The year of COVID had an impact — but our Chiropractic Economics Fees & Reimbursements Survey shows resilience
FROM 2018-20 WE SAW AN OVERALL LEVELING OF FEES AND REIMBURSEMENTS. This year, we’re seeing little ups and downs here and there (with a few exceptions), but for the most part the numbers indicate the chiropractic industry has weathered the COVID storm of 2020 and is ready to forge ahead. Given the rise of the Delta variant and the increasing number of COVID “long-haulers” for whom COVID has become a chronic condition, the U.S. is primed for an increase in the number of people seeking out holistic, non-drug solutions to chronic pain and other health issues according to the latest Chiropractic Economics Fees & Reimbursements Survey.
Our annual Chiropractic Economics Fees & Reimbursements Survey went out in August, when new COVID sanitation and prevention protocols were well in place. Schools were opening back up, too, albeit cautiously, typically with masking recommended but not required. As of Aug. 30, only seven states — Hawaii, Illinois, Louisiana, Nevada, New Mexico, Oregon and Washington — still require masks in most indoor places regardless of a person’s vaccine status, while some states such as Texas and Florida expressly banned mask-wearing in government locations and/or schools, and in public mask-wearing has largely become a matter of personal choice.
As a health care provider, you are likely still using personal protective equipment (PPE) such as masks, face shields, hand sanitizer and more. While it varies widely whether patients will agree with your disease prevention protocols, the rapid spread of the Delta variant will undoubtedly lead most of your patients to appreciate your precautions. According to the Centers for Disease Control (CDC), this variant is more than twice as contagious as the original strain, and current data suggests it causes a more severe illness in unvaccinated people (and vaccinated people can still spread the virus, adds the CDC).
Our survey results show slight declines and upticks here and there with fees and reimbursements, suggesting that chiropractic has successfully survived the chaos that came with COVID-related closures and restrictions. This flattening comes after a slow decline up until 2020, when average fees settled at $60; this year’s average fee is up a bit, to $64. Reimbursement averages increased from $41 last year to $44 this year, for a reimbursement rate of about 69%.
One 2021 development we’re keeping a close eye on that could impact fees and reimbursements in the future is the introduction of HR 2654, the Chiropractic Medicare Coverage Modernization Act of 2021, sponsored by Rep. Brian Higgins (D-NY). This act would increase Medicare coverage of services provided by chiropractors within the scope of their licensure, meaning chiropractic patients could seek some covered services from chiropractors rather than MDs.
As always, our survey is subject to statistical variation, and all figures herein presented should be considered approximate. Normal fluctuations in most categories occur year over year, and we suggest that our results are best used for spotting general trends to guide strategic planning.
Below you will find a few key points from this year’s Fees & Reimbursements Survey:
West, Midwest lead reimbursements this year
The West led regional reimbursement rates in last year’s survey, and that trend continues this year; it tied with the Midwest in reporting the highest reimbursement rate in 2021 at 67%. The South followed close behind at 63%.
Chiropractic Economics Fees & Reimbursements: Going Solo
As usual in this survey, most DCs (71%) work solo, with no other DCs in the office. When asked what type of specialists they work with in their practice, the largest number of chiropractors, also as usual in our survey, said “none” (54%). The other half reported a variety of specialists, the most popular being licensed massage therapist (34%, the same as last year) and acupuncturist (7%, a little bit down from last year).
Cash remains popular
Cash-based practices had been on the decline, according to our yearly survey results, before making a jump in 2018. In 2016, 13% of practices were cash-only, decreasing to about 10% in 2017. In 2018, that number leapt to 19.9%, and then dropped in 2019 to 16%. In 2020 the percentage of cash-based practices bounced back from that dip, coming in at 19.8%, and holds steady at 19.8% again this year. Thirty percent of 2021 survey respondents reported they collect up to 25% of their fees in cash — and 13% receive all their fees in cash.
How patients pay you
According to our 2021 data, 45% of chiropractors offer patients payment plans; pre-payment plans are offered by 37%. Discounts for cash continue to be a popular choice; the same as last year, our survey results showed that about 28% of DCs offer this type of payment plan.
Regional fee comparisons
Across the nation, average fee and reimbursements among chiropractic practices continue to vary by region. The West and the Midwest reported the highest reimbursement rates in 2021 at 67%. The South followed close behind at 63%, trailed by the East at 62%.
Average overall fees ($64) and overall reimbursements ($44) stayed the same this year, so the reimbursement rate holds steady at 69%.
The West reported the highest average fees: $72, down a bit from $75 last year.
Fees and reimbursements
From 2020-21 we observed a small increase in both fees and reimbursements. Overall reimbursement rates ticked up from 67% last year to 69% this year in the Chiropractic Economics Fees & Reimbursements Survey.
