Is the Grass Really Greener?

by Natalie Digate Muth, MD, MPH, RD on Jul 01, 2005

Exploring medical reimbursement for personal fitness trainers.

Results of an informal IDEA online poll recently completed by 185 personal fitness trainers (PFTs) revealed that 87% of respondents either agreed or strongly agreed that the personal training industry would benefit from pursuing medical reimbursement (see “PFTs Weigh In on Reimbursement,” page 100).

With more physicians writing exercise prescriptions, the epidemic of inactivity, an emerging respect for prevention, and a growing personal training industry, third-party reimbursement may sound attractive for medical fitness centers, some PFTs and the general public. But would excessive paperwork, set pricing, increased regulation and delayed reimbursement—inherent components of the traditional healthcare reimbursement model—negate the potential benefits for trainers?

This article intends to inform a discussion of the issue by introducing the topic of third-party reimbursement, assessing its pros and cons for trainers and describing alternative volume- and revenue-generating reimbursement models.

Healthcare Reimbursement

The U.S. healthcare system is based largely on third-party reimbursement. At the simplest level, a healthcare professional provides a service to a patient who is insured by Medicare, managed care and/or a private insurance company. The provider then completes and submits the necessary paperwork, which includes 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 (a negotiated rate based in part on Medicare’s fixed rates, not the provider’s usual price) or is denied reimbursement for the claim. Physicians recently sued several insurance companies who had continually denied or delayed valid claims (Kesselheim & Brennan 2005).

Nonetheless, many health professionals rely heavily on insurance reimbursement. PFTs are not routinely reimbursed for their services. Some argue that perhaps they should be.

The Pros

Third-party reimbursement for PFTs could do much more than introduce challenges with paperwork and getting paid. It could actually help millions of people, including patients, providers and, of course, personal trainers.

Reverse Inactivity

Despite intensified public-health efforts and countless exercise-promoting campaigns and programs, 64% of Americans are not regularly active (Centers for Disease Control and Prevention 2003). As a result, more than 90 billion healthcare dollars are spent each year on conditions related to obesity and physical inactivity (Colditz 1999).

Physicians are beginning to recognize the importance of an exercise prescription. A special article in the Archives of Internal Medicine issued a call to action, urging clinicians to regularly prescribe physical activity for overweight and inactive patients (Manson et al. 2004). Even better, physicians could refer sedentary, overweight geriatric patients to personal trainers specializing in fitness for older adults, or postcardiac rehab patients to trainers working in hospital-based fitness facilities.

However, right now insurance companies won’t pay for those initial appointments—appointments that could not only improve the quality of life and longevity for millions but also drastically increase the insurance company’s bottom line. A lifetime prescription of Lipitor costs far more than a few critically important exercise sessions with a trainer.

“If reimbursing personal trainers for their services could increase the number of physically active people by just 2%, millions more could realize the many benefits of exercise,” says Colin Milner, chief executive officer (CEO) of the International Council on Active Aging.

Increase Volume of Clientele

Some may argue that if personal trainers simply developed relationships with other healthcare providers, they could secure a large number of referrals without having to lobby for insurance reimbursement. However, according to Greg Mack, founder and CEO of Physicians Fitness in Columbus, Ohio, and chair of the IDEA personal trainer committee, physicians hesitate to refer to nonreimbursable providers because (1) many of their patients cannot afford a trainer’s services; and (2) physicians do not want to risk referring to a potentially incompetent trainer.

Physicians might be more likely to refer patients if insurance preapproved and reimbursed fitness centers and trainers. Then, fitness professionals could generate more income during slow midday hours training geriatric, postrehab, postcardiac or other insurance-eligible clients. Even if the pay was only a fraction of the trainer’s normal rate, some supplemental revenue would be better than an unfilled training slot.

