By Sue Shekut, Owner, Working Well Massage, Licensed Massage Therapist, Certified Wellness Coach, ACSM Personal Trainer
Back Muscles and Spine
Massage therapists and and chiropractors have had a symbiotic relationship over the years. Chiropractors hire massage therapists and massage therapists often refer clients to chiropractors and/or rent space from chiropractors. I used to teach the Business class at one of the local massage schools, and, as a business owner myself, I have to keep up on laws and regulations regarding massage…and chiropractic. Unfortunately a recent law has put the chiropractic profession a bit at odds with massage therapists. To enlighten clients and other massage therapists, I am going to break down some of the current laws regulating massage and chiropractic are in Illinois.
The Law Regulating Massage Therapists in Illinois
The State of Illinois began requiring massage therapists to obtain a state License for Massage in January, 2005. This law requires massage therapists to complete schooling of at least 500 hours, take and pass the National Certification Exam and pay a fee every two years. In Illinois, Massage Therapist’s are also required to take 24 hours of continuing education credits every two years. This licensing act was an attempt to further legitimize massage therapy (and make it clear massage is not prostitution) and give massage therapists a uniform standard of education and ethics to follow. Prior to this law, each municipality regulated massage according to their own guidelines. Some cities had stringent regulations, others had none. The state law helped eliminate this confusing patchwork of regulations and put massage therapy under one set of rules, the Massage Licensing Act.
The Massage Licensing Act requires licensees to be fingerprinted as part of the license application process. This is required to help protect the public from sexual predators and other people with a history of sexual violations. The law also requires massage therapists to have taken and passed courses including kineseology and anatomy and physiology. This means that licensed massage therapists know how your muscles attach, work and can be injured–and how to reduce muscle tension and “knots” in your muscle tissue.
The Law Regulating Use of Unlicensed Persons to Perform Massage In Chiropractic Offices
However, the State of Illinois then passed an act, 22S ILCS 60/Medical Practice effective January, 2010, that allows Chiropractors to hire unlicensed, and potentially untrained staff to give clients “therapeutic” massages at the Chiropractor’s office. Chiropractors may have lobbied for this bill saying that they did not want to have to wait for students to pass their licensing exam before they could work for chiropractors. However, there is no shortage of Licensed Massage Therapists in Illinois (According to the ABMP, there are currently about 8,000 Licensed Massage Therapists in Illinois). And chiropractors can directly bill insurance companies for massage services, while independent massage therapists cannot for most insurance companies in Illinois. Ironically, according to a representative I spoke to at Blue Cross Blue Shield, even with a high-end Blue Cross insurance plan, only chiropractors are allowed to perform the massage, not massage therapists, in order for the insurance company to reimburse for the massage.
Unfortunately, this paves the way for chiropractors to now hire unlicensed, potentially unqualified people to give clients their massages and then in some cases, the chiropractor may bill the insurance company for those massages even if the chiropractor does not perform the massages. Thus untrained employees can be allowed to provide direct patient care to patients with medical conditions. Untrained people can injure you while doing massage work because they haven’t had the 500-hour massage school training (which includes not only training on proper massage techniques, but also anatomy, kinesiology and physiology. And ask a massage therapist: most chiropractors do not stand over massage therapists as they work, monitoring their massage performance–chiropractors are usually working on other patients. In some offices, chiropractors work in one room while the massage therapist works behind closed doors in another room.
License Massage Therapists may lose work to unlicensed people because the chiropractor can hire someone else to do the same work for less pay. In addition, Public Act 096-0618, does not afford the public protections from sexual predators or require unlicensed massage therapists to be finger printed or background checked! It is not clear how this new law protects the public or can be said to be for the public good.
Note: Reimbursement requirements depend on your particular insurance plan.
As a client, what can you do to protect yourself and make sure your massage therapist is qualified and licensed?
1. Check the State of Illinois Division of Professional Regulation website to look up your Massage Therapist by name and see if he or she has a valid state Massage Therapist license here.
2. If you receive massage from someone at a chiropractor’s office, ask the chiropractor if the massage therapist is licensed. If not, ask for a massage therapist that is licensed by the state and has completed all required training and testing.
