New rules governing manual therapy as a managed benefit and shock wave therapy guidelines took effect this month, changing how private health insurance claims are processed. Policyholders should check the itemized billing statement when paying in a lump sum, understand the physician's note requirements for the 24-session exception, and know how session counts are calculated for shock wave therapy before filing a claim. [123rf]
New rules governing manual therapy as a managed benefit and shock wave therapy guidelines took effect this month, changing how private health insurance claims are processed. Policyholders should check the itemized billing statement when paying in a lump sum, understand the physician's note requirements for the 24-session exception, and know how session counts are calculated for shock wave therapy before filing a claim. [123rf]

Starting this month, manual therapy has been reclassified as a managed benefit and voluntary guidelines now apply to extracorporeal shock wave therapy, changing how private health insurance policyholders file claims. More than two weeks into the new system, clinics have been canceling appointments and scaling back treatments, adding to the confusion — but coverage for manual therapy has not been cut off across the board.

However, limits have been placed on the number of sessions and the conditions that qualify for coverage, and the documentation required for lump-sum payments and exceptional treatments has become more stringent. Policyholders who want to be reimbursed on time will find they need to prepare more paperwork at the claims stage, including itemized billing statements and physician's notes.

Why the rules changed: 'Prices and session counts were left entirely to hospitals'

More than two weeks after the new system took effect, policyholders have continued to ask whether manual therapy and shock wave therapy are no longer covered by private health insurance. Anxiety has grown as some clinics have scaled back manual therapy or canceled appointments.

Manual therapy had long been an unregulated, non-covered service, leaving hospitals free to set their own prices. The average cost per session was about 110,000 won, with wide variation across providers. Despite being largely supplementary rather than a primary treatment, the combination of private health insurance coverage and minimal restrictions meant some patients with minor conditions received hundreds of sessions a year. Annual manual therapy costs borne by private insurers reached 1.4 trillion won, and those losses were ultimately passed on to all policyholders through higher premiums.

The shift to managed-benefit status was designed to fix that structure. The price per session has been standardized at 43,850 won, with a 95 percent patient co-payment. Sessions are capped at twice a week and 15 times a year; patients with a clear clinical finding of joint contracture or stiffness caused by surgery or a fracture may receive up to 24 sessions a year at a physician's discretion. Shock wave therapy, governed by voluntary guidelines from the Korean Medical Association rather than mandatory managed-benefit rules, is covered for up to six sessions per body part and 12 sessions per year.

The actual amount a patient pays out of pocket and the insurance payout will vary depending on when the policy was purchased, its terms and the deductible. The new limits may look tight, but their real-world impact is narrow. An analysis of 2025 private insurance claims found that about 95 percent of users received 15 or fewer sessions a year, and about 98 percent received 24 or fewer. The insurance industry says the new system targets a small group of patients who repeatedly received excessive treatment, not the typical policyholder.

Ultimately, this overhaul is less about restricting patients' right to treatment and more about bringing a non-covered service — one where prices and session counts had been left entirely in hospitals' hands — back to appropriate pricing and limits for those who genuinely need it.

Switching hospitals, paying in bulk — what to know before filing a claim

The most common reason for supplementary reimbursement requests since the new rules took effect has been lump-sum payment — where a hospital charges for multiple future sessions at once. Even if a clinic collects payment for several sessions upfront as part of a treatment plan, insurers pay out based on the date and amount of each session actually received. Fees for sessions not yet completed must be claimed separately after the treatment takes place, with supporting documents submitted at that time.

An insurance industry official said the insurer checks the itemized billing statement to determine the amount incurred on the actual date of treatment and pays accordingly, with the remainder released after the treatment is completed and additional documents are submitted.

Submitting only a receipt without an itemized billing statement will prompt the insurer to request additional documents, delaying payment. Anyone who paid for multiple sessions in a lump sum must provide not just the receipt but also an itemized billing statement showing the treatment details and amount for each individual session.

For patients seeking the exception that allows up to 24 sessions — beyond the standard 15 — the physician's note is critical. A note that simply states the pain is ongoing may not be enough to qualify.

The note must cover three points: the affected joint where contracture or stiffness has developed; the cause and objective clinical findings, specifically how much range of motion is restricted compared with normal; and the physician's judgment that additional manual therapy is necessary.

An insurance industry official said a vague statement about persistent pain is not sufficient; what is needed is objective clinical evidence showing how much the joint's range of motion is limited compared with normal.

The session-counting method for shock wave therapy differs from that used for manual therapy. While the "annual" limit for manual therapy follows the calendar year from Jan. 1 to Dec. 31, the annual cycle for shock wave therapy runs one year from the date of the first session. A patient who first received treatment on July 8 would have a cycle running through July 7 of the following year. The seven eligible body parts are the shoulder, elbow, hip, knee, ankle, foot and spine; left and right sides count as the same body part, so receiving one session on each shoulder counts as two shoulder sessions.

Patients do not need to track session dates themselves. An insurance industry official said cumulative session counts are managed in the insurer's system, and policyholders are notified in advance at the payment stage if they are approaching the limit; those who inquire can be told their current count. In practice, early shock wave therapy claims have mainly been flagged for treatments applied to body parts outside the guideline's approved indications; given that the system is still in its early days, those cases are being paid out after prior notification.

Meanwhile, concerns about a last-minute rush to receive treatment just before the rules took effect have been addressed. The industry said some reports of clinics pushing package payments did come in, but no significant surge in claims was confirmed at the end of June, and those cases are being processed normally under the new standards.


psj@heraldcorp.com