Increase Integration With Other Health Professionals

PFT reimbursement would formally acknowledge medical fitness trainers as important members in the continuum of care. “The personal training industry needs to move forward beyond just serving fit people. We need a seamless treatment plan from physician to physical therapist to personal trainer to a regular club membership,” Milner says.

The major certifying organizations are eager to fill this need.

The American Council on Exercise (ACE) developed the Clinical Exercise Specialist certification for trainers wanting to design physical activity and lifestyle programs for individuals who have been cleared to exercise following treatment for or rehabilitation from chronic disease, musculoskeletal injury and disability (ACE 1999).

The American College of Sports Medicine (ACSM) has long offered the Exercise Specialist and the Registered Clinical Exercise Physiologist certifications for advanced and highly educated trainers. These fitness experts deliver a variety of exercise assessment, training, rehabilitation, risk factor identification and lifestyle management services to individuals with or at risk for cardiovascular, pulmonary and metabolic diseases—diseases that require management by an interdisciplinary team of health professionals.

Recognizing that standardization, credibility and accountability are necessary for personal trainers to be respected members of the allied health team, the National Academy of Sports Medicine (NASM) is working toward developing a personal trainer registry and reimbursement program. “We’re trying to get fitness professionals up to the level of other allied health professionals,” says Michael Clark, DPT, MS, PT, and CEO of NASM. Registry trainers will be part of an effort to bring standardization, consistency, credibility, role delineation and scientifically proven training methods to the industry, he says.

Ultimately, appropriately qualified trainers will have a greater opportunity to build relationships with other healthcare providers if the trainers’ services are reimbursable.

Increase Quality of PFTs and Respect for the Industry

In order to become an approved provider, the healthcare professional must meet certain eligibility criteria and complete an in-depth, peer-reviewed application. For example, providers for BlueCross BlueShield (BCBS) of North Carolina’s Alt Med Blue (alternative medicine discount) program are first screened by American WholeHealth Networks Inc. This organization specializes in the recruitment and management of alternative and complementary medicine practitioners who are providers for healthcare plans. Applications are then evaluated by a committee of peer practitioners who participate in the BCBS Alt Med Blue program. The panel’s decision on whether to accept a provider is based on factors such as education, credentials, experience, quality and availability of services, facility standards and geographic location (www.bcbsnc.com/blueextras). This screen- ing process would weed out clearly incompetent and unqualified trainers.

“Right now physicians have a low level of confidence in the fitness profession,” says Graham Melstrand, education director for ACE. If, as an industry, personal trainers took the necessary steps to be approved as reimbursable allied health professionals, then patients and providers would likely take trainers more seriously.

The Cons

“Don’t be blindly optimistic,” warns Anthony Carey, MA, CSCS, a biomechanics specialist and the owner of Function First Inc. in San Diego. Trainers should proceed with caution before demanding something that, in the end, may not benefit either individual trainers or the industry, he says.

Set Pricing and Delayed Reimbursement

Personal trainers should not expect that increased volume of clientele will necessarily translate into increased income. Insurance companies determine the price they are willing to pay for a particular service. The amount is generally based on a national average for how much the service is thought to be worth. For personal training this could be about $12 an hour, estimates Melstrand.

The upfront loss of income on a per-client basis compounded by the expense of a billing specialist (it is doubtful that any individual trainer could effectively navigate through the codes, loopholes and jargon without one) and the wait for reimbursement (30 days to 6 months) could lead to overall revenue losses.

“Overall, [third-party reimbursement] sounds appealing, but the trend of decreasing reimbursement dollars and the increasing level of paperwork and manpower needed to get it done makes me wary to go in that direction,” says Catherine Fiscella, MSPT, an IDEA personal trainer committee member who works as both a physical therapist and a personal trainer.

In fact, for these reasons many physicians and other professionals have opted out of insurance programs and now accept only out-of-pocket payments.