3. If your insurance company has been paying a portion or all of your massage bills at the chiropractor, check with the insurance company to find out the exact requirements for reimbursement. Does your insurance company require the chiropractor to personally perform your massage or can they have someone in their office perform the actual massage for reimbursement?
If the insurance company requires the chiropractor to perform the massage, and your chiropractor charged your insurance company for performing massages then he/she delegated the massage to a staff member that is not a Licensed Chiropractor, your chiropractor could run into trouble with the insurance company. If the insurance company ever found out, you may also be in trouble too. You may have to pay back the insurance company for your massages and you may also be accused of committing insurance fraud. But, if it’s a great deal for you and the chiropractor to have the insurance company pay for your massage, who would ever tell the insurance company? Well, a disgruntled employee of the chiropractor’s office for one. Or a spouse divorcing one of the chiropractor’s patients could be a whistle blower. Anyone with a bone to pick with the chiropractor. (Bad pun intended.) Ask yourself if saving a few dollars is worth the legal risk.
4. Note that using a Flexible Spending Account or Health Savings Account (HSA) for to pay a massage therapist directly for your massages IS legal IF the massage is considered therapeutic. For example, if you have been diagnosed by a doctor or chiropractor with plantar facitis or a low back or cervical disorder that requires massage, that would be a therapeutic massage. Or, if you have fibromyalgia or a repetitive injury such as a thoracic outlet syndrome, massage to help with these conditions would be considered therapeutic. Check with your Flex Spending or HSA account administrator for details of your specific plan. To be an expense for medical care, the expense has to be primarily for the prevention or alleviation of a physical or mental defect or illness. Check the U.S. Government’s rules for “qualifying medical expenses” here.
For example, a Cigna plan allows you to use a FSA or HSA funds to pay for massages if they are used to treat a physical defect or illness. Cigna Plan - Fees paid for massages are not reimbursable unless to treat a physical defect or illness. Physician’s diagnosis letter required.”
I don’t want to scare anyone out of getting a massage at your chiropractor by any means! Most chiropractors are law abiding and follow insurance company guidelines. I work closely with several chiropractors and I refer clients to them often. But knowing the law and abiding by it may save you from problems and legal issues down the road.
regarding your chiro comments, we here in ga are watching ILL for changes also. We suspect they are trying to get assistants qualified to do massage.
Q- you mentioned pre tax accounts. I have not had any luck getting set up to receive compensation from any, even though United health care with teachers and others offer it. Is there an easy way to get the code set up in your cc terminal to accept swipes of their benefit card? I have even had several come in and try to use their benefit card and its denied even though it looks like a Master Card.
I had medical massage insuracne billing training but it has not worked here in GA , yet.
HSA and Flex spending accounts are different types of accounts. I have had no problem with HSA debit cards at all. Banks and credit unions offer them to account holders and the account holder must verify that the charge is a legit medical expense at tax time. Otherwise the HSA debit card works just like any other debit card. Flex spending really depends on the administrator of the account which is often your client’s employer or HR dept. The client needs to call their account admin to find out if massage is covered. I am not sure what “benefit cards” your clients are using. If they are not flex spending or HSA account cards then they likely will not be accepted. Hope that helps! Sue
Can you give me any info on the laws in Ohio? I’ve googled it and can find little. I work for a chiropractor and am a licensed massage therapist. Recentley he has been having unlicensed staff members do massage when I am not there or busy working on someone else. Is it legal? Any info would be greatly appreciated.
Thanks!
Melissa,
Thanks for reading! I am not as educated about the laws in Ohio, but I will give you what I could find and encourage you to contact AMTA-Ohio. AMTA chapters tend to be very well versed on the laws of their states. Call 800.281.6548 Link: http://www.amtaohio.org/contact/
Another place I would suggest you call is the Ohio State Chiropractors board at 1-888-772-1384. I would not start with a complaint but I would ask them if his behavior is legal according to the Board’s regulations. Link here: http://chirobd.ohio.gov/complaint.stm
You could also call other Ohio massage therapists that accept insurance and are knowledgeable about it: George Komar and Cindy Layman at Ohio Valley Massage Associates, 740-544-6644. Their web site has a LOT of info about insurance and massage in Ohio: http://www.massageohiovalley.com/insurance_billing.htm
Also, in the recent Massage Today newsletter, Vivian Madison-Mahoney, LMT, wrote a great article on the same concerns you have about your chiropractor. Read it here: ww.massagetoday.com/mpacms/mt/article.php?id=14311 You may want to contact her directly as well (She charges but peace of mind and a legal practice is well worth the fee!): http://shoppingcarts4you.com/massageinsurancebilling/catalog/index.php?cPath=12
Hope that helps!
