Here is your massage franchise busting-strategy: The low-price massage franchise session is probably a one-time deal. You also can only get that price if you sign an annual membership contract with a higher fee (say, $60 per month), which generally entitles you to one massage per month.
Keep in mind that in addition to the $60, you're expected to give the massage therapist a gratuity. The suggested gratuity on a one-hour massage is $20-$25. All of a sudden, that massage costs a whole lot more.
A massage franchise may give members one credit a month, but if you miss a month or more and you want to cancel your membership, you likely have to use up all of your credits within 30 days (similar to some mobile service data plans). If you don't use it, you lose it, and massage franchises typically will not let you transfer your credits to a friend without an additional fee.
Create Your Own Massage Membership Program
In a chiropractic setting, patients get to know their massage therapist, unlike at a massage franchise, where you may just get the next therapist in the rotation. I recommend creating a 12-month membership. Set your pricing to undercut the massage franchise price a little bit, but add better perks. Use an auto-debit charge on the first of the month. If patients prepay for 12 months, give them a 13th massage for free. Allow patients to use their massages in any increments they please. Your membership credits don't expire.
Additional family members can be added to your membership plan. Offer a discounted rate of $5 off per massage for added family members. For example, if a husband and wife both purchase a plan, the first one is full price and the second one is $5 less per massage.
Additional perks can include allowing members to purchase hour-long gift cards at a 10 percent discount. They can buy their co-workers a day of massage or provide their bridesmaids with a pre-wedding day of luxury at a discount. Use auto-renewal to create more value. Allow members to opt out with 30 days' notice and a $100 cancellation penalty.
Massage as a Loss Leader
The idea in loss-leader pricing is to offer patients a lower-than-market-rate price for massage. This way, you use massage not to generate income for the practice, but to cover the expense of paying the massage therapist and increase access to potential new patients. The strategy is to train the massage therapist to identify patients who could become chiropractic patients or patients who could tap into other profit centers in the practice, and to utilize massage as a conversion for that.
Given a choice, a larger portion of the general population will chose an hour-long massage over a chiropractic adjustment. This creates a portal of entry that can be used to convert massage clients into chiropractic patients.
The key component is to train the massage therapist to recognize when a patient would benefit from a chiropractic examination. This is a crucial factor because normally, a massage therapist does not feed a chiropractic practice. It's a rare event that a massage therapist builds a chiropractic practice. Typically, it's the chiropractic practice that feeds the massage practice.
I recommend using a form with a map of trigger points across the neck and torso, and having the massage therapist check off those areas of tension on the form. At the completion of the massage, the therapist can show the form to the patient, explaining these are some areas of tenderness that could indicate an underlying condition.
The therapist can ask the patient, "Would you like to have the doctor check that for you? We can arrange for an examination." A properly trained massage therapist can recognize and point out key issues, and recommend an exam and other services.
Editor's Note: Part 2 of this article appears in the May issue and discusses massage therapist hiring and pay guidelines, how to market massage and the potential revenue added to your practice.
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