Diminished Quality of Services

In general, PFTs currently devote one hour to each client. The 2001 IDEA Work Satisfaction Survey found that 83% of fitness professionals believe they have adequate time to do their job well, compared to 64% for the average U.S. worker (Gavin 2001). This could change in a reimbursement scenario. For example, in order for a physical therapy clinic to be profitable, outpatient physical therapists can spend only 20–30 minutes with each patient.

“There are a lot of great physical therapists, but they get a bad rap because patients don’t feel they get enough attention when a therapist can spend only a few minutes with them. The same thing could happen to personal trainers,” says Justin Price, MA, a biomechanics consultant and IDEA’s PFT spokesperson. Clients will expect the individual attention, time and energy that personal trainers have traditionally provided, but in a reimbursement scenario PFTs might be too hurried to provide that level of service because of profitability concerns. As a result, the tangible and intangible results of participating in a personal training program could be diminished.

Compromised Client Motivation

The supposed benefit of medical reimbursement for patients may also contribute to a client’s failure. “When clients no longer have to pay for a personal trainer out of their own pocket, motivation and compliance always go down,” says Carey. And when clients fail to see results, the trainer is the first person they blame, Price adds. That news may quickly get back to the referring physician.

Scope-of-Practice Concerns

Healthcare providers are already resistant to embracing personal trainers as allied health professionals—sometimes, unfortunately, with good reason.

“[Medical reimbursement for personal trainers] would be more of a turf issue than a bridge-building issue,” Fiscella says. than a bridge-building issue,” Fiscella says. “It would appear to healthcare professionals as if PFTs were attempting to practice medicine without the appropriate education and licenses, which is obviously a problem. With a reimbursement system, the lines will get even grayer as to what a PFT can do. I think it will be bad news for all involved.”

For some special populations, the difference between the services of a physical therapist (a degreed and licensed professional) and a personal trainer (who is sometimes degreed and certified by a credible organization and other times the product of a weekend workshop) can easily be unclear. In order to be welcomed and embraced by the medical community, personal trainers would need to work within a clearly delineated and narrow scope of practice.

Increased Regulation and Insurance Premiums

Insurance companies would likely influence scope of practice. They would also determine who is an approved trainer, how much a trainer’s services are worth and which patients are eligible to see a personal trainer. Similar to other health professionals, trainers would be required to document all of their work and submit careful records to the insurance company. If insurers deemed a particular exercise or action inappropriate or unnecessary, they could easily deny reimbursement. The control of the fitness industry might slowly leave the hands of fitness professionals and enter the powerful arms of insurance regulators.

Further, with increased responsibility and accountability, trainers would be at an elevated risk for lawsuits; undoubtedly, liability insurance premiums would increase.

Change Would Be Needed

But for now, much of this discussion is theoretical. Experts agree that in order for Medicare or private insurance companies to routinely pay trainer services, or for physicians to routinely refer their patients to personal trainers, the industry would first need to make some substantial changes.

To start, a standard would need to be established, whether it be a degreed program, a special certification, accreditation or licensure. The industry would also need to persuade insurers that personal trainer reimbursement would not only improve their bottom line but also be low risk and acceptable to other healthcare providers.

“Pursuing reimbursement is really premature right now,” says Melstrand. “The industry lacks the maturity and supporting documentation and evidence to convince insurance companies [to pay for our services].”

While Mike Niederpruem, MS, director of certification at ACSM, agrees, he predicts that in 5 years the climate will favor reimbursement for personal trainers. But in order for it ever to be successful, he points out, trainers who are now getting reimbursed must do a great job, going above and beyond to pave the way for future trainers. ACSM, he says, is working to advance the profession to make that happen.

Potential Options

Although routine medical reimbursement from private insurance companies is not imminent, trainers and their clients can still realize some of the benefits of third-party reimbursement through alternative venues.

