Insuring Massage, Part 1
Warrior Massage is what is referred to as a "cash only" practice. This doesn't mean that cash is the only form of payment accepted; it just means that insurance is not accepted. In order to understand why, it is necessary first to understand a bit about insurance. This is a vast, complicated topic, so it will be split into multiple blog entries. In this first one, we'll just go over the basics of the four types of insurance that pay for massage therapy.
DISCLAIMER: I am not an insurance or billing professional, nor do I work for or with an insurance company (though I am married to someone who does) and have limited experience with the topic that follows. As a profession just emerging as insurance-compensated providers, there is a LOT of material (in the form of industry articles, continuing education classes, and seminar topics) educating massage therapists about insurance. The following should not be taken as medical or insurance advice, but simply the perspective of a massage therapist and medical provider on the topic as it stands. If you feel I've got something wrong, I would graciously invite you to (politely) bring it up in the comments below.
Worker's Compensation (L&I)
Commonly called Labor & Industries in WA state (or L&I for short), referring to the state agency that insures most Worker's Comp claims in Washington. In addition to providing certain OSHA-like regulation and oversight of employment conditions in the state, L&I acts as a state-owned insurance company, funded by mandatory payments by employers and employees (in the form of a payroll tax) into an insurance fund. There are 400 or so large employers who can opt to self-insure, but MOST employees in the state of Washington are covered by L&I.
Worker's Comp claims are for injuries that occur as a result of one's employment, most notably traumatic injury (fell off scaffolding, foot run over by a forklift, etc) and repetitive stress injury (i.e., carpal tunnel syndrome, or any strain/sprain resulting from repeatedly performing the same physical task for 40 hours a week).
L&I covers massage and will pay for 6 visits with a referral from the Attending Physician (the doctor primarily responsible for treating this particular injury, not necessarily your regular doctor). Visits beyond the first 6 may be paid for, but the provider must submit progress notes showing efficacy of treatment and medical necessity before they will be approved.
I don't know what eldritch formulae the number-crunchers at L&I use to decide which cases will be given approval for additional visits and which ones will be denied, but I assume that it involves a hat or dartboard, because it doesn't seem to have any correlation with the aforementioned efficacy and/or medical necessity of treatment.
In order to accept L&I payment, a massage therapist needs to be licensed to practice in the state of Washington, and also needs to register themselves and their clinic with the Department of Labor and Industries.
Personal Injury Protection (PIP)
This is the medical coverage that you pay for as part of your auto insurance, assuming that you did not waive PIP coverage when purchasing insurance in order to save money on your premiums. If you DID waive coverage, your auto insurance WILL NOT cover any of your medical expenses if you are in a Motor Vehicle Collision (MVC). We are fortunate in WA state in that auto insurers will cover massage up to the limits of coverage for your PIP insurance, which (unless you are also getting lots of expensive treatments from other, non-massage providers) you are unlikely to meet before your massage therapist closes your case (either because you have reached "pre-injury status" or because continued treatment is unlikely to yield any more improvement).
In WA state there is no other requirement for a therapist to bill PIP except that they be licensed to practice in the state.
3rd Party Insurance (Liability)
This category includes any insurance claim that is being paid by someone else's insurance. Usually this is either a MVC where the other driver was at fault, or any injury otherwise resulting from someone else's negligence (commonly referred to as a "Slip & Fall" because the most common cause is injury from slipping and falling on a wet floor or icy walkway on commercial property).
3rd Party claims involve law suits, which involves lawyers, and lots of arguing. Sometimes they go on for years before a final judgement or settlement is made, and the therapist is not paid until that time. There is no guarantee that the final judgement or settlement will include payment for massage or any medical bills at all, so sometimes a patient can be stuck holding the bill for rather more massage than they would have opted to receive had they known they would be paying for it themselves. In these cases, massage therapists (and other medical providers) are left in the very unfortunate position of either becoming a bill collector or writing off a large amount of income they have already done the work for.