Sue
Let me know what you find out!
Also the massage they are doing is being billed to insurance. I have refused to let my signature be used in those cases but is one of the chiropactor’s initials enough even though they are not the one’s performing the massage?
Refusing to put your initials on the form is a good start. But if you know this practice is going on at your workplace and you do nothing about it. you may be complicit if there is insurance fraud going on. In Illinois, our chiropractors can pretty much take anyone off the street and let them do “massage” on their clients. At least by law they can. However, insurance companies may also require that the chiropractor perform the massage him or herself for reimbursement. Your best bet is to call a few of the insurance companies directly and ask them if what you need to do for your clients to get insurance coverage. You would also need to know which plans are being used because insurance companies have a variety of plans with a host of different levels of payment and also restrictions. It’s a headache. Vivian Madison-Mahoney, LMT, may know what the case is in Ohio, but you may have to do some actual legwork. Check out her site here: http://shoppingcarts4you.com/massageinsurancebilling/catalog/index.php?cPath=12
Good luck and keep me posted! I’d really like to hear what you find out.
Sue
[...] Legal issues for Massage and Chiropractic May 2010 6 comments 5 [...]
I was wondering about massage performed in a Chiropractors Office in IL by his office manager or his receptionist. Does he have to be in the office at the time of the scheduled massage. And are they allowed to do chair massage at marketing events in schools and other businesses that he is not present at.
Michelle,
Those are good questions. In my mind, having a receptionist perform a massage, whether or not the chiropractor is in the same office, is unethical, even if it were legal in Illinois. However, there are other stipulations that restrict the use of the receptionist and office manager from performing massage. And specifically, these unlicensed people may not practice massage on new patients to market outside the office setting even if the chiropractor is present due to the language cited below.
Here is the link to the final law: http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1309&ChapterID=24
I pasted the relevant text below. Note that although the text says physicians, chiropractors are included as physicians in this act. My clarifications are given in brackets.
(225 ILCS 60/54.2)
(Section scheduled to be repealed on November 30, 2011)
Sec. 54.2. Physician delegation of authority. [Which also includes chiropractors]
(a) Nothing in this Act shall be construed to limit the delegation of patient care tasks or duties by a physician, to a licensed practical nurse, a registered professional nurse, or other licensed person practicing within the scope of his or her individual licensing Act. Delegation by a physician licensed to practice medicine in all its branches to physician assistants or advanced practice nurses is also addressed in Section 54.5 of this Act. No physician may delegate any patient care task or duty that is statutorily or by rule mandated to be performed by a physician.
(b) In an office or practice setting[so only in the office, not at health fairs or to market] and within a physician‑patient relationship, [which means, within the context of an existing patient/physician relationship, not to market new clients] a physician may delegate patient care tasks or duties to an unlicensed person who possesses appropriate training and experience provided a health care professional [which in this case would either be training by the chiropractor OR licensed massage therapist], who is practicing within the scope of such licensed professional’s individual licensing Act, is on site to provide assistance [so the licensed massage therapist must be on site to provide assistence].
(c) Any such patient care task or duty delegated to a licensed or unlicensed person must be within the scope of practice, education, training, or experience of the delegating physician and within the context of a physician‑patient relationship. [Again, the massage given must be within the scope of practice of the chiropractor/and or licensed massage therapist on site AND must be within an existing physician-patient relationships, not for marketing purposes or for new patients]
(d) Nothing in this Section shall be construed to affect referrals for professional services required by law.
(e) The Department shall have the authority to promulgate rules concerning a physician’s delegation, including but not limited to, the use of light emitting devices for patient care or treatment.
