Mark Sanna, DC, ACRB Level II, FICC

Mark Sanna, DC, ACRB Level II, FICC

According to a recent survey, massage therapy is the most frequently integrated service in chiropractic practices. But how do you integrate massage therapy profitably? In this article I will cover how to best hire and pay massage therapists. I’ll review cash and insurance coding procedures including the most effective time increments and pricing strategies for delivering massage therapy. You’ll also learn the best ways to market your massage therapy practice and how to convert massage patients into chiropractic patients.

Insurance or No Insurance?

Whether to bill insurance or have a cash practice for massage therapy varies by state. In a number of states, massage therapy is covered by insurance, but is covered as 97124, Massage Therapy, and it is only covered under certain types of cases, specifically, Personal Injury and Workers’ Compensation. Most private payers have reduced or eliminated their coverage for massage therapy.  Some states and some insurance carriers will allow massage therapists to use 97140, Manual Therapy, based upon their scope of practice laws and by provider contract.

If you are billing 97140, you must be very specific with your documentation. Manual therapy is not massage therapy.  Your notes must document the components that are included in the description of manual therapy; those being manual trigger point therapy, myofascial release, and manual traction. This differs from the description of 97124, which includes effleurage, petrissage and/or tapotement (stroking, compression, percussion).

What about billing units? In an insurance setting, I’ve heard of chiropractors billing up to four units of 97140. In my experience, this is a red flag. It is difficult to establish medical necessity for three and certainly four units.  I encourage providers, if they’re going to do insurance-based massage therapy in their office, to bill a maximum of one or two units of therapy and, if a patient wants additional time, to charge the patient cash separately from the insurance-based units.

What about the Timeframe?

It’s tempting to use massage as a compliance tool because of how enjoyable it is for the patient to receive. Realize that third party payers require the documentation of medical necessity. This will vary; however, somewhere between a three- to six-week timeframe most carriers are going to say, “Enough is enough.” If you’re going to do insurance-based massage, you’d better have specific goals that you are working toward and objectively document improvement.  If not, you won’t establish medical necessity.

In an insurance-based practice, I recommend region-specific, 15-minute increments that are associated with the diagnosis that you’re working under.  It is also important to remember that manual therapy, 97140, must be performed on a separate region from the chiropractic adjustment. For example, if you are adjusting the cervical region, you might apply the 97140 to either the upper extremity region or thoracic region, as many muscles have origins and insertions that span multiple regions.

15- or 60-Minute Massages?

15-minute region-specific, sports-style massages have a higher rate of patient compliance. It is not unusual that when scheduling massage in 60-minute, spa-style blocks of time, that if the massage therapist isn’t available, the patient will cancel their chiropractic visit. With proper scheduling and coordination between the massage therapist and the front desk, it is possible to offer a range of times including 15-, 30-, 45-, 60-minute massages without creating a bottleneck. Note that 60-minute massages are actually 50 minutes because you must build in break time for the massage therapist.

The front desk must know how to cluster book massage therapy appointments. If a patient wants a 60-minute massage, the front desk should schedule the massage during points in the daily schedule where there is less volume and demand. For example, the front desk could lead a patient who wants a 60-minute massage to the 10:00 or 10:30 time slot, because you know you can fill the time from 9:00 to 10:00 with 15-minute therapy massages. Book primetime where you can turn over 15 minute spots easily and schedule hour-long massages out of primetime.

What About Pricing?

In a cash-based practice, it’s appropriate to charge more for the shorter-term massages. You can generate more revenue per hour if you sell four 15-minute blocks than one 60-minute block. It’s not unusual to charge around $25 cash for a 15-minute unit, which generates approximately $100 per hour, whereas if one patient were purchasing one full hour massage it’s going to be in the range of $75 to $80 per hour.

What happens when a Massage Franchise comes to town and patients can drop in whenever they want for a $39, 50-minute massage? Here is your Massage Franchise busting-strategy: the $39 Massage Franchise session is a one-time deal. It’s $39 and you can only get that if you sign an annual membership contract with a fee of $59 per month, which entitles you to one massage. In addition to the $59, you’re expected to give the massage therapist a gratuity. The suggested gratuity on a one-hour massage is $20 to $25.  All of a sudden that $59 massage costs a whole lot more.

Most Massage Franchises give members one credit a month, but if you miss a month or more and you want to cancel your membership, you have to use up all of your credits in 30 days. If you don’t use it, you lose it and Massage Franchises typically will not let you transfer your credits to a friend without an additional fee.

Create Your Own Massage Membership Program

In a chiropractic setting, patients get to know their massage therapist, unlike at a Massage Franchise where you get the next therapist in the rotation. I recommend creating a 12-month membership. Set your pricing to undercut the Massage Franchise price a little bit, but add better perks. Use an auto-debit charge on the first of the month. If patients pre-pay for 12-months, give them a 13th massage for free. Allow patients to use their massages in any increments that they please. Your membership credits don’t expire.

