From 2018-22 we saw an overall leveling of fees and reimbursements. This year, we observed a slight increase in the average fee per service, as well as a small increase in the average reimbursement, so essentially services are yielding about the same revenue, according to our survey respondents.
On a brighter note, we did observe an uptick in the number of female chiropractors who took our survey, a suggestion that the percentages of each gender are leveling out, after a reduction last year. The field is becoming more equally divided between men and women, which better reflects the divide in the enrollment in chiropractic colleges.
Our annual Fees & Reimbursements Survey went out in August, when almost all talk of the coronavirus pandemic had receded into the background; the federal “public health emergency” declaration for COVID-19 officially expired in mid-May. But as of the time of this publication, infection rates were starting to pick up again with some of the new subvariants of Omicron circulating. In addition, more and more people were identifying as struggling with the frustrating and persistent symptoms of Long COVID, post-acute sequelae of of SARS CoV-2 infection; expect to see increasing numbers of patients with this chronic condition, which can also officially be a disability under the guidelines of the Americans with Disabilities Act if it significantly limits major life activities, as we continue to move forward.
Our survey results show a lot of small upticks in a variety of numbers, suggesting that chiropractic is slowly entering the period of resurgence that we predicted after reviewing last year’s survey numbers. This year’s average fee ticked up a bit, to $67.40 from $64.09 last year.
Reimbursement averages, after increasing from $41 in 2020 to $44 in 2021, then dropping several dollars to $38 in 2022, inched up to $42.55 this year, which indicates a 2023 reimbursement rate of 63%, a 2% increase compared to 2022’s 61%.
In 2023, one issue affecting reimbursement rates is new changes in Medicare Parts B and C (Medicare Advantage) reimbursement rates, designed to help patients save money. In addition, Medicare reimbursement figures decreased across the board, along with several chiropractic code changes.
As always, our survey is subject to statistical variation, and all figures presented should be considered approximate. Normal fluctuations occur yearly, and we suggest our results are best used for spotting general trends to guide strategic planning.
On this and the following pages you will find a few key points from this year’s Fees & Reimbursements Survey:
West, Midwest lead reimbursements again this year
The West led regional reimbursement rates in our 2020, 2021 and 2022 surveys, and that trend continues this year; it reported the highest reimbursement rate in 2023 at 73%. The Midwest came in second place with a reimbursement rate of 63%, followed by the South (59%) and the East (55%).
Solo operations
As usual in this survey, most DCs (73%) work solo, with no other DCs in the office. When asked what specialists they work with in their practice, the largest number of DCs, also as usual in our survey, said “none” (58.5%). The other portion reported a variety of specialists, the most popular being licensed massage therapist (31%), nurse or nurse practitioner (8.5%), physician assistant (8.5%) and acupuncturist (8%).
Females charge more (but collect less)
For the first time this year, female chiropractors in our survey reported charging higher fees than male practitioners, with an average fee of $76 vs. $63 for men; however, this development was undercut by a lower reimbursement rate for women DCs ($41 vs. $43).
About this survey
During August 2023, Chiropractic Economics invited readers to complete a web-based survey on fees and reimbursements. Additionally, we encouraged state, national and alumni associations to distribute it to their members (thank you to all organizations that participated!).
We limited participants to practicing chiropractors, their designated office managers or CAs to ensure accuracy.
- Participants: This year’s analysis is based on 125 respondents. Due to this lower (than typical) response, you will see cases where there was no statistically relevant data to Such cases are indicated by N/A.
- Regional distribution: Participants hailed from the South (30%), the Midwest (30%), the West (30%) and the East (10%).
- Averages: Unless indicated otherwise, all numbers are
- 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.
Cash remains popular
Cash-based practices had been on the decline, according to our yearly survey results, before making a jump to nearly 20% in 2018. That number dipped and bobbed slightly for the next few years until 2022, when it leapt to 34%. This year saw another drop in this number, back down to 20%. Cash is popular, though: In 2023, 38% of our survey respondents indicated they receive up to 25% of their revenue in cash — and about 8% receive all of their practice income in this format.