(Source: P.A. 96‑618, eff. 1‑1‑10.)
Hope that helps!!!
Sue
[...] time ago I wrote a post about chiropractors using unlicensed massage therapists to give massages in Illinois in my client-centered blog, Working Well Resources. Recently, I had a reader post a question to this [...]
It is my opinion that if a student completes 500 credit hours in massage thereapy school, it should be legal for them to work. I graduated from a two year clinical massage therapy school seven years ago, so I would have a career to fall back on if I ever got laid off from my current job. Now I am laid off, and find out I have to take this stupid test before I can get licensed! I know the muscles and bones of the body, but I do not remember all of the latin names given for the origins and insertions of them… It cost me 20,000 to go to school. I am a good therapist who is not allowed to work. The test cost 250.00 and if I fail, I have to keep paying until I pass. Massage therapy is not rocket science, and the states make it so hard to pass the test. Most therapists don’t remember all of the technical terms for every part of the body, nor do they know every disease a body can have, but we are required to know off the top of our heads if massage is indicated or contraindicated for each of them. If a client fills out a questioneer and they have a particular condition I’m not sure of, I simply look it up. So stop crying about the license. I’m sure no decent doctor would let some flunky off the street work and not know what they are doing. Especially if they are doing trigger point or myofacial realease techniques. Chiropractors don’t hire regular therapists anyway, they have to be certified clinical massage therapists who have completed at least 500 hours in a school. No one would risk losing their buisiness by letting a therapist hurt their clients. Quit your crying.
Tammy,
I appreciate you sharing your thoughts and opinions and illustrating why it is so important for licensed massage therapists to practice in chiropractic offices. You address many issues in your comment. First off, I sense that you are feeling frustrated and anxious about having no job or income. Perhaps you are worried you won’t be able to pass the certification exam. Rest assured, if you completed a 500-hour massage program, all you really need to do is study up for the exam and you will likely be able to pass it. There are a number of study guides available to help you study for the national certification exam.
Your comments that “massage is not rocket science” and that “most therapists don’t know all technical terms for the body…but we need to know if massage is contraindicated” worries me. Massage is not rocket science but it is a healthcare service and massage CAN injure clients. I know the “technical terms” for the body as well as muscular origins, insertions and actions and so do all the massage therapists I work with. You say if a client has a condition you are not sure of you would look it up. That also concerns me. Before I completed massage school, I’ve been injured myself from massage therapists that thought that “quadricep” was a “complicated Latin terms” and that knowledge of anatomy and kinesiology was something they “could just look up.”
As to being certain that no decent doctor would hire some flunky off the street, I wonder how you discriminate decent doctors from indecent doctors. Laws are made not only for those that are ethical and honest, but also to provide some recourse when doctors and other practitioners are not decent and honest. I do not know what you mean by “regular” therapists versus clinical certified massage therapists. If you read the actual links and understood what this post is saying, you would note that the current law allows nonclinical, non-certified massage therapists to work on patients in chiropractic offices. And this law allows chiropractors to risk their businesses and let a therapist work on clients with only minimal training or oversight. The chiropractor does not even need to be in the same room. So he/she would not know if their untrained massage therapist injured a client or not.
I wish you luck in studying for your licensing exam, but I also advise you to think about other career options outside of massage therapy. Completing a massage program, paying for your schooling and paying for and passing the licensing exam are normal business expenses. If the test and requirements are too difficult for you, massage may just not be a good fit for you.
Sue
As a Chiropractor in the State of Illinois, I felt compelled to respond. I have Massage Therapists on staff at both of my offices. The first thing I do is check that they are licensed, or if just out of school, they have applied and awaiting their license to show up in the mail. I don’t know any of my colleagues that are having an untrained person perform massage in their office. I’m sure that it has and is happening somewhere. I certainly believe that it is few and far between. I find it almost ridiculous to hire an untrained person or have an untrained member of your staff do Massage Therapy. There are too many risks involved. Many comments within this discussion, I feel, could make readers feel skeptical about the ethical nature of the Chiropractic profession. Nothing could be further from the truth. There are unethical and unreasonable people in every profession, but I find my colleagues as a whole are ethical, moral and very well intentioned Doctors. If I ever knew that a Doc that I know was having untrained staff give massage to patients, I would most definitely tell them how I feel. I think it is a good idea for a person to inquire as to whether a Massage Therapist is licensed or not.