Additional family members can be added to your membership plan. Offer a discounted rate of an $5 off per massage for added family members. For example, if a husband and wife both purchase a plan, the first one is full price and the second one is five dollars less per massage. Additional perks can include allowing members to purchase hour long gift cards at a 10% discount.  They can buy their co-workers a day of massage or provide their bridesmaids with a pre-wedding day of luxury at a discount. Use auto-renewal to create more value. Allow members to opt out with 30-days notice and a $100 cancellation penalty.

Massage as a Loss Leader

The idea in loss leading is to offer patients a lower than market rate price for massage. In this way, you use massage not to generate income for the practice, but to cover the expense of paying the massage therapist, and to increase access to potential new patients. The strategy is to train the massage therapist to identify patients who could become chiropractic patients or patients that could tap into other profit centers in the practice and to utilize massage as a conversion for that.  Given a choice, a larger portion of the general population will chose an hour-long massage over a chiropractic adjustment. This creates a portal of entry that can be used to convert massage clients into chiropractic patients.

The key component is to train the massage therapist to recognize when a patient would benefit from a chiropractic examination. This is a crucial factor because normally a massage therapist does not feed a chiropractic practice.  It’s a rare event that a massage therapist is going to build a chiropractic practice.  Typically, it’s the chiropractic practice that feeds the massage practice.

I recommend using a form with a map of trigger points across the neck and torso and having the massage therapist check off those areas of tension on the form. At the completion of the massage, the therapist can show the form to the patient, explaining that these are some areas of tenderness that could mean there’s some underlying condition.  The therapist asks, “Would you like to have the doctor check that for you?  We can arrange for an examination.”  A properly trained massage therapist can recognize and point out key issues and recommend an exam and other services.

Staffing and Hiring

This is one of the most challenging components to massage because massage therapists tend to be free-spirited, independent thinkers. Having them work in a structured, well-run chiropractic practice, can require a change in mindset. A good idea is to hire two part-time massage therapists. Consider hiring a male and a female therapist, as many patients have a specific preference, and you will be able to accommodate either request.

Most experts say that a massage therapist can perform five hours of massage in a day. So if you’re thinking in the context of 60 minutes, five 60-minute sessions in a workday is capacity. Hiring two part-time therapists allows you to have one work in the morning and one in the afternoon. Massage is physical work and this helps to not burn out your therapists. It also is your insurance policy that if one massage therapist is sick or on vacation, your entire massage department won’t shut down.

Longevity of employment can be challenging with massage therapists and having a back-up when somebody inevitably moves on, or goes to work somewhere else, keeps you operational. Always have a massage therapist to hire in the wings, who can fill in when someone is absent or take the position when someone moves on.

If you have only one massage therapist, it is essential to have internal policies in place. Have your massage therapist hold a brief massage report of findings with new massage clients. Have the therapist go over the policies for scheduling and rescheduling, including any penalties, so that they are aware of your cancellation and rescheduling policies.

Independent Contractors or Employees?

I recommend hiring massage therapists as W-2 employees.  The reason for this is that you may want to pay a slightly lower base salary and incentivize the therapists based upon the number of massages they deliver. A bonus structure also keeps therapists engaged in the treatment process with patients and encourages them not to act as a technician simply delivering a service. As W-2 employees you can bonus therapists for converting massage clients to chiropractic patients.

Be aware that if the massage therapists are independent contractors and you are paying them on a 1099 basis, you are prohibited from bonusing based upon the value or volume of services delivered or for conversion. Profit sharing with a 1099 employee can violate Stark regulations.  You should be sure, if you have a 1099 independent contractor, that your Employment Agreement is Stark-compliant.

There are other issues of employment that fall under the guidelines of a W-2 that provide you with more control over therapists as an employer.  You can set their hours of operation, treatment style, and require a specific uniform. This may not be possible with 1099 employees.

How to Pay Massage Therapists

When massage therapists are W-2 employees, most chiropractors pay a base hourly rate plus a bonus based on performance, client conversion to chiropractic and outside new patient generation. Massage therapists typically earn between $15 and $20 per hour and then an additional $5 per hour bonus for each full hour of hands-on massage they deliver.  The bonus can be broken down into fractional hours, which work out to $1.25 for each 15-minute unit.

Additionally, if the therapist is not hands-on with patients, they should expect to do other work in the practice. These tasks could include backing up the front desk or performing other clerical work or assisting with passive therapy or rehab exercises, where state law allows. When therapists are on the clock, they’re on the clock. There’s no surfing the net or hiding out in the massage room with the door closed if they are not with a patient.

Having a well thought out office policy in place when you hire therapists, including a complete job description, can head off many potential challenges before they occur. In a Massage Franchise, therapists are massaging or they’re hanging out at the water cooler.  In a chiropractic practice, if they are not hands-on massaging, they are doing some other value-building work.