Trainer or Fitness Center Participates in Insurance Company Network. Some insurance companies offer fitness facilities and their trainers the opportunity to join their provider networks. American Specialty Health Inc. (ASH), the nation’s largest complementary health program, has created a Personal Trainer Option for participating health centers. In this plan, ASH reimburses the facility at the contract rate for 6–24 one-hour personal training sessions. All interested ASH members are eligible for trainer services. See www.ashcompanies.com for more on this.

Trainer or Fitness Center Offers Discount. In most states, medical fitness centers can form a partnership with an insurance company. In exchange for up to a 30% discount on membership and personal training services, the insurance company provides a stream of referrals.

Insurance Reimburses Client. Some highly motivated and savvy clients can negotiate with their insurance companies to receive approval and submit the paperwork for reimbursement themselves. In this scenario, the client pays the trainer or fitness facility at the usual rate and receives partial reimbursement from the insurance company. In general, the client is successful only when he or she has a diagnosable condition, a physician’s referral to the trainer and persistence. The trainer spends about 30 minutes or less completing the appropriate paperwork.

Insurance Offers Client an Incentive. BlueCross BlueShield and other insurance companies offer incentive programs for consumers. Offers can include a monthly or yearly credit for members to spend on various allied health services, including personal training.

Trainer or Fitness Center Submits Workers’ Compensation or Personal- Injury Claims. With workers’ compensation, automobile insurance and personal-injury claims, there is more flexibility as to the services covered and the rates of reimbursement. Generally, if a trainer has an established relationship with the insurance company and the client’s physician and has been preapproved to provide a necessary service (such as gait or balance training), the PFT will be eligible for reimbursement. There are no billing codes specific to personal trainers; however, there are codes that can sometimes be used by personal trainers with the insurance company’s preapproval.

Trainer Collaborates With Other Providers. Occasionally a physician or another healthcare provider who is involved in a patient’s care and works closely with a personal trainer will seek reimbursement for the trainer’s services under the provider’s own medical license.

What Is Your Vision?

A discussion of whether personal trainers should pursue medical reimbursement extends beyond a simple listing of potential advantages and disadvantages; it opens the door for an exploration of the vision, goals, shortcomings and assets of the industry. Armed with this wider perspective, the personal training community will be well prepared to strategically determine where the grass is greener.

From the Field

A Case Study of a Fitness Facility With Medical-Reimbursement Experience

Physicians Fitness, Central Ohio

Owner: Greg Mack, CES, CPFT, 2003 IDEA Personal Trainer of the Year

Logo Tagline: Where Medicine and Fitness Merge

Website: www.physiciansfitness.com

Trains Clients Suffering From These Conditions:

athletic injury

chronic muscle pain

COPD (cardio obstructive pulmonary disease)

coronary artery disease

depression

diabetes (types 1 and 2)

hypertension

neuromuscular disorders

obesity

osteoporosis

postural imbalances

sarcopenia

Experience With Medical Reimbursement:

  • billed directly for services
  • billed under the licenses of various medical providers
  • hired a physician to screen patients and bill insurance
  • billed workers’ compensation and personal-injury claims
  • helped clients receive reimbursement

“We have had some success with third-party reimbursement, but this is unpredictable and very difficult,” Mack says. “We are not licensed medical providers as defined by insurance company standards. Therefore, we establish a comfortable private-pay plan with the patient (our client) and support the client’s efforts to obtain reimbursement. We have often found that a strong referral from a physician with an appropriate diagnosis has assisted clients in attaining reimbursement, as payers begin to realize that our services are appropriate and cost-effective.”

Physician Testimonial:

“The treatment provided by Physicians Fitness personnel could play a very important role in the recovery of one’s health and fitness. When patients have completed physical therapy, they are expected to continue to advance in an exercise program independently to regain full fitness. Often the traditional gym program or home facility does not accommodate these individuals’ special needs. The trainers at Physicians Fitness provide the level of expertise, medical coordination and proper environment for the higher-risk population that needs to improve fitness with medical guidance over a period of several months.”—Mary Ann Everhart-McDonald, MD

Resources

American Council on Exercise (www.acefitness.org): ACE’s Clinical Exercise Specialist certification prepares trainers to work with special populations.