Dr. Durham
Dr. Durham,
Thanks so much for your thoughtful reply! It is not my intent to make people skeptical of the Chiropractic profession, just to alert the public to this change in the law. I do, unfortunately, know of some Chicago area chiropractors that hire untrained, unlicensed massage therapists. I worked alongside one such young lady at a charity event. She had no license and, according to what she told us, her training consisted of hanging around the rehab room after soccer practice. Apparently she, and the chiropractor that hired her, thought that osmosis was a valid training technique for massage skills. I am glad that you would talk to a chiropractor that you knew had hired untrained unlicensed people. And I applaud your own hiring standards! At the same time, having a law that allows chiropractors, or any doctor for that matter, to hire unlicensed people to perform massage is not only damaging to those of us with licenses to practice massage in Illinois, but to the public at large.
Thanks so much, Dr. Durham for stopping by and adding your comments!
Sue
[...] 4 Legal issues for Massage and Chiropractic [...]
[...] of Chiropractic and Massage Therapy for AthletesMassage parlour arrests in TrentonLegal issues for Massage and Chiropractic .page-title { -pie-background: linear-gradient(left top, #0F2D4D, #2880C3 ); background: #0F2D4D; [...]
In my opinion massage therapist must have a license before they can practice. Thank you for sharing this article.
Jordan,
Thanks for reading and commenting!
Sue
I am a Massage Therapist in Illinois who was recently hired by a Chiropractor with the agreement that I would be taking my exam 2 weeks after my hire date however, after all of my studying and prep I failed by 3 points. He has agreed to fund my test retake within the next month however I am currently practicing massage at the office during the wait time. We are a cash only practice so there is no insurance “fraud” involved, I can only practice when he is on site and in my paperwork it does state that I am a Certified Massage Therapist and I am currently not licensed. I feel that this post is saying that even though it is legal for a chiropractor to hire a non licensed MT that it is unsafe for most people to get a massage at a chiropractic office because most hired are unskilled. I consider myself skilled and knowledgeable about the Massage Therapy field, I completed the program just like everyone else but unfortunately I happen to be a horrible test taker! I look forward to passing my exam next month and in the meantime I proudly display my Massage and Reflexology Diplomas in my therapy room.
Annebell,
First off, congratulations on completing your massage program! Having gone through it myself, I know how difficult it can be and how frustrating it is to have to wait to work until you get your license. In my case, even though I graduated and had done months of practicum in school, I could not work at all in the City of Chicago until I had my license. (This is before state licensing when the city handled it all. It was much harder back then!) It was frustrating to be turned down by many potential employers simply because I did not have my official license and they knew it could take months for the city to process it. But I, like hundreds of other massage therapists, waited out the two months and started working once I got my license. I have enjoyed my career ever since!
Now you are in a different position. You are already working as a massage therapist, even though you do not have your license and did not pass your exam. I understand that some people have text anxiety and that can make it difficult to pass tests even when they know the material. It sounds like that is what you feel happened in your case. And my post is not saying that people that have had training in massage therapy are not qualified to perform massages. However, I don’t know you and I can’t attest to your level of skills or knowledge. In Illinois, the state considers you to have the skills and knowledge if you can pass the test. The test is an attempt to be objective in evaluating our skills as massage therapists. If you can’t pass the test and don’t get your license however, for whatever reason, in Illinois, you can continue to work under your chiropractor. In my book that is not safe nor does it protect the public good. Again, I am not saying that you specifically do not have the skills needed to perform massage therapy safely, but I also can’t say for certain that you are capable of performing massage safely either. I don’t know you and can’t evaluate your work. That’s why we have tests and standards. So that the system is as fair and objective as it can be to protect the public good. Maybe your skills are fine but the next massage therapist is not fine, has the same story and does not pass because of skills and not due to test anxiety. Or maybe your chiropractor or another chiropractor hires someone who has no massage experience. It doesn’t make a difference according to the current law. Any chiropractor can hire anyone and say he/she has been “trained” by the chiropractor or is supervised and that person can give massages. And the chiropractor can pay him/her less than you.