How to Market Massage

Having a massage therapist on your practice team provides marketing opportunities that a chiropractic practice that doesn’t have massage is not able to take advantage of.  You can add massage to your outside marketing events such as health fairs, or delivering chair massages at local businesses.

If the massage therapist has a background in sports massage, you can work with local student athletes.  This is a great entry point to care for your local school teams, as you can provide massage as a natural performance enhancement, and to increase flexibility and range of motion.  Massage therapy is a great marketing tool at 5K runs and other road races where the chiropractic practice has a booth and provides either pre- or post-race massage to the participants.

When marketing chiropractic we know we are really only reaching the 10% who know about chiropractic when marketing massage and chiropractic together you access that other 90%.  Let’s face it everyone knows they want a massage but not everyone knows they want an adjustment.  This opens the window to potential patients much wider.

Promoting massage with gift certificates is a nice additional source of revenue because people buy gift certificates for massage all the time, especially around the holidays. Have a menu of options that provides easy-to-purchase gifts for Mother’s Day, Valentines, Father’s Day, and other special occasions.

The Financial Opportunity of Massage

How much income can you generate by adding massage to your chiropractic practice? This depends on if you are using massage therapy as a new patient acquisition tool or as an income diversification strategy. As a patient acquisition tool, you’ll keep your cash fee on the lower side, unlike the income-focused fee of $60-$80 per hour.

I recommend setting your hour-long massage fees at just $50 and to pay therapist $20-$25 per hour. In this way, you’ll be paying your therapists the going rate. This will increase employment longevity and cut down on employee poaching by other massage businesses. It also provides you with a fee for massage that you can aggressively market outside of your practice and not only to your existing patient base.

A $45-$49 massage increases traffic to your practice of people who would never set foot in a chiropractic office before. A therapist who is properly trained in conversion dialogue, who is comfortable with introducing the concept of a screening exam or consult with the chiropractor, can be expected to convert 20-25% of their clients into chiropractic patients. When you calculate what a new chiropractic patient is worth to your practice and the increase in patient compliance that accompanies massage, it’s a big financial upside!

Massage helps your Patient Visit Average (PVA). Patients love their massages.  Set a policy that the only way patients can get their massages is by coming in and getting their chiropractic care, within the confines of medical necessity. After patients receive their massage, they can have their chiropractic adjustment. This encourages patients to remain under care after their insurance stops paying. You’ll find that wellness patients come in more often, as they see a benefit of getting adjusted after a massage. Schedule your massage plan members to come in once a month and schedule their adjustment right afterwards.

Ancillary product sales can provide an excellent source of income for your practice. There are many massage therapy creams, oils and aroma therapy products that generate natural sales. Lavender-scented eye shades and bolsters make great gifts and have a high profit margin. Cervical pillows are also an easy piggy-back sale. You can increase sales by displaying ancillary products both in the massage room and at your front desk.

Where to Find Massage Therapists

Working in a chiropractic practice is a very attractive position for massage therapists because it’s a professional environment.  They do not have to go to people’s homes where it is potentially dangerous and unsecure.  Also, it’s very predictable revenue for them.  They might make a little bit more if they were doing home massages for $120 an hour, but have to travel back and forth between locations.  It takes a lot more for an independent massage therapist to give an hour-long massage when you include the travel time, meeting and greeting, and carting the table and supplies.

When hiring a massage therapist, let your patients know about it, and post an announcement in your reception room. You will find that the word-of-mouth of your patients is a great referral source. There are massage schools in most major markets. Post a job notice on the school bulletin board and in their newsletter. I’ve also found great therapists on, a pay-per-click posting service that is similar to, but not as broad. You set your own maximum budget and after you reach your cap the posting is removed.

The right ad places the fact that you are a chiropractic practice front and center. You don’t want to waste time with people who have a prejudice against chiropractic. Screen them right out.  Mention your professional setting and talk about teamwork. Ultimately, that’s the attitude you’re looking for, trying to balance between what they’re doing when they’re not with patients and how they interact with the rest of your practice team. You want to be sure that your therapist can keep up with your volume. “We’re a fast-paced office, looking for a friendly, patient-oriented, team player” is perfect wording.

Include wording about your compensation plan so that candidates don’t feel like it’s just going to be a J-O-B. If you will pay for all or part of their health and malpractice insurance, be sure to mention it. If you have a 401K or other matching plan, add that as well. If you’ll pay for seminars and training, put that in your advertisement.  Bringing your massage therapist to chiropractic seminars so that they can be trained in other office procedures helps them become more valuable employees. They get to see the bigger picture of how their role supports the other roles in the practice and builds loyalty and employment longevity. When done the right way, the combination of chiropractic and massage can be a win-win-win for the patient, the therapist and the chiropractor!

Dr. Mark Sanna is a member of the Chiropractic Summit and a board member of the Foundation for Chiropractic Progress. He is the president and CEO of Breakthrough Coaching ( 1-800-723-8423).