How patients pay you
According to our 2023 data, 44% of chiropractors in our survey offer patients payment plans; pre-payment plans are offered by 29%. Discounts for cash continue to be popular; our survey results showed that about 27% of DCs offer this type of payment plan, up from 18% in the 2022 survey.
Despite the several types of payment plans offered by most respondents, a majority (76%) indicated they do not negotiate patient payment on a case-by-case basis.
Regional fee comparisons
Across the nation, average fees and reimbursements among chiropractic practices continue to vary by region. The West and the Midwest reported the highest reimbursement rates in 2023 at 73% and 63%, respectively. The South and East trailed behind at 59% and 55%.
Average overall fees ($67) increased, and overall reimbursements ($43) also increased this year, so the reimbursement rate tracked upward a bit to 63% from last year’s 61%.
The East reported the highest average fees in the nation, $78; while the Midwest, which had a relatively high reimbursement rate at 63%, reported the lowest average fees at $57.
Fees and reimbursements
From 2022-23 we observed that average fees increased by a few dollars, as did reimbursements. Overall reimbursement rates went up to 63% this year from 61% last year.
The last three years’ reimbursement rates have hovered between 64-70%; this year we saw those rates vary for the first time in a while, with the West, as last year, leading the pack with a 73% reimbursement rate. Reimbursement rates in the East and South dipped into the 50s (55% and 59%, respectively), while reimbursement in the Midwest hovered at 63%.
It is worth noting that the East, which had the lowest reimbursement rate of all the regions, had the highest average fee; this suggests that reimbursement may not be keeping pace with the costs of doing business for many health care providers.
Team play
Among our survey participants this year, almost 21% reported operating in a group setting. This is a small decrease from 2022, where 24% reported working in a group.
We had slightly more responses from associates this year, nearly 5%, and about 2% indicate they’re working as independent contractors in a practice. At 73%, slightly up from 2022’s 70%, DCs with solo practices once again made up the vast majority of our survey respondents in 2023.
Typically in this survey (with the exception of 2021), group practices report higher fees, reimbursements and reimbursement rates than solo operations. That did not hold true this year; in 2023, fees were nearly identical. Group practices had average fees of $65.07 and reimbursements of $41, while solo practices had average fees and reimbursements of $65.44 and $43, respectively. Reimbursement rates were super-close as well: 65% for solo practices and 63% for groups. For group practices this is a decrease from last year’s 64%, while solo practices saw an increase from 63% over the same period.
Both types reported working with specialists, the most common being a licensed massage therapist (23% of solo practices and 44% of groups).
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. We can see these parallels when evaluating the common procedure 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 merged with 99202.)
In 2023, in a survey conducted by Medical Economics, a business journal for medical doctors, their data indicated that 48% of physicians thought their practice was doing “about the same” financially; in the previous year’s survey, 50% provided that response. Thirty-three percent of doctors reported their practice was doing “worse than a year ago,” while 19% said their practice overall was faring “better than a year ago.”
In 2023, DCs (per this survey) and MDs (according to 2022 insurance company estimates, the latest figures available) reported mixed reimbursements on average for these three codes noted. MDs were seen to be reimbursed at a higher rate for codes 99202, 99203 and 99204 — but their reimbursements dropped a tiny bit this year.
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 is:
For code 99202, medical doctors’ average reimbursements were $80, while doctors of chiropractic who took our survey reported an average of $68.
For code 99203, MDs’ reimbursements averaged $123, while DCs’ reimbursements averaged $93.
For code 99204, MDs reported a reimbursement average of $183, while chiropractors reported an average reimbursement of $115.
Specializing pays off
In spring 2023, our annual Salary & Expense Survey showed multidisciplinary and integrated practices achieving success, and increased salaries and reimbursement rates have followed. That said, DCs 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 $168,000, compared to the
$138,000 reported by strictly solo operations.
