As a result of a not very complicated negotiating process, Worker’s Compensation in Vermont now pays for Rolfing in most cases where a client’s injury or problem is job related. Further, in Vermont, Workers Compensation pays a providers full fee, unlike some other states where a fee schedule, somewhat or very much lower than the provider’s fee, is established for various services.* This is an important development for us and may suggest a strategy for Rolfers to pursue coverage by other segments of the health insurance industry. In this piece I will explain why Worker’s Compensation is strategically important, how this development happened in Vermont and how we are making use of the opening that has occurred here.
This breakthrough is important for several reasons. Occupational injuries often involve structural problems where our work can be useful. In those cases where we believe we will be useful, though we cannot be certain, we will almost always have clear evidence within three sessions that we are going to make a significant difference or we can reasonably predict that we will not. Rolfing will be helpful to many workers injured on the job. At the same time having insurance coverage enables people to be Rolfed who otherwise might not, and helps in practice building.
Having this coverage has also proven useful in discussing insurance coverage for Rolfing with other categories of health insurance companies looking into Rolfing coverage for those clients who submit claims. Worker’s Compensation coverage legitimates Rolfing in the eyes of claims adjusters and their supervisors. It is a leverage point into the system.
Finally, emerging trends in the insurance industry make Worker’s Compensation a particularly useful focus for our efforts. Companies providing Worker’s Compensation coverage have a history nationwide of more openness to covering what works than do other categories of health insurance providers. They are more prone to be receptive to us. Potentially of greatest significance, conversations in the insurance industry may lead to elimination of the distinctions of general health insurance and Worker’s Compensation, via the integration of Worker’s Compensation into general health insurance programs and policies. Should this happen, the inclusion of Rolfing as an existing coverable service Worker’s Compensation programs would bode well for its inclusion in integrated policies. It is worth going after.
The starting point of the success in Vermont was our noticing that Worker’s Compensation was one type of insurance where we were having same success in getting coverage for our clients, though admittedly only modest success. We also had denials of payment for our services by such companies. In Vermont, Worker’s Compensation policies are sold by about twenty different companies to employers required to provide Worker’s Compensation to employees under state law. Our clients’ efforts and our efforts to obtain coverage in Worker’s Compensation cases were dependent on the individual company and even on the openness of the particular agent in a company with whom we dealt. This was perfectly legal on their part since the question of Rolfing coverage under Worker’s Compensation is not mentioned in any of the state legislation mandating and shaping Worker’s *Compensation in Vermont or in any administrative memos or actions of the various Directors of Worker’s Compensation over the years. Of course this would be so since none had raised the question of Rolfing coverage.
In Vermont, the State Director of Worker’s Compensation has enormous influence over which services are covered in that program, though I do not know if this is the pattern in other states. She can suggest or even mandate that companies providing Worker’s Compensation cover particular services. If companies deny a worker’s claim for that service, the worker can appeal the denial to the state, which means that the appeal eventually will go to the State Director of Worker’s Compensation. Knowing that the Director favors coverage for Rolfing makes it unlikely that a company will deny Rolfing coverage since they can anticipate an appeal process that will likely result in a reversal of this denial.
I wrote to the State Director of Worker’s Compensation. In my letter I described Rolfing and its potential contribution to the resolution of some injuries. I explained that the process is generally limited to ten sessions and that we can make a reasonably good judgement of the likelihood of success after three sessions. I enclosed literature, including the Cottingham studies. I explained that we had fair success in having clients covered by Worker’s Compensation but also some denials, with the result that workers in the same state with similar health problems, but covered by different vendors, were being treated in an unequal way. I asked if she would be willing to write a directive supporting coverage of Rolfing that we could then give to individual companies considering claims. I closed with thanks for her consideration of the issue and by letting her know I would be in touch shortly.
