Common Practice Concerns
Common Practice Concerns
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When encountering unfamiliar or potentially difficult to navigate situations, may RMTs will have difficulty figuring out how they should respond. Although you are familiar with the CMTO Standards of Practice as well as the CMTO policies and positions, you may be unsure of how they would apply to your current scenario. You may not feel confident enough in your knowledge of your rights and responsibilities to be able to confidently respond in certain situations. There are also a lot of details about massage therapy practice that don’t come up often in your day-to-day experience, so you may not be sure where to begin searching for the information you need.
Below we have compiled some common practice questions we receive at the RMTAO office.
A Patient Behaving Inappropriately
As a profession that deals regularly with the general public, it is likely that many RMTs will encounter patients who behave inappropriately in their practice. Whether this is a patient making racially inappropriate comments or a patient behaving in a sexually inappropriate way, or any other action that makes the RMT feel attacked or uncomfortable, you are under no obligation to treat patients behaving in these ways.
You can discharge a patient if their needs are outside of your skills, experience, or scope of practice, or if the patient is abusive. You only have to arrange a referral if you judge that it is necessary or appropriate. This can be a referral to another RMT better equipped to help this patient or a referral to a different type of health professional who would better be able to help the patient.
You are required to let the patient know why you are no longer able to treat them and where you will be transferring their patient file. You must initiate this conversation either before or after treatment, not during treatment.
A Patient Refusing to Follow Requirements
You know what your requirements are for a massage therapy treatment. Patients are required to fill out their health history information, and then you will conduct an assessment and develop a treatment plan, obtaining their consent for treatment. But what if a patient refuses to participate in a certain part of the process?
If the patient refuses to wear a mask, you may refuse to treat them at that time. If you decide not to treat, you should have a discussion with the patient about the risks and why you are not providing treatment. This discussion must be documented in the client health record.
You may need to make modifications to accommodate the patient’s ability to safely and comfortably wear masks throughout treatment. If a patient cannot wear a mask (e.g., due to a health condition), please use your professional judgement to assess the risk of providing treatment.
If a patient is reluctant to comply with more routine treatment requirements, e.g. they do not want to fill out a health history form, often it is effective to just let them know that RMTs are obligated to collect this information as regulated health professionals by their regulatory college, and that this information is kept confidential based on the requirements of the Personal Health Information Protection Act, which protects the health information they provide to any health professional.
Standard 6 of the Standards of Practice to Obtain, Update and Record the Client's Health History states that Health history information must be requested from the client to identify indications and/or contraindications to treatment. It also goes over the minimum information required on the health history. If a patient refuses to provide that information, you can let them know that you won’t be able to provide them with massage therapy treatment. If the patient does agree to provide the minimum outlined but not any additional information you include in your health history form, you may continue with treatment. This can include not consenting to the health history, not consenting to the assessment or not consenting to any aspect of treatment. You should make note of this in your patient records.
If you have to discharge a patient because they refuse to provide health history information you should ensure that you are following the standard relating to the discharge of a patient. You should make a reasonable effort to arrange alternate services for the patient, e.g. let them know that any RMT or other health professional would be happy to see them for treatment but would also require certain health history information.
What Should I Charge?
The CMTO does not set fees that RMTs must charge their patients, and no organization sets fees that an RMT is required to charge. The RMTAO has a Schedule of Services and Fees Guideline with offers suggestions of fees for service, as well as an overview of fees for cancelled and missed appointments, receipt issues and gift certificates, but this is merely a suggestion based on the average situation of RMTs in Ontario. However, the fee you charge is likely to vary on the city or town you’re practicing in, as well as a variety of factors unique to your practice.
You may offer discounts to certain patients, e.g. some RMTs offer discounts to students, to seniors or to people with financial difficulties. You just have to be transparent about why you’re offering a different fee, and ensure the patient accepts the different fee. You also have to note the reason for this different fee in the patient’s health record.
Conflicts with Fellow Health Professionals and Clinic Owners
RMTs deal with people all day and when interacting regularly with others, conflicts are bound to arise. These conflicts are often with other health professionals that you work closely with, or clinic owners.
One way to deal with these potential conflicts is to ensure you have a detailed contract outlining expectations so conflicts don’t arise. Often conflicts arise when there are misunderstandings or miscommunications about who is responsible for what in shared space or with shared equipment, so a contract could outline those expectations.