That all said, I am glad you are reading my blog and took the time to comment and express your opinion. I wish you luck on your next exam retest. I hope that you do well and are able to pass and then join the ranks of licensed Illinois Massage Therapists!
Sue
I am an Office Manager for a chiropractor’s office in Kansas and we are considering hiring a licensed massage therapist for our clinic. I have never dealt with this situation before nor do I know of any chiropractors in my town that employ massage therapists. Where can I get started in trying to learn about everything there is to know about wages, contracts, liability issues, billing insurances, etc….
Thanks for reading our blog and commenting, Kathy. I am not familiar with Kansas law regarding massage and chiropractic. Your best bet is to check out some of the books on the subject and speak with other mangers of chiropractic offices in your area. One book I’d recommend that may be helpful is Business Mastery by Cherie M. Sohnen-Moe You can find it via this link: http://www.amazon.com/Business-Mastery-Creating-Fulfilling-Successful/dp/0962126578
Hope that helps!
Sue
My 18 year old daughter recently enrolled in the Massage Therapy Certificate program at our local junior college. Upon successful (hopefully)completion of this one year program and passing her national test and getting a license in illinois/missouri, she would like to enroll in the Physical Therapist Assistant program while working as a part-time massage therapist. Do many physical therapists hire massage therapists? Do massage and physical therapy go together or is this education overkill? Also, which national massage certification test should she take next year if she wants to practice in Missouri and Illinois – the NCBTMB or the MBLEx? Thank you for helping us.
Susan,
Each state regulates massage therapy and physical therapy differently so I can only answer with what I know for Illinois. Physical therapists tend to make more money, have more opportunities to work with hospitals and doctors and are, sadly, more respected than massage therapists. That’s my opinion. Physical therapists don’t often hire MTs (not sure if they can, legally, hire MTs), but chiropractors hire both here. I don’t think the education you explained is overkill. Actually if it were my daughter, I’d pull her out of massage school and send her to physical therapy school or nursing school instead of massage school. But it really depends on her and her goals. If she gets a Certificate in MT, in 1 year she can work right away, and still go to school for a more stable, lucrative career while she earns some money as a MT.
Massage therapy can be rewarding in that you help others and learn some about the body and muscles. But it is not highly respected by the medical community, it is regarded by some as a cover for prostitution (which it’s not, but it regarded by some as this), has a high burn out rate and is tough on the body. For some, the flexibility of the hours, the ability to make a difference in people’s pain and stress and the ability to “be your own boss” is rewarding enough. But you have to be really really good to make decent money in private practice. And emotional maturity helps a lot in building a private practice. If she works for others, she will make a lot less and, depending on where she ends up, it can be a good work environment or a hassle, just like any other job. I don’t want to bust her bubble, but since you are her mom, I’m going to be honest with you, Ask 5 other MTs and they may tell you a different story. I love my clients and the work I do. But if I had a daughter, I’d send her to medical school or nursing school!
Hope that helps!
Sue
Greetings! I’ve been reading your web site for a while now and finally got the courage to go ahead and give you a shout out from Lubbock Tx! Just wanted to tell you keep up the fantastic job!
Thanks, May! Glad to have you reading our blog. Enjoy!
Sue
Good day! I know this is kinda off topic nevertheless I’d figured I’d ask.
Would you be interested in exchanging links or maybe guest writing a blog article or vice-versa?
My blog addresses a lot of the same topics as
yours and I think we could greatly benefit from each other.
If you are interested feel free to send me an email.
I look forward to hearing from you! Wonderful blog by the way!
Marshall,
I’d be happy to hear more about your blog and share what you have with my readers. I sent you an email outlining my needs for a guest post.
Thanks so much,
Sue
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Ezequiel,
Thanks for reading and commenting!
Sue
Good post. I learn something new and challenging on websites I stumbleupon on
a daily basis. It’s always useful to read articles from other authors and practice something from other websites.
Nora,
Thanks for reading and commenting! Keep stumbling and finding new content you like!
Sue