Chiropractic fees and reimbursements, according to our survey analysis, have remained very steady, albeit with some very slight increases since last year.
Much like last year’s chiropractic fees and reimbursements survey, which was much like the year before. You will see as you read this article a lot of variations on the theme, “this was almost the same as last year, but not quite identical.” A state of more-or-less equilibrium might not be quite as exciting as the pandemic rollercoaster ride we experienced only a few short years ago, but it is a good place to be.
Our annual Fees and Reimbursements Survey went out a bit earlier than usual, in May instead of August of 2024. Last year, we predicted a resurgence in chiropractic, and it looks like that prediction may have been premature, but be assured it is coming. Maybe not this year, but keep an eye on 2025.
Last year’s small perks upward and downward in numbers continue, according to the survey; the average overall fee increased a bit, for example, to $76 from last year’s $67 and 2022’s $64. The overall reimbursement decreased enough to take last year’s rate of 63% down to 57%.
So, things seem to be holding steady out there financially, while chiropractic care continues to shine with its promise of natural ways to address the chronic illnesses so many people are still living with here in the U.S. and worldwide.
Speaking of worldwide, this year, we included some of our global partners and asked several professional chiropractic associations and institutions to distribute the survey, including those with international membership. For the first time, we have data from DCs in Belgium, Canada, France, the Netherlands, New Zealand, Saudi Arabia, Singapore, Sweden and the U.K., which provided some interesting findings.
For example, many nations besides the U.S. use the current procedural terminology (CPT) codes, which were designed to offer a uniform language to healthcare billing. It has been interesting to see that although our systems differ, for example, in the Netherlands and Belgium DCs are not allowed to order X-rays of patients, that we all face similar challenges, often fueled by the public’s misunderstanding of chiropractic’s efficacy and scope.
About the Fees and Reimbursements Survey
During May 2024, Chiropractic Economics invited readers to complete a web-based survey on fees and reimbursements. Additionally, we encouraged state, national, international and alumni associations to distribute it to their members. (Thank you to all organizations that participated!) We limited participants to practicing DCs, their designated office managers or chiropractic assistants to ensure relevant data.
Participants: This year’s analysis is based on 168 respondents comprised of 51% from the U.S. and 49% from outside the U.S. Due to this relatively low number of people who responded, you will see occasional cases where there was no statistically relevant data to report. Such cases are indicated by N/A.
Worldwide distribution: Participants hailed from the South (29%), the Midwest (12%), the West (6%) and the East (4%), and, for the first time ever in our survey, we received a significant number of international entries, 49% of the total, due to survey distribution through international chiropractic organizations. Nations represented in addition to the U.S. include the Netherlands, New Zealand, the U.K., Belgium, Canada, France, Saudi Arabia, Spain, Singapore and Sweden.
Averages: Unless indicated otherwise, all numbers are averages.
Cash-based practices: Cash-based practices reported fees only
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, rather than for specific fee-setting. Our survey results are provided for informational purposes only.
Key findings and analysis
Solo practices
DCs with solo practices (with no other DCs in the office) once again made up a majority of our survey respondents in 2024, though the percentage, 45%, is significantly lower than last year’s 73% and the prior year’s 70%. We attribute this at least in part to our reconfiguring of that question to allow several more specific options, such as multidisciplinary and hospital based practice.
When asked what specialists they work with in their practice, the largest number of DCs said “none” (52%). The rest reported a variety of specialists, the most popular (26%) being a licensed massage therapist (LMT).
Group practices and associate DCs
Among our survey participants this year, 20% reported operating in a group practice setting. This is the same percentage as in 2023’s survey. as opposed to last year’s 5%, and about 5% indicate they
are working as independent contractors in a practice. This represents an uptick in the number of DCs in our survey who are not practice owners, which is a situation we may have to address differently in our future Salary and Expense Survey.
Solo vs. group chiropractic fees and reimbursements
Historically, group practices bill and collect a higher rate than solo DCs, even if the margins are razor-thin. That trend held true again this year, as did the nearly-invisible margins, as group practices billed an average overall fee of $78 and were reimbursed $46, while solo practitioners billed $74 overall and received $41 in reimbursements. That equals reimbursement rates of 59% and 55%, respectively.
Both types of practitioners reported working with specialists, the most common being a licensed massage therapist (16% of solo practices and 32% of groups).