Several weeks later I reached her by phone. (Vermont is a small state, after all.) I reviewed the contents of my letter, emphasizing inequities resulting from the absence of a clear policy, and the self-limiting nature of the Rolfing process. That is, I pointed out that she would not be opening the door to expensive open ended treatment. I asked again for a pro Rolfing directive. She was surprisingly amenable and actually solicited from me ideas about how such a directive might be worded. Several weeks later we had a very positive letter from her suggesting that insurance companies consider Rolfing a viable option in appropriate cases. We have now successfully used this letter as a lever with several recalcitrant insurance providers. I will mail you a copy of my initial letter and her response on request. As a point of strategy, I had available for her, but did not need to draw on, names of clients, insurance companies and involved M.D.’s and D.C.’s in cases where Rolfing coverage had been granted and where it had not been granted in Worker’s Compensation cases.
Getting this endorsement does not bring new clients to our door automatically. The next job is to let potential clients and potential referral sources know about this development. This will take time. We started by sending a mailing of 1,000 pieces to M.D.’s in our area, D.C.’s, O.D.’s, P.T.’s, massage therapists, personnel or human resources directors of some larger businesses, and lawyers who mentioned Worker’s Compensation or personal injury in their yellow pages ad. The lists took a minimal amount of time and not too much money to compile.
The mailing was sent in our business envelopes with a large, red, stamped notice on the front, “IMPORTANT INSURANCE INFORMATION ENCLOSED?. The notice itself was on one side of a heavy stock paper, legal envelope size. The title was “Developments in Insurance Coverage for Rolfing. At the bottom was the logo and our address and phone. The main text was as follows.
Recently, the Director of Worker’s Compensation for the State of Vermont has determined that “In appropriate circumstances, I would anticipate mat coverage for Rolfing services could be found … The fact that Rolfing usually involves a self-limiting treatment plan, with a definite limit on the number of sessions, and the fact that the success or failure of the treatment can usually be predicted within the first few sessions, both are important considerations in favor of coverage.”
We have worked with many Worker’s Compensation cases involving structural problems, where realignment of the overall structure was indicated as part of a rehabilitation program. At the same time, the uncertainty of insurance coverage has limited physicians’ and others’ referrals to Rolfing. The recent clarification from the Director of Worker’s Compensation resolves this uncertainty, given appropriate medical or chiropractic referral.
We welcome your inquiries about the contribution Rolfing can make to people with whom you are working.
Copies of this piece are also available to you or request.
There are same obvious next steps for us to take and I suspect some steps mat will emerge as we continue to work in this arena. As I mentioned, we are using this development on a case by case basis, on behalf of clients submitting claims in non-Worker’s Compensation cases I have also written the state Commissioner responsible for all insurance matters in Vermont outlining our situation and stressing the limitation on clients’ freedom to choose Rolfing when they deem it most appropriate because of insurance denial. He is higher in me hierarchy and harder to reach than the Director of Worker’s Compensation. However, given our very limited resources for lobbying, pursuing the avenue of administrative policy and directive is far more realistic than pursuing legislative mandate, and while me Insurance Commissioner does not have the specific influence with health insurance companies that the Director of Worker’s Compensation has with Worker’s Compensation companies, at least in Vermont, his support of Rolfing would be very influential with companies doing business here. For now I will keep a slow but steady stream of letters aimed at him, copying him in on correspondence with insurance companies questioning and challenging their denial of payment for clients where Rolfing has already proven useful or looks as though it might prove useful. I suspect other strategies will emerge over time, but this is the status as of now.
* For example, we recently were referred a client from New York by a New York physician. (We are the nearest Rolfing available to a large New York population on the New York side of Lake Champlain.) The client was already established as a Worker’s Compensation case. The New York Worker’s Compensation program has no formal experience with Rolfing and denied the claim. The physician and we appealed and eventually Rolfing was approved for the client. However, in establishing a fee schedule, since New York does not pay the provider’s full fee in Worker’s Compensation cases, the administrator set a payment of $35.00 per session and made it clear that it is not considered acceptable for the provider to bill the client for the remainder of the full $80.00 fee. In any case, the client could not cover the difference and we were not able to influence the administrator’s seemingly arbitrary determination. I did discover that the percent of our fee that they would cover was lower than the coverage rate for other services. When Rolfing coverage is evaluated on an ad hoc basis like this, we stand lobe denied far more often or to be compensated at an unacceptable level.Worker’s Compensation Coverage in Vermont