the legal resource for fitness entrepreneurs
the legal resource for fitness entrepreneurs

Fitness Training + Medical Insurance

Being fit and healthy, stepping things up after finishing with a physical therapist, or exercising to alleviate illnesses with lifestyle factors are all great reasons to engage a fitness trainer. Your clients might work with you for any one of these reasons – their doctor might have even told them that they should drop some pounds, build some muscle, or improve their aerobic and cardiac fitness. In fact, there is an emerging trend for both insurance companies and employees to pay for personal training and fitness programs.

So, if their doctor is recommending personal training, does this mean you can bill their health insurance?

Maybe.

The health industry is a trillion-dollar industry. This includes both health insurance and the fitness training sectors. Every year health insurance companies pay billions of dollars for the treatment of illness, disease, and injury that might be preventable or treatable with dietary changes and guided exercise. If you are wanting to work as a medically effective personal trainer your business and guidance needs to be toward the goal of improving the health of the individual client that will save the insurance company money in the long-run.

So how does it work? In basic terms a healthcare professional or allied healthcare professional provides a service to a patient who is insured by a private insurance company, Medicare, or managed care. The provider completes and submits the necessary paperwork to the insurance company, including: diagnosis and billing codes, a referral number, visit codes, the patient’s insurance plan number and any other information the insurance company requires. After weeks or months, the provider either receives payment from the insurance company for services rendered (usually on a negotiated rate, not the provider’s fee schedule) or is denied reimbursement for the claim.

Can personal training be covered by health insurance?

In order for health insurance companies to pay out on personal training sessions, the exercise activity must be medically necessary for your client’s condition. You need to tailor your services to the specific medical condition(s) in a manner that will produce a predictable, and positive, outcome.

The conditions that many fitness trainers who work with insurance provide services for include: diabetes, high blood pressure, back pain, sports injuries, post cardiac rehab, and joint replacements. Often personal training sessions step in when physical therapy sessions conclude but help the client resume full activity. In effect, many personal trainers who bill insurance are offering a post-rehab program that help their clients transition from physical therapy to full activity.

One of the reasons for the fierce debate around licensing of fitness professionals, specifically personal trainers, is that many believe that by implementing uniform licensing there will be more opportunities for fitness professionals to engage with medical insurance and find additional revenue streams and client base opportunities.

If you would like to bill insurance for your services you will likely need to put some robust documentation and procedures in place to meet the needs and requirements of the referring doctor and the insurance companies you’d like to work with. You will need to show that you use evidence based protocols and training program.

You will need to be approved as a provider with each specific insurance network you’d like to work with – some of them with work with personal trainers more than others – and in order to be approved you will need to hold a nationally recognized certification or qualification. Generally speaking, insurance companies require all providers to meet certain eligibility criteria and complete a detailed peer-reviewed application. Some health insurers often offer specific alternative or supplemental health programs. New provider applications are usually evaluated by a peer committee on the basis of education, credentials, experience, protocols and quality assurance procedures, availability of services and facilities, and geographic location. The motivation for the screening and evaluation process is to ensure a minimum level of quality, and to select competent and qualified professionals.

It may be advantageous to hold an additional certification for training a specialized population.  Some examples include the Clinical Exercise Specialist certification (ACE), Exercise Specialist and the Registered Clinical Exercise Physiologist certification (ACSM), and Personal Trainer certification (NASM).

Even if approved by an insurance company you may be considered as “out of network” – this may change the amount of any co-pay your clients are responsible for. Most, if not all, insurance companies will require you to agree to their fee and payment structure and billing procedures. Fitness professionals should analyze the potential benefits and challenges of an increased volume of clientele, loss of control over fee schedules, and long delays in reimbursement. The decrease in cashflow in the short to medium term as a consequence of the long delays in reimbursement (30 days to 6 months) may be compounded by the additional expense of hiring billing staff or outsourcing billing. Medical coding and billing is especially complex and may be challenging for a fitness professional to navigate on their own. The complexities of billing may be sufficient for a fitness professional to decide not to pursue insurance reimbursement. However, a steady stream of referrals and filled appointments may alleviate the reduced fee recovery.