Common conflicts often crop up because expectations weren’t clearly outlined in advance. By outlining in the contract how and where files are stored, expectations around work hours, holiday pay, sick days and locums, who sets fees, how often RMTs are paid and how other fee related concerns are to be handled, you can avoid many conflicts that might occur simply because expectations weren’t clear.
There are also some general tips to conflict resolution that might help you approach conflicts that do arrive professionally and with a positive resolution in mind.
Firstly, it’s important that all parties understand exactly what the problem is. You should do your best to remain calm and leave any hurt feelings out the equation. If you’re the one explaining the problem you should make sure to stick to the facts of the situation, and if you’re hearing someone else describe a problem, you should ensure you are giving the other person adequate time to explain the situation before jumping in.
Try to restate the problem so you’re sure you’re understanding the issue correctly. E.g. “What I understood you saying is…” Both parties should also consider and share what they’d like the ideal end result to be. Your ideal end result doesn’t have to be the same, you should consider whether some sort of compromise can be reached.
If the conflict is with another health professional because you do not agree with what treatments a patient should receive, you should ensure that you discuss the situation with the patient, and you should make sure your ultimate goal is reaching the best possible outcome for the patient. You should provide the patient with the most thorough and accurate explanation of your rationale for treatment so they can make an informed decision, but recognize and respect that the ultimate choice in health care rests with the patient. A discussion of alternative treatments should always focus on the pros and cons of the treatment and avoid any assumptions or judgements about other health professionals or the practice of other health professions.
Incorporating Modalities Into Practice
There are a wide variety of modalities that RMTs might want to incorporate into practice, some of which are more commonly used or popular among RMTs than others. Many RMTs are curious as to whether the modality they’re interested in can be incorporated into their practice.
The CMTO no longer has a list of modalities that would be in scope of practice for an RMT. Such a list would be unlikely to be comprehensive as there is a massive number of modalities that might be considered acceptable. There are certain factors that RMTs should consider when determining whether a modality can be used within the scope of practice.
You should determine whether it is appropriate based on the CMTO Code of Ethics, whether it supports the assessment and treatment of the soft tissues and joints of the body, whether it promotes the prevention of physical dysfunction of the soft tissue and joints, whether it helps to develop, maintain, rehabilitate or augment physical function, or relieve pain, and whether you can apply it based on the massage therapy Standards of Practice.
There is more information on determining whether a modality is within the Scope of Practice on the CMTO Practice Advice page. Trisura’s Professional Liability Insurance covers everything within the scope of practice of massage therapy.
If a modality is within the scope of practice of massage therapy, the description of the service on the receipt should be “massage therapy treatment” and it should include all other required elements of receipts as defined by the CMTO. If a modality is complementary to the scope of practice of massage therapy, such as low-intensity laser therapy, but is part of a larger massage therapy treatment plan, you would follow the same requirements.
If the complementary modality is not part of a larger massage therapy treatment plan, the receipt cannot include your RMT designation or registration number, and you cannot include massage therapy treatment as the description of the service provided. You do however have to include the name of the specific modality as the description of the service provided.
Releasing records
Often an insurance company, lawyer, or other third party will ask to have access to your patient’s records. This is often to verify an insurance claim or serves as evidence in a legal case. In order to release this information, you need a signed consent form from your patient to put in the patient’s file. This consent should be dated within the past 6 months, and if it is not, you can advise the third party that a new consent will be required. Many RMTs choose to incorporate this consent in their normal intake process.
RMTs can charge for sending this information to third parties, and the RMTAO recommends that RMTs do so. You should charge for the time it takes you to gather and send the necessary files, based on your regular hourly rate. You should also charge for the cost of the materials and the cost of sending the files. More information on what to charge for this sort of thing is available in the RMTAO Fee Guideline.
Conflict of Interest
It is an RMT’s duty to act in the best interest of their patients. It’s important to avoid situations where finances conflict with what is in the best interest of the patient, or even appear to conflict with that. A conflict of interest can be potential, actual or perceived, and this should all be avoided. There are a variety of situations that would make it appear as if an RMT’s professional judgement has been compromised by a potential personal benefits. These situations damage both the patient’s trust in the individual RMT, as well as overall trust for the massage therapy profession.
