The Chiropractic Economics Annual Fees & Reimbursements Survey (2022)

Thirty-four percent of 2022 Fees & Reimbursements Survey respondents reported they collect up to 25% of their fees in cash — and 23% get more than 75% of fees in cash

FROM 2018-21 WE SAW AN OVERALL LEVELING OF FEES AND REIMBURSEMENTS. This year, we observed a slight increase in the average fee per service, while there was a drop in reimbursement, so essentially the same services are now yielding less revenue, according to our Fees & Reimbursements 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 reflects the divide in the enrollment in chiropractic colleges.

Our annual Fees & Reimbursements Survey went out in August, when most aspects of life had largely settled into a post-pandemic new normal. As of the time of this publication, monkeypox has largely taken over the national conversation, with COVID-19 becoming part of the fabric of this new normal; at this point most people who want to be vaccinated have been, though health care professionals are still recommending booster shots as new variants evolve.

“COVID-19 continues to circulate globally, however, with so many tools available to us for reducing COVID-19 severity, there is significantly less risk of severe illness, hospitalization and death compared to earlier in the pandemic,” the Centers for Disease Control and Prevention noted in an August press release on cdc.gov.

Our survey results show slight declines and upticks here and there with fees and reimbursements, suggesting that chiropractic is primed for a resurgence as we put the COVID chaos behind us. This flattening comes after a slow decline up until 2020, when average fees settled at $60; 2021’s average fee ticked up a bit, to $63.64, and held steady at $64.09 again this year. Reimbursement averages, after increasing from $41 in 2020 to $44 last year, dropped several dollars to $38 this year, which indicates a 2022 reimbursement rate of 61%, an 8% drop from 2021’s 69%.

One issue we are still keeping a close eye on that could impact fees and reimbursements in the future is 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 of the time of this publication, this legislation has not moved forward beyond the subcommittee stage.

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.

Here are 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 both our 2020 and 2021 surveys, and that trend continues this year; it reported the highest reimbursement rate in 2022 at 78%. The Midwest came in second place with a reimbursement rate of 57%, followed by the South (53%) and the East (49%).

Going solo

As usual in this survey, most DCs (70%) 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” (41%). The other portion reported a variety of specialists, the most popular being licensed massage therapist (23%, down from last year) and acupuncturist (9%, the same as last year).

About this survey

During August 2022, 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 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 301 respondents.
• Regional distribution: Participants hailed from the South (31%), the Midwest (26%), the West (22%), the East (17%), and “other.”
• 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.

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 dropped a bit to 17% this year. Thirty-four percent of 2022 survey respondents reported they collect up to 25% of their fees in cash — and 23% get more than 75% of fees in cash.

How patients pay you

According to our 2022 data, 48% of chiropractors offer patients payment plans; pre-payment plans are offered by 37%. Discounts for cash continue to be popular; our survey results showed that about 18% of DCs offer this type of payment plan, down from 28% in the 2021 survey.

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 2022 at 78% and 57%, respectively. The South followed close behind at 53%, trailed by the East at 49%. Average overall fees ($64) remained the same, but overall reimbursements ($38) decreased this year, so the reimbursement rate dropped to 61% from last year’s 69%. The West reported the highest average fees: $69, down a bit from $72 last year.

Fees and reimbursements survey stats

From 2021-22 we observed that average fees remained the same, while reimbursements fell. Overall reimbursement rates dropped to 61% this
year from 69% last year. The last three years’ reimbursement rates have hovered between 64-70%; this year we saw the numbers remain
among those averages, with the exception of the West, which led the pack with a 78% reimbursement rate. With much of the chaos of pandemic-related closures and restrictions behind us, the fall in most of the nation’s reimbursement rates suggests that dealing with coding and insurance
continues to pose challenges for chiropractors and their staff. (The same doesn’t seem to hold true for MDs, whose reimbursements ticked up slightly this year — see the MD/DC code comparisons section for details.)

Team play

Among our survey participants this year, slightly more than 24% reported operating in a group setting. This is a small increase from 2021, where 20% reported working in a group. We had slightly fewer responses from associates this year, nearly 4%, and about 3% indicate they’re working as
independent contractors in a practice. At 70%, slightly down from 2021’s 71%, DCs with solo practices made up the vast majority of our survey respondents in 2022.

Typically in this survey (with the exception of 2021), group practices report higher fees, reimbursements and reimbursement rates than solo operations. That held true this year; in 2022, group practices had average fees of $72 and reimbursements of $46, while solo practices
had average fees and reimbursements of $63 and $40, respectively. Reimbursement rates were nearly identical: 63% for solo practices and 64% for groups.