In order for a Physician to be willing to prescribe sessions with you as the personal trainer (or make a referral), you may need to also submit your credentials to the physician so that they are personally comfortable in writing a personal training prescription. Your clients will likely need this prescription or referral to pursue medical reimbursement from the insurance company.

You need to be away that there is still some resistance from healthcare providers to refer clients to personal trainers and to consider personal trainers as allied health professionals – partly because of the lack of uniform licensing of the fitness industry. You will need to be prepared to justify your training and experience.

Once you have been approved, you will need to perform an assessment of the client in which you determine the types of services and the care plan you propose. You will then contact the clients Primary Physician to obtain approval of the program, and then request pre-authorization from the client’s insurance company before commencing the program with the client. The insurance company will respond to the request for pre-authorisation with information about the extent and type of coverage your client may have for your services. You may find it helpful to advertise which insurance you are able to accept.

Each month you would submit the bill for the sessions completed by each client directly to the insurance company. The client would be responsible for any co-pay and any additional amount not covered by their insurance. It is important to make sure your clients understand their financial responsibility if you choose to work with insurance companies.

Other Options other than direct billing the health insurance company

Some trainers work in a wellness medical center environment in conjunction with primary care physicians. By collocating and collaborating with other providers, a personal trainer may be able to bill insurance providers for services through a centralised billing system directly under a primary care physician’s supervision.

A flexible spending account (FSA) or Health Savings Account (HSA) is often able to be used for personal training services. The client is responsible for paying into the FSA and HSA sufficient funds to cover the cost of personal training sessions. In order to use FSA or HAS, the client will need to obtain a prescription or referral from your Doctor before you begin to work with them. You will also likely need to send reports on the client/patient’s progress to the physician each month.

Some clients may be able to seek reimbursement from their insurance company, submitting their own request for approval and reimbursement. The client pays out of pocket for the personal training sessions on your fee schedule, they then submit for partial reimbursement from their insurance company. You may be able to charge a fee for the initial consultation and assessment. In order to claim reimbursement from their insurance company, the client generally needs to have a diagnosed condition, a referral for the personal trainer prescribed by their primary care doctor, and some grit to navigate their insurance.

Company Wellness programs often have personal training as part of their offerings. Trainers are usually pre-approved by the company’s insurance. Company provided insurance often function on a tiered payment system whereby the client can opt in to the wellness program which in turn provides insurance premium reductions as a consequence of participation. Personal training sessions may be partially covered under a company wellness program, a gym membership reimbursed, or a premium deduction offered to your clients (and clients pay out of pocket for the sessions).

Workers’ compensation, automobile insurance and personal-injury claims may be another source of revenue. There is significantly more flexibility as to the services covered and the rates of reimbursement. Usually third party insurance claim approval require an established relationship with the referring physician and the insurance company. There may be specific services they will approve such as balance training or functional strength. The insurance company will usually indicate the approved billing codes to be used.

So what now?

As a fitness professional you will need to decide if you should pursue medical reimbursement through an analysis of the potential advantages and disadvantages for your business. But would detailed billing procedures and documentation, pricing schedules, increased regulation and delayed reimbursement—inherent to healthcare reimbursement models —negate the potential benefits for trainers? There are some industry advisors who argue that pursuing insurance reimbursement is premature without additional licensing standardization, but this is not definitive.

 

About the author

Anna Blanch Rabe is a communications consultant, writer, and speaker. A non-practicing attorney, she works with social impact businesses and non-profit organizations to develop and effectively execute narrative initiatives to gain exposure, develop community capacity, and reach new customers. A former college level athlete, she now enjoys yoga and swimming, and crewing for her trail and ultrarunning husband.

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