American College of Sports Medicine (www.acsm.org): ACSM offers a variety of resources and certifications for trainers working in a clinical setting.

American Physical Therapy Association (www.apta.org/reimb): This site discusses the intricacies of third-party reimbursement. .

Department of Health and Kinesiology, Purdue University (www.sla.purdue .edu/academic/hk/learning/undergraduate.htm): Purdue offers the first undergraduate degree in personal training. See the website for details.

Medical Fitness Association (www.medicalfitness.org): This is the premier professional resource for medical fitness trainers.

Movement by Design (www.movementbydesign.com): The networking resource manual Relationships and Referrals: A Personal Trainer’s Guide to Doing Business With the Medical Community by Anthony Carey, MA, CSCS, is available for purchase at this website.

PFTs Weigh In on Reimbursement

Do you think the personal training industry would benefit from pursuing medical reimbursement for services rendered to clients?

Source: Results collected from an online survey fielded February 18, 2005, www.ideafit.com.

5%

strongly disagree

8%

disagree

54%

agree

33%

strongly agree

Although difficult, the most effective method of increasing volume of clientele, generating more income and becoming a respected medical fitness trainer is to establish relationships with other healthcare providers. Experts recommend the following four steps to do this successfully:

1. Get Appropriately Educated. “MDs won’t refer to us unless they are confident in our education and expertise,” says Anthony Carey, MA, CSCS, a biomechanics specialist and owner of Function First Inc. in San Diego who has written a resource manual to help trainers generate referrals (please see Resources on page 97). “[For physicians] to even consider [letting us work] with their patients, our level of expertise has to go way up.”

2. Market Your Services. “It’s all about marketing,” says Graham Melstrand, education director for the American Council on Exercise. A trainer can build credibility with physicians by sending introductory letters, visiting physicians’

offices, mailing educational information and making phone calls. Promotional materials should look professional and include the trainer’s background, experience, area of expertise and references. Melstrand suggests that trainers and fitness centers take their lead from physical therapists, who have long had to market to physicians for referrals.

3. Speak Medical Professionals’ Language. Understand and adopt high-priority practices such as staying abreast of the latest relevant knowledge; maintaining confidentiality; appropriately documenting client visits; working within an appropriate scope of practice; and regularly reporting progress to other providers (with the client’s permission).

4. Be an Outstanding Trainer. As all personal trainers recognize, word of mouth is the best way to generate business. Make efforts to assure both the client’s and the referring provider’s satisfaction.

Network, Network, Network

References

American Council on Exercise (ACE). 1999. Clinical Exercise Specialist: ACE’s Source for Training Special Populations. San Diego: American Council on Exercise.

Centers for Disease Control and Prevention. 2003. U.S Physical Activity Statistics: 2003 State Summary Data. http://apps.nccd.cdc.gov/PASurveillance/StateSumResultV.asp?Year=2003&State=0#data; retrieved April 4, 2005.

Colditz, G.A. 1999. Economic costs of obesity and inactivity. Medicine & Science in Sports & Exercise, 31, S663–67.

Gavin, J. 2001. The first industry-wide work satisfaction survey of fitness professionals. IDEA Health and Fitness Source, 19 (7), 29–37.

Kesselheim, A., & Brennan, T. 2005. Overbilling vs. downcoding—the battle between physicians and insurers. New England Journal of Medicine, 352 (9), 855–57.

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About the Author

Natalie Digate Muth, MD, MPH, RD

Natalie Digate Muth, MD, MPH, RD IDEA Author/Presenter

Natalie Digate Muth, MD, MPH, RD, is a registered dietitian and a recent graduate of the UNC School of Medicine. She has made several appearances as a nutrition expert on CW's San Diego 6, been quo...