One way conflict of interest can crop up is through referrals. Referrals should be based on what would be in the best interest of the patient. There shouldn’t be any type of compensation from another professional for a referral, whether monetary, gift based or any personal advantage of any time.
Concerns about conflict of interest can also occur when RMTs are selling products. RMTs are permitted to sell products that are closely related to the practice of massage therapy such as massage therapy related products for home use, or books relating to massage therapy. However, you need to inform your patients in advance when you stand to benefit financially from a product sold in your practice. You should also only recommend products that are in the best interests of your individual patient. You should also inform the patient about potential alternative sources for this product, and ensure the patient understands that purchasing the product elsewhere will not negatively impact the treatment they receive from the RMT.
Receipts for Different Situations
When RMTs are offering different modalities or services, it can be difficult to determine how to appropriately write receipts for those services.
All receipts you write should include:
• The date of the financial transaction
• The product or service provided
• The HST number if the RMT is HST registered
• The address of the RMT
If the product or service is within the scope of practice of massage therapy, the receipt should include everything above as well as:
• “massage therapy treatment” as the description of the service
• the duration of treatment
• the name of the payee
• the name of the therapist (printed or stamped), including the RMT designation
• the massage therapist’s registration number
• the signature of the therapist
If a product or service is not within the scope of practice, the receipt cannot include the RMTs registration number or RMT designation, and massage therapy treatment should not be in the description of the treatment.
If the receipt is for products or services complementary to the massage therapy scope of practice, if the treatment is part of a broader massage therapy treatment plan, you should follow the same requirements for services within the scope of practice, and the treatment description should be “massage therapy treatment”.
Leaving a Practice
When you are leaving a massage therapy practice for a different opportunity, it is important to remember your obligations to your patients and fulfill them in any way that you can.
Your primary obligations are:
Record retention. The patient’s health records can be kept with the RMT or with the clinic. The records should be kept 10 years after the patient’s last appointment or 10 years after their 18th birthday, whichever is later.
Contacting the patient. The RMT has the obligation to notify their patients that they are leaving the practice, though they do not need to tell patients where they are going. This is to inform the patient where they can continue care if needed (either with the RMT or at the clinic) and where they can access their health records. The clinic can also provide patients with this information on the RMT’s behalf. This can be done in person, over the phone, by letter or by email.
Ensuring you have access to the records. If the records are staying with the clinic, the RMT should ensure that they have access to the records as needed. The RMT can either take copies of the record or reaching an agreement to allow for access to the records.
Some agreements with clinic owners such as non-compete and non-solicitation clauses make it feel more difficult to fulfil your obligations.
You can review our Guidelines to Leaving a Practice in our Resource Centre for more advice on how to fulfil your obligations.
HST – Don’t Eat the Tax
Many RMTs choose to incorporate HST into their fees out of a fear that their patients will refuse to pay more. This is called “eating the tax”, because instead of collecting and remitting tax, RMTs are treating the tax as part of their income, and essentially paying the tax on behalf of the patients. For example, instead of an RMT charging $100+ tax, meaning they would collect $113 from the patient, and remit $13 of that to the government without every considering that $13 as their income, leaving them with $100, they would collect $100 to the patient and say the tax was included, meaning they would ultimately make $88.50, as they would still have to remit the 13% HST.
In addition to the economic impact, “eating the tax” will mean that you will work just as hard but earn less income. When you make the decision not to collect the added tax, you are making a decision for your client, as well as making a judgment on your client’s ability to cover this tax.
In addition, as we fight for HST exemption across Ontario, the government will not be interested in the impact to an RMT’s income as an argument. Best business practices are to be tax collectors and not “eat the tax” which means that HST exemption should not have a positive impact on an RMT’s income if they have been following best business practices. In fact, RMTs who have been heavily utilizing input tax credits, they might be slightly negatively impacted by HST exemption. However, the primary goals for HST exemption is to make massage therapy more accessible to patients so that they have access to the health care they need, and a secondary goal is to ensure that RMTs are viewed as equal to other regulated health professionals.
As a result, the RMTAO has always strongly recommended to all RMTs that they be tax collectors not tax payers when it comes to the services you provide and the HST. Don’t eat the tax; pass it along to your patients.
You can read more about how HST impacts your practice in our HST Guideline for Ontario RMTs.
Don't Hesitate to Ask
If you have any questions or concerns, feel free to contact the RMTAO at 416-979-2010 or info@rmtao.com