Multidisciplinary practices participating in this survey reported higher fees but lower reimbursement percentages than those without specialists. Practices of both types reported almost identical average fees and reimbursements: $65 and $41 for those with specialists, while non-specialist practices reported averages of $65 and $43, respectively.
Licensed massage therapists (LMTs) remained the most popular practice add-on, with 31% having at least one on board. LMT was followed by nurse or nurse practitioner (8.5%); physician assistant (8%); acupuncturist (8%); MD/DO (8%); fitness trainer (7%); nutritionist (7%); physical therapist (6%); naturopath (3%); and other (2%).
Franchise facts
Although we saw an increase in survey participants reporting as franchises over the years prior, we saw the percentage drop in 2019 to 5%, again in 2020 to less than 1%, again in 2021 to 0.5%, and then a slight uptick to 1% in 2022. This year, 6.5% of survey respondents identified their chiropractic practice as a franchise.
The very small number of responses for the franchise category might seem to suggest that the popularity of franchise ownership is low, but the increasing number of locations of chiropractic franchises such as The Joint and NuSpine 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 Fees & Reimbursements survey.
Cash, please
The percentage of cash-only practice survey participants has hovered between 16-20% for the past few years, and that trend continues this year, with 20% reporting cash-only operations.
Those DCs who did report a cash-based practice fared well in their collections.
For cash-based practices, average fees were reported at $67, a bit more than overall average fees. In 2019, cash fees came in at $61, then decreased to $60 in 2020 and perked up to $65 in 2022, so this year’s data serves as an indication that cash collections are up a bit from last year.
This year we asked what percentage of your collections is cash-based to dig deeper into this type of practice. About 38% of respondents answered that their practice had 25% or less cash income. Twenty-eight percent had 26–50% cash, 9% had 51–75% cash, 14% had 76–100% cash collections and 8% reported collections of 100% cash.
Chiropractic and gender
Over the past few years the number of female survey respondents has hovered around one-quarter of all participants. This year, we saw an all-time high of 32% women, up from 30.5% last year and 27% in 2021. The gender gap in the chiropractic profession seems to be closing, slowly but surely, to better reflect the close-to-50/50 gender divide among current chiropractic students.
Female DCs reported higher average fees than males ($76 compared to $63), but lower reimbursement averages ($41 to $43). They reported much lower reimbursement rates (54%) than male practitioners (68%).
The 68% reimbursement rate for men is up from 64% last year, and reimbursement rates for women ticked down to 54% compared to 59% last year.
Women respondents reported an average younger age (50), compared to men (54.5), which is approximately the same as last year. In addition, female DCs reported being in practice for fewer years (23), while male respondents have been in practice for an average of about 26 years.
While a licensed massage therapist is consistently the most popular specialist in our survey, massage isn’t the most popular modality. The top three modalities offered by male chiropractors were instrument adjusting, electrotherapy and ultrasound; while instrument adjusting, kinesiology taping and electrotherapy were the most popular modalities among female chiropractors.
How patients pay
The number of DCs offering payment plans to patients this year dropped a bit (45% in 2023 compared to 48% in 2022). 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. This year 28% of DCs reported they have a discount-for-cash plan in place.
The remaining responses were “prepay” (28%), “down payment” (14%), “patient financing” (14%), “discount medical plan organization” (7%), and “other” (7%).
A final response choice, “negotiation per case,” came in at 0% last year — but came in at 25% this year.
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. Average fees for range-of-motion testing were $43, while average reimbursements were $22 — a reimbursement rate of 51%.
Average fees for muscle testing were $34, with an average reimbursement of $20 — a reimbursement rate of 59%.
Average fees for physical-performance evaluation were $30, with an average reimbursement of $11, and a reimbursement rate of 37%.
ALLISON M. PAYNE is the associate editor of Chiropractic Economics.
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