Major Medical Insurance
This category includes most other insurance not covered by those above. Whether included in a benefits package from an employer, paid for at great personal expense, or obtained through the state via Medicaid, this is a person's primary or "main" insurance used to cover most medical expenses. WA state is fortunate in that it is one of several states where medical insurance covers massage. However not EVERY insurance plan covers massage - indeed, most of them still do not. In addition, there are so many different carriers with so many different plans that the details of how much coverage is provided and what restrictions are placed on coverage vary greatly.
Some medical insurance will pay for "out of network" benefits, meaning ANY provider can bill the insurance company for services provided - or the patient can pay out of pocket, and submit their own request for reimbursement from the insurance company after the fact. Most commonly, however, in order to receive payment from medical insurance, a therapist must be what is called a "participating provider," meaning that they have entered into a contractual agreement with the insurance company. Every company and every plan is different, but generally the provider agrees to accept a certain allowed amount for the service provided, and is not allowed to bill the patient more than that. Other stipulations or benefits in a provider contract can vary.
In order to become a contracted provider, many insurance companies require that a provider have a certain amount of experience, references from colleagues in the field, and other requirements to establish the provider's bona fides. Furthermore the insurance may restrict the number of providers they will contract with, limiting them for instance to a certain number of providers in a given zip code.
There are other types of insurance out there, such as Medicare (federally-subsidized insurance for the elderly and/or disabled). Medicare definitely does not cover massage, and if there are other kinds of insurance than those listed above that DO cover massage, I have not heard of them.
If you have read this far, congratulations! You are a highly tolerant reader! You can look forward to more explanation of why a massage therapist would choose not to accept insurance in a future blog entry here.
Gratuities Not Accepted
The question I am most frequently asked by new clients is about my policy on gratuities - specifically why I do not accept them. The answer is long, complex, and multivariate. I have a few answers I give verbally, but none are truly satisfying. So please, bear with me while I lay out the full answer below.
Disclaimer: please note that this is all my own opinion, and is in no way (except where explicitly noted) meant as a criticism of how others do business.
Tipping in general serves several purposes:
First, I'd like to critically address these three elements in a general context not specific to my business or even to the massage industry:
1. Cost of Service
Whatever system is used to compensate employees for their time, the wages paid to service staff is part of the cost of providing that service (whether the service is a massage, food, or something else). In a typical wage system, a business owner subtracts the costs (including the wages of staff) from the net proceeds, and the remainder is their profit. In order to attract enough consumers to pay off their fixed costs and make some profit, they have to set a price point low enough that consumers will consider it a good value, but high enough to maintain a profit margin over the per-customer costs. You might say, then, that the customer is ALWAYS paying the cost of service, because it is included in the total amount billed to them, less the owner's profit margin. This is true.
In comes the tipping system. By paying employees far less than their labor is worth (in some cases virtually nothing), owners are able to choose a much lower price point, enticing more customers into their business. They then expect you to pay for their employees' labor, but don't include the amount on your bill: it's optional, so it doesn't necessarily factor into your decision about whether to purchase a service, or which business to purchase it from.
Either way, the consumer is paying the cost of service. But in a system with tipping, the consumer is offered a false picture of what that cost is by a menu price that does not include the full cost of service. Perhaps that seems fair to you, but to me it seems like dishonesty.
2. Labor Flexibility
We all know there is an ebb and flow to business: if you've ever been in a restaurant in the middle of a Tuesday afternoon, you know they're not nearly as busy as they are on a Friday or Saturday night. Paying with tips, rather than wages, allows a business owner to keep staff on hand without losing too much money during the slow times, while rewarding staff who work at the busiest times of day with higher wages (more customers means more tips).
This sounds good in theory, but in my experience working in the foodservice industry, it does not stand up to a reality check. Staff on a slow shift might not see as many customers as staff on a busy shift, but that doesn't mean they don't do as much work. Much of the behind-the-scenes work at a restaurant (cleaning, stocking, food prep, etc) occurs during the slow shift, and in many cases this work is harder, nastier, and generally less-desirable than actually serving customers, no matter how hectic. And it is no less critical to the customers' service experience, even if the customer never meets the employees who do the work!
