Direct billing is a relatively new technology for massage therapists and a privilege, not a right. Therapists must uphold high ethical standards when using direct billing portals. When billing works it is wonderful for therapists and clients, however, there are still system hiccups and variances. For this reason, clients are asked to bring a backup form of payment, in case direct billing does not work
There are many different reasons why direct billing will not go through which can cause client frustration. Please be aware that reception is only the messenger of an insurance company’s predetermined response. Claim refusal is usually due to regulations set up by specific health benefits plans. Reasons can include:
Plan requirement states that a doctor’s note is needed for treatment or having a doctor’s note expire after a year of use.
Some health benefits plans will only pay the insured member, not the servicing provider. In this case, the therapist can submit the direct billing paperwork on the client’s behalf. The client will need to pay the therapist directly for treatment and will receive the treatment amount directly from their health benefits provider at a later date. It really should be called runaround not direct billing in this case.
Some health benefit plans will only pay for a percentage of the massage. In this case, the balance owing is paid directly to the therapist.
Benefit coordination happens when a client has their own coverage and is also covered by a spouse’s plan. The client’s primary benefits must be exhausted first before their spouse’s coverage can be used. This is the most complicated level of direct billing. Some clients find it easier to pay for their massage out of pocket and submit the billing themselves since it must be done in a specific order and the health benefits companies make it a hassle to redo if it wasn’t done correctly the first time. With children, the billing is first submitted under the parent whose birth date is earlier in the year.