The last three years’ reimbursement rates have hovered between 64-70%; this year we saw the numbers remain among those averages. This year’s results indicate a fairly stable chiropractic market for the time being.
The chaos of 2020’s pandemic-related closures and restrictions seemed to pose a threat to the welfare of chiropractic practices at the time, but the relative stability of the numbers that year, and their slight uptick this year, suggest that chiropractic was, and continues to be, well-positioned as the type of health care provider of choice for a growing number of people.
Among our survey participants this year, slightly more than 20% reported operating in a group setting.
We had about the same number of responses from associates this year, nearly 6%, and about 3% indicate they’re working as independent contractors in a practice. At 71%, up from 2020’s 65%, DCs with solo practices made up the vast majority of our survey respondents.
Typically in this survey, group practices report higher fees, reimbursements and reimbursement rates than solo operations. Not so this year; in 2021, group practices had average fees of $58 and average reimbursements of $35, while solo practices had average fees and reimbursements of $65 and $48, respectively.
Reimbursement rates in group practices decreased slightly from last year’s 62% to 61% this year, and solo practices increased from 71% to 73% over the same period.
Group and solo practices reported working with several kinds of specialists. The most common specialist in both groups and solo practices is a licensed massage therapist, reported by 77% of solo practices and 23% of group practices.
DCs and MDs
The ebb and flow of reimbursements in the chiropractic field often mirrors what’s happening in the health care industry as a whole, albeit to a different or lesser extent. These parallels can be seen when evaluating the common codes shared by DCs and MDs alike, specifically the set of codes for the evaluation and management of new patients, including 99202, 99203 and 99204. (In 2020, code 99201 was merged with 99202. An additional code, 99205, is also in the new-patient set of codes, but was not included in this year’s survey.)
In 2020, in a survey conducted by Medical Economics, a business journal for medical doctors, their data indicated that 43% of physicians thought their practice was doing “about the same” financially; in the previous year’s survey, 55% provided that response. Forty-six percent of doctors reporting their practice was doing “worse than five years ago,” while only 11% said their practice was faring “better than five years ago.”
In 2021, DCs (per this survey) and MDs (according to 2021 insurance company estimates, the latest figures available) reported mixed reimbursements on average for the three codes noted above. MDs were seen to be reimbursed at a higher rate for codes 99202, 99203 and 99204.
While both industries bill for these codes, the results consistently illustrate a cleft dividing the industries. Because the MD data obtained applies solely to reimbursements, our comparisons will be limited to DC reimbursements as well. The breakdown of specific codes in 2021 is as follows:
For code 99202, MDs’ reimbursements were $74, and DCs reported an average of $65.
For code 99203, MDs’ reimbursements averaged $114, while DCs’ reimbursements averaged $83. For code 99204, MDs reported a reimbursement average of $172, while chiropractors reported an average reimbursement of $102.
Chiropractic Economics Fees & Reimbursements: Specializing pays off
In spring 2021, our annual Salary and Expense Survey showed multidisciplinary and integrated practices achieving success, and increased salaries and reimbursement rates have followed. That said, chiropractors who have been in the industry longer have seen the larger paychecks that come with more experience.
Those salary survey participants with specialists working within their practice reported average total compensation of more than $161,000, compared to the $122,000 reported by strictly solo operations in the Chiropractic Economics Fees & Reimbursements Survey.
Multidisciplinary practices participating in this survey reported higher fees but lower reimbursements than those without specialists. Specifically, practices with specialists reported average fees and reimbursements of $64 and $40, while non-specialist practices reported average fees and reimbursements of $59 and $42, respectively.
Licensed massage therapists (LMT) remained the most popular practice add-on, with 77% having one on board. LMT was followed by acupuncturist (24%); fitness trainer (17%); physical therapist (16%); and nurse or nurse practitioner (16%). Rounding out the total were nutritionist (15%); MD or DO (13%); physician’s assistant (9%); and naturopath (8%).
Although we saw an increase in survey participants reporting as franchises over the three years prior, we saw the percentage drop in 2019 to 5% and again in 2020 to less than 1%. This year, 0.5% of our survey respondents identified their chiropractic business as a franchise.
The very small number of responses for the franchise category may suggest that the popularity of franchise ownership is waning, but the increasing number of locations of chiropractic franchises such as NuSpine and The Joint suggests otherwise. It is impossible for us to tell definitively without a larger survey sample. For this reason, we are unable to draw any solid conclusions about chiropractic franchising from the results of this year’s Chiropractic Economics Fees & Reimbursements Survey.
