By Betsy Gifford, MusicWorx Intern

When I first decided to major in music therapy in college, one of the first questions my family asked me was, “Does insurance cover that?” (Cue one of the most avoided questions of my college career….)  “Uh, yeah I think so…” (Ooh yeah, way to come back with a solid, definitive answer…) Five years have passed since I first heard that question, and until recently, I still didn’t know much more about the answer than a simple, “Yes, in some cases.” I know that many, if not all, of my peers face the same question and likely have a similar answer to mine.  So, what are the different ways music therapy can be reimbursed through insurance?

Some good resources are the Reimbursement Primer published by AMTA, and Music Therapy Reimbursement by Judy Simpson. I would recommend Music Therapy Reimbursement for any new private practice music therapists due to filing forms and detailed information that is included in the book. From these resources, I have found that there are three main ways that music therapy is reimbursed through insurance:

• Medicare
• Medicaid
• Private Insurance

Medicare

Music therapists can only directly bill Medicare for reimbursement if they are providing services as part of a partial hospitalization program providing psychiatric care.

Another way that music therapy can be reimbursed through Medicare is through a Prospective Payment System (PPS). PPS is a set rate that Medicare pays a facility per year in order for the facility to provide services that allows the residents to reach their goals. The facility can then use those funds to provide services to clients through whichever service they feel best serves their clients. In order for music therapy to be included in those services, there has to be evidence that music therapy helps residents reach their goals cost-effectively so that facilities can see that they would be using their Medicare funds efficiently. The funds then pass through the facility to the music therapist rather than directly from Medicare to the music therapist.

The final way that music therapists receive reimbursement through Medicare is through Minimum Data Set (MDS). MDS is a whole team treatment program that ensures clients are receiving the care they need to maintain their skills such as social interaction, range of motion, and communication. This is a similar process to PPS, but the goals and regulations are different in this program than they are for PPS.

Medicaid

Medicaid is typically thought of in two parts: core Medicaid and Medicaid waivers. Core Medicaid typically requires music therapists to get additional training and certification such as mental health counseling or social work. Music therapists have had more difficulty receiving reimbursement through core Medicaid than through waivers.

Through Medicaid waivers, music therapists can receive reimbursement in either a home and community care setting or a rehabilitation/habilitation setting. Not all states currently have music therapy written into their waivers, which is another reason that music therapy advocacy is so important.  The best way for music therapists to go about getting reimbursement through Medicaid waivers is for them to network with other music therapists in their region and see what has been successful for them.

Private Insurance

Music therapists have had the most success receiving insurance reimbursement through private health care companies. However, most insurance companies review music therapy claims on a case-by-case basis. Music therapy still has not achieved enough recognition to gain blanket coverage for services.

Twelve steps to filing claims through private insurance.

Throughout all the steps, the important thing to remember is to be clear, concise, professional, and knowledgeable in your interactions with the client, family, and insurance company.

1. Referral: the referral can come from a physician, case manager, parent, client, or friend.
2. Collect insurance information from client
3. Determine client needs: before contacting the insurance company, you want to make sure you have evidence that music therapy is medically or behaviorally necessary for the client. Each insurance company defines medically or behaviorally necessary differently. See if you can research on their website how they define it.
4. Prepare marketing materials: you will likely have to educate the insurance agent or case manager on what music therapy is. Helpful items to include in your marketing materials are:
   • The definition of music therapy
   • An annotated bibliography of research pertaining to the client’s diagnosis or expected treatment outcomes
   • AMTA reimbursement brochure listing examples of previous cases where music therapy was covered by insurance companies.
   • Information from the CBMT about the qualification of a Board Certified Music Therapist.
   • Public Relations materials from AMTA regarding facts, statistics, and other data.

5. Written order from physician: although a written order is not necessarily required, it will support music therapy being medically or behaviorally necessary for the client.
6. Call insurance and request coverage decision: you will likely speak to an insurance agent when you first call who will not be able to provide the information you need. In that case, ask to speak with the client’s case manager. This may take several phone calls and be a somewhat longer process.
7. Obtain prior approval: once you are able to contact the case manager, ask for approval to be reimbursed for seeing the client. If the case manager denies the request, politely ask why and see if there is additional information they need to allow your request.
8. Confirm rates and billing: ask for the coverage rate and negotiate if necessary. Confirm the frequency of billing and updates, the contact information for sending the billing forms and the correct Current Procedural Terminology (CPT) codes to use on the forms. Health care providers use CPT codes to describe the services they are providing, and having the correct CPT codes can make the difference between receiving reimbursement or the claim being denied.
9. Send confirmation letter: be sure to include all of the information discussed on the phone.
10. Begin MT interventions: document ALL elements of treatment, including the assessment, any cost savings on the part of the family, the effectiveness of treatment, and all outcomes achieved.

11. Prepare claim form: include the CPT codes (from the case manager), International Classification of Diseases 9^th Edition (ICD-9) codes (from the client’s physician), and National Provider Identification (NPI) number. The ICD-9 code lists the client’s diagnosis for which you are providing services. The NPI is a HIPAA mandated registration of health care providers that helps with the billing process. It is free to get an NPI by going to the National Plan and Provider Enumeration System (NPPES). You can also submit your personal invoice along with the claim form, although it may not be necessary.
12. Follow-up with payer: after submitting the claim, contact the case manager and thank them, being sure to note progress and outcomes achieved as well as offering your expertise on referrals for future clients.
13. Dealing with denial: even with all of these steps being followed clearly, concisely, and on time, the claim may still be denied. If that happens, there are steps you can take for appealing the decision. Some initial questions to ask are “Why was the claim denied? Who made the initial decision? Was it a physician? Was the reviewer a specialist in the field for the services being reviewed? What is the formal appeal process?”

One of the most important things to remember in this process is that you will not receive reimbursement unless you try. Network with the music therapists in your area and find support through them. AMTA is working to provide the research necessary to streamline the process of receiving reimbursement from insurance companies. Share your stories, whether your claims are approved or denied, in order to help AMTA and your fellow music therapists in this process. Even though it might be frustrating, both you, as the music therapist, and the insurance company are working to provide the best service most cost-effectively for the client and their family. If you are a client, family member, or friend of someone you think could be a good candidate for music therapy, the best way to determine if insurance will cover music therapy is to either contact a music therapist in your area to see if they have experience with that or contact your case manager about looking into music therapy.

Regardless of where you are in the process, keep your goal in mind and keep pushing through until you achieve what you set out to do!

Additional Resources:

AMTA. Reimbursement Primer. Jan. 1998.

AMTA E-course. Music Therapy Reimbursement. Judith Simpson. 2012.

AMTA.pro. Music Therapy Reimbursement. Judith Simpson. Feb. 2009.

Simpson, J., Burns, D. S. Music Therapy Reimbursement. Feb. 2004.