Specializing pays off
Practices with specialists and those without reported average fees and reimbursements at nearly identical levels: $75 and $44 for those with specialists, while non-specialist practices reported averages of $77 and $43. That’s a 56-59% reimbursement rate, which is in line with the U.S. national average our data showed.
Historically, we’ve seen practices with specialists command higher fees than those without specialists, but in the last couple of surveys the numbers have been very close. That trend continues again this year. Having specialists on your premises allows you to offer a greater diversity of services to your patients instead of having to refer them out for complementary therapies. Even if specialists don’t increase your income right away, their presence will pay off in the long run by increasing patient satisfaction, which typically results in more word-of-mouth referrals and loyal patients who make (and keep) more appointments with you.
Licensed massage therapists remained the most popular practice add-on, with 26% of all respondents having at least one LMT on board, followed by:
• Physical therapist (10%)
• MD or DO (9%)
• Acupuncturist (8%)
• Nurse or nurse practitioner (7%)
• Fitness trainer (5.4%)
• Nutritionist (4.8%)
• Physician assistant (4%)
• Naturopath (1%)
Franchise facts
Historically, we’ve had very low percentages of franchise owners in our survey. This year, we broke out franchises into a separate question and saw those numbers jump significantly, although the vast majority (70%) indicated they were not involved in a franchise operation. Whereas in recent surveys respondents who were owners of chiropractic franchises numbered in the single digits, this year 27% stated they owned a franchise, while 4% worked in one. While this increase may be in part a reflection of the international reach of this year’s survey, it is worth noting that 12% of survey participants are franchise owners in the U.S.
This one question is typically the only coverage we give franchises in our survey, but the increasing number of DCs involved in them and the growing number of chiropractic franchise brands going national suggests this could be an area to delve into more deeply in future surveys.
Coupled with the increase in associate DCs who responded to the survey this year and the decrease in the number of DCs labeling themselves solo practitioners, these numbers suggest more DCs may be forgoing the traditional “start a solo practice” route in favor of putting their skills to work in someone else’s chiropractic business, at least for a while.
Regional chiropractic fees and reimbursements comparison
Across the U.S., average chiropractic fees and reimbursements among practices continue to vary by region. The Midwest and East reported the highest reimbursement rates in 2024 at 70% (up from last year’s 63%) and 64% (up a tad from 2023’s 55%), respectively. The South and West trailed behind at 53% (down from 59% last year) and 45% (down from 73%). Note: You can enlarge the Codes and Fees by Regions table below by clicking on it.
Average overall fees and reimbursements remained essentially the same as last year; the average fee ($76) increased from last year’s $67, while overall reimbursements ($43) held steady, so the reimbursement rate dipped to 57% from last year’s 63%.
The South reported the highest average fee in the U.S., $93, while the East pulled in the next highest at $73, followed by the West with $71 and the Midwest with a $66 average fee, though the Midwest led reimbursements at 70%. The West had the lowest reimbursement rate at 45%.
The average overall fee for DCs outside the U.S. was $70, with a 56% reimbursement rate. Zeroing in on the U.S. only, the average fee was reported at $80, the average reimbursement at $45 and the average reimbursement rate at 56%.
Chiropractic care and gender
The percentage of female respondents in this year’s survey dropped slightly to 30% from 32% last year. However, over the last several years, we have seen an increase in female participants, which provides a more balanced perspective of the profession overall.
Male DCs reported higher average fees than females ($78compared to $71), as well as higher reimbursement averages ($45 to $38). Those numbers equate to a slightly higher reimbursement rate (58%) for male DCs than for female practitioners (54%). The 58% reimbursement rate for men is down from 68% in last year’s survey, while the reimbursement rate for women held steady at 54%.
On average, women in our survey are younger in age (42 years vs. men’s 51) and have fewer years of experience: 16 years vs. men’s 23. This has held true for the past couple of years, but this year’s set of survey respondents is younger overall than in previous years, as last year both men’s and women’s average age was their early 50s.
While an LMT is consistently the most popular specialist in our survey, massage isn’t the most popular modality. The top three modalities, after chiropractic care, offered by male DCs were instrument adjusting, exercise programs and flexion distraction; while instrument adjusting, kinesiology taping and flexion distraction were the three most popular modalities among female DCs. Overall, the top five modalities by all survey responders are as follows:
- Instrument adjusting (64%)
- Exercise programs (51%)
- Flexion distraction (46%)
- Kinesiology taping (46%)
- Physical therapy/rehab therapy (39%)
Cash-based practices
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 has hovered in the 20% range ever since, but this year it jumped way up, with 44% of respondents reporting they run cash-based practices, meaning that all of their collections come across the front desk.