3. Positive/Negative Reinforcement
For people familiar and comfortable with tipping, this is most often the accepted purpose for tipping: to reward excellent service by leaving a good tip, or to punish poor service by leaving a poor tip or no tip. It is also the most fraught with problems and, to me, the most offensive reason for tipping. Here are, in no particular order, my objections to tipping for this reason:
1. Cost of Service
I prefer to be honest and up front about my prices, so the cost of labor is included in the price I list to my clients. If I am not making enough to cover my costs and still feel I've been fairly compensated for my own efforts, I'll raise my prices. Currently I am the sole owner and employee of Warrior Massage, so there is no cost of labor: my profits ARE my wages. If at some point I have employees, I will pay them what their labor is worth, and set prices that still allow me to keep my business running and compensate me for my time running it.
2. Labor Flexibility
I only do bodywork by appointment, and if I have employees at some point, so will they. So this simply isn't an issue.
3. Positive/Negative Reinforcement
As the business owner, my positive reinforcement is for a satisfied customer to return and purchase my services again, not to pay me more for the services already rendered. If a customer feels they received exceptional service and wants to give a little more, there are other ways they can reward me other than paying more than they have been asked to pay: by referring others to my business, by writing positive reviews/ratings, or just by being a pleasant customer. These are all highly rewarding.
If at some point I have employees, I intend to compensate them in a way that encourages doing an excellent job, such as with pay raises, bonuses, and other benefits. Customer feedback will play a role in deciding these things, so satisfied customers can still give back to reward their therapist.
Finally, I'd like to critically address tipping in the specific context of the massage industry, and answer some common pro-tipping objections or questions.
Massage Therapy is a Profession
Don't take this the wrong way: I have the utmost respect for servers, delivery drivers, cooks, bartenders, and others in tipped jobs. But they are not professions. They are vocations, and jobs, but there is a difference. You can check out the wikipedia article on professions for specifics; it's pretty good so I won't belabor the point here. Suffice it to say that those things above are not professions, and massage therapist IS a profession (at least in Washington state).
Other professions include: doctor, lawyer, accountant, physical therapist, nurse, psychologist, engineer, architect, electrician... if you've ever tipped anyone on that list, you're doing it wrong.
Now add massage therapist to that list.
Massage Therapists are Medical Providers
The extent to which this is true varies from state to state, but in Washington state, massage therapists can be compensated by insurance for their work. In the case of private insurance, it is a violation of their contract with the insurance company for a massage therapist to accept any payment from a patient beyond the contractually-accepted copay or coinsurance rate. In the case of state-funded insurance (such as L&I, or Medicare/Medicaid if those were ever to cover massage), it is straight up illegal. Either way, it is unethical.
If you are seeing a massage therapist and paying with insurance, they should NOT be accepting any tips from you. Similarly, if you are tipping your physical therapist, doctor, dentist, chiropractor, or nurse, you should stop immediately. If they have been accepting your tips, you should seek a more ethical medical provider immediately.
Massage Therapists at Spas are Grossly Underpaid
I mean this both in the sense that the disparity between what they should be paid and what they are paid is large, and that it is disgusting.
If you patronize an establishment where tipping is the norm, I encourage you to continue tipping your massage therapist. Because chances are they are not being paid a living wage, much less a wage that fairly compensates them for the educational and financial investment they have put in to being a massage therapist, or for the grueling, injury-inducing labor involved in providing massage therapy (yes it is harder than it looks. MUCH harder, if your therapist is good at making it look easy).
Essentially, if you don't pay them, nobody will.
I'm sure I could go on, but I believe I have answered the question and covered most of the points I wanted to address. If I missed something or confused you, please post your question in the comments below. If I have offended you, please let me know via email or comment so I can ease your woes. If you have a clever retort or objection which obliterates my arguments against tipping, please post it in the comments so that I may refute you, or bow down to your superior logic and change my misguided ways (or maybe we can just disagree).
Comments, questions, objections? Put them in the comments. Thanks!
This area of the blog is for discussion on topics specific to massage, wellness, and the massage industry. If there is a topic you'd like to see discussed here, please ask!