Although the percentage of cash-only practice survey participants decreased from 19.9% in 2018 to 16% in 2019, the percentage of cash-only practices rose to 19.9% in 2020, making only a slight dip this year to 19.8%. Those DCs who did report operating a cash-based practice fared well in their collections.
For cash-based practices, average fees were reported at $64, the same amount as overall average fees. In 2019, cash fees came in at $61, then decreased to $60 in 2020, so this year’s data serves as an indication that cash collections are up a bit from last year.
By strict definition, a cash-based practice would have no reimbursements. So fees in a cash-only practice are equivalent to reimbursements (collections). The average cash-only practice fees of $64 are way up compared to an overall average reimbursement of $44.
This year we asked what percentage of your collections is cash-based to dig deeper into this type of practice. About 30% answered that their practice had 25% or less cash income. Twenty-eight percent had 26–50% cash, 14% had 51–75% cash, and 13% had 76–99% cash collections. Slightly more than 13% of respondents reported receiving 100% of collections in cash.
Your typical cash-only practice respondent is male (72%), with women making up 27% of this group (1% of respondents declined to report a specific gender). Of cash-based survey participants:
- 47% offer homeopathy;
- 25% offer nutrition;
- 18% offer instrument adjusting;
- 18% offer laser therapy;
- 17% offer instrument assisted soft tissue mobilization;
- 16% offer kinesiology taping;
- 16% offer massage therapy;
- 14% offer acupuncture;
- 13% offer exercise programs;
- 12% offer physical therapy;
- 11% offer electrotherapy; and
- 11% offer ultrasound.
Chiropractic and gender
Over the past few years the number of female survey respondents has hovered around one-quarter of all participants. In 2019, we saw an all-time high of 30%. In 2020, that number dipped slightly to 28%, and it dipped slightly again this year to 26.8%.
Female chiropractors reported slightly lower average fees than male DCs ($61 compared to $65), along with lower reimbursement averages ($36 to $48). Female practitioners also reported lower reimbursement rates than male DCs (58% to 74%).
The 74% reimbursement rate for men is up from 68% last year, and reimbursement rates for women are down to 58%, compared to 66% last year.
Women respondents reported an average younger age (49), compared to men (52), which is approximately the same as last year. In addition, female DCs reported being in practice for fewer years (20), while male respondents have been in practice for an average of 23 years.
Interestingly, when asked about which additional modalities they offer, both men and women reported the same top three modalities: Instrument adjusting (61%), ultrasound (49%) and electrotherapy (44%) were the most popular. Rounding out the top five were nutrition (43%) and, in a tie for fifth place, exercise and flexion distraction (38% each).
How patients pay
The number of DCs offering payment plans to patients this year decreased a bit (45% in 2021 compared to 49% in 2020). Historically in this survey, this percentage fluctuates up and down, but is always near 50%.
A significant number of chiropractors also offer discounts when patients pay in cash. The same as last year, this year 28% of DCs reported they have a discount-for-cash plan in place.
The remaining responses were “prepay” (37%), “down payment” (15%), “discount medical plan organization” (8%), “patient financing” (6%) and “other” (13%).
Interestingly, a final response choice, “negotiation per case,” came in at just over 20% — but came in at less than 1% last year, likely influenced by the pandemic.
3 more codes
Every year, we ask doctors of chiropractic to report on three additional codes: 95851 range-of-motion testing; 95831 muscle testing; and 97750 physical-performance evaluation. It should be noted that we did include these codes when calculating the fees and reimbursement averages for the other sections, not including the regional comparison chart.
Average fees for range-of-motion testing were $43, while average reimbursements were $17 — a reimbursement rate of 40%.
Average fees for muscle testing were $25, with an average reimbursement of $8 — a reimbursement rate of 32%.
Average fees for physical-performance evaluation were $33, with an average reimbursement of $13, and a reimbursement rate of 39%.
ALLISON M. PAYNE is a freelance writer, editor and proofreader based in Central Florida. She can be reached at allisonmpaynewriter.com.
About this survey
During August 2021, Chiropractic Economics extended an invitation to readers to complete a web-based survey on fees and reimbursements. Additionally, we encouraged a number of state, national and alumni associations to distribute the Chiropractic Economics Fees & Reimbursements Survey to their members (thank you to all organizations!).
We limited survey participants to practicing chiropractors or their designated office managers or CAs to ensure accuracy.
- Number of participants: This year’s analysis is based on responses from 377 respondents.
- Regional distribution: Participants hailed from the South (34%), the Midwest (33%), the West (22%) and the East (11%).
- Averages: Unless indicated otherwise, all numbers are averages.
- Cash-only practices: Cash-only practices reported fees only.
Our survey results are provided for informational purposes only. They are not intended to be used as a recommendation for setting fee levels.