In 2023, we asked a slightly different question, “Are you a cash-only practice?” More than 60% of survey respondents receive more than half their revenue in cash, including 20% who report 100% cash collections. About 93% of respondents report they receive at least some of their practice’s income in cash; only 7% said they have no cash-based income.
Trends in self-pay
In 2023, we asked participants, “What percentage of collections are cash payments?” This year, we revised the question and asked, “What percentage of your collections are patient self-pay, including copayments, coinsurance and deductibles?” Survey responders answered in this way:
• 15% reported receiving 1-25% of collections via self-pay
• 19% reported receiving 26–50% of collections via self-pay
• 18% reported receiving 51–75% of collections via self-pay
• 20% reported receiving 76–99% of collections via self-pay
• 21% reported receiving 100% of collections via self-pay
How patients pay
The number of DCs offering payment plans to patients this year decreased a bit to 35% compared to 45% in 2023. Historically in this survey, this percentage fluctuates up and down, but is always near 50%.
A significant number of DCs also offer discounts when patients pay in cash. This year 15% of DCs reported they have a discount-for-cash plan in place.
The remaining responses were prepayment (17%), discount medical plans (8%), patient financing (6%), down payment (5%) and “other” (5%). We took our usual final response choice, negotiation per case, and broke it out into a separate question this year. When asked “Do you negotiate per case?” 82% of our survey responders said no, leaving only 18% who are willing to negotiate payment for each patient’s case individually.
DCs and MDs
The ebb and flow of reimbursements in the chiropractic field often mirrors what’s happening in the healthcare industry as a whole, albeit to a different 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.)
Parallels may also exist when it comes to practice management. In June 2024, in a survey of 864 medical doctors by business journal Medical Economics, the editors highlighted from their data the healthcare trends challenging today’s physicians. Fifty-seven percent of MDs cited reimbursements as their biggest challenge. Other responses included the burden of administrative work (66%); staffing issues (56%); and working at a medical-related side job (44%).
In 2024, DCs in this survey and MDs (according to the Medicare Physician Fee Schedule) reported mixed reimbursements on average for these three codes noted. While both DCs and MDs bill for these codes, the results consistently illustrate a cleft dividing the industries. The breakdown of specific codes is:
• For code 99202, MDs’ average reimbursements were $72, while DCs who took our survey reported an average of $51.
• For code 99203, MDs’ reimbursements averaged $112, while DCs’ reimbursements averaged $68.
• For code 99204, MDs reported a reimbursement average of $167, while DCs reported an average reimbursement of $81.
New codes this year
This year, we asked DCs to report on three additional codes: 97010 hot/cold packs, 99205 new patient evaluation and management services (high complexity) and 99215 established patient evaluation and management services (low complexity). Here’s the recap of their responses:
• For code 97010, survey responders reported an average fee of $19 and an average reimbursement of $14, which is a 74% reimbursement rate.
• For code 99205, survey responders reported an average fee of $132 and an average reimbursement of $73, which is a 55% reimbursement rate.
• For code 99215, survey responders reported an average fee of $101 and an average reimbursement of $53, which is a 53% reimbursement rate
The future is looking bright
A bright spot in 2024 has been the American Medical Association’s deployment of the Physician Practice Information Survey, an effort to compile numbers on what it really costs to run a healthcare practice. More than 300 DCs were invited to participate, which will add a much-needed layer to those cost reports. Among other purposes, the data from this report will be shared with members of the U.S. Congress as well as the Centers for Medicare and Medicaid Services, which determines a specific multiplier for use in figuring out reimbursement rates. The current multiplier is informed by outdated practice expense info from 2006 (you read that right). This update from the AMA’s survey will surely have an impact on the checks you get back and the numbers you report in our survey in the years to come.
GLORIA N. HALL is editor-in-chief of Chiropractic Economics. She can be reached at ghall@chiroeco.com.
ALLISON M. PAYNE is associate editor of Chiropractic Economics. She can be reached at allisonmpaynewriter.com.