Reimbursement rates in group practices increased slightly from last year’s 61% to 64% this year, while solo practices dropped from 73% to 63% over the same period. Both types reported working with several kinds of specialists. The most common is a licensed massage therapist (39% of solo practices and 28% 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. 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 merged with 99202.)

In 2022, in a survey conducted by Medical Economics, a business journal for medical doctors, their data indicated that 50% of physicians thought their practice was doing “about the same” financially; in the previous year’s survey, 43% provided that response. Twenty-nine percent of doctors reported their practice was doing “worse than a year ago,” while 21% said their practice was faring “better than a year ago.”

In 2022, 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 — and their reimbursements rose a 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 in 2022’s surveys is:

• For code 99202, MDs’ reimbursements were $81, and DCs reported an average of $61.
• For code 99203, MDs’ reimbursements averaged $124, while DCs’ reimbursements averaged $85.
• For code 99204, MDs reported a reimbursement average of $185, while chiropractors reported an average reimbursement of $106.

Reimbursements survey: specializing pays off

In spring 2022, our annual Salary & 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 $176,000, compared to the $130,000 reported by strictly solo operations. Multidisciplinary practices participating in this survey reported higher fees but lower reimbursement percentages than those without specialists. Specifically, practices with specialists reported average fees and reimbursements of $72 and $46, while non-specialist practices reported average fees and reimbursements of $63 and $40, respectively.

Licensed massage therapists (LMT) remained the most popular practice add-on, with 23% having one on board. LMT was followed by acupuncturist (9%); fitness trainer (5%); physical therapist (4%); nurse or nurse practitioner (4%); and nutritionist (4%). Rounding out the
total were MD or DO (3.5%); physician’s assistant (2%); and naturopath (close to 1%).

Franchise facts

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%, again in 2020 to less than 1%, and again in 2021 to 0.5%. This year 1% of our survey respondents identified their chiropractic business as a franchise.

The very small number of responses for the franchise category might seem to 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 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 17% reporting cash-based operations. Those DCs who did report a cash-based practice fared well in their collections.

For cash-based practices, average fees were reported at $65, about the same amount as 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 34% answered that their practice had 25% or less cash income. Thirty percent had 26–50% cash, 12% had 51–75% cash, and 23% had 76–100% cash collections.

Your typical cash-only practice respondent is male (73%), with women making up 25% of this group (2% of respondents declined to report a specific gender). Of cash-based survey participants:
• 22% offer homeopathy;
• 19% offer nutrition;
• 17% offer kinesiology taping;
• 16% offer instrument assisted soft
tissue mobilization;
• 14% offer exercise programs;
• 13% offer stim/ultrasound;
• 13% offer instrument adjusting;
• 13% offer electrotherapy;
• 12% offer laser therapy;
• 11% offer physical therapy;
• 8% offer massage therapy; and
• 5% offer acupuncture.

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 30.5%, up from 27% in 2021. The gender gap in the profession seems to be closing, albeit very slowly.

Female chiropractors reported slightly lower average fees than male DCs ($59 compared to $64), along with lower reimbursement averages ($35 to $41). Female practitioners also reported lower reimbursement rates than male DCs (59% to 64%).

The 64% reimbursement rate for men is down from 74% last year, and reimbursement rates for women are up a bit at 59%, compared to 58% last year.

Women respondents reported an average younger age (49.6), compared to men (54.2), which is approximately the same as last year. In addition, female DCs reported being in practice for fewer years (21), while male respondents have been in practice for an average of 25 years.

Interestingly, both men and women reported offering the same top three modalities: nutrition (46%), instrument adjusting (44%), and ultrasound
(44%) were the most popular. Rounding out the top five were cryotherapy/dry hydrotherapy (40%) and, in fifth place, electrotherapy (37%).

How patients pay

The number of DCs offering payment plans to patients this year increased a bit (48% in 2022 compared to 45% in 2021). 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 18% of DCs reported they have a discount-for-cash plan in place. The remaining responses were “prepay” (37%), “down payment” (14%), “discount medical plan organization” (11%), “patient financing” (11%) and “other” (9%). Interestingly, a final response choice, “negotiation per case,” came in at just over 20% last year — but came in at 0% 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 $28, while average reimbursements were $10 — a reimbursement rate of 36%. Average fees for muscle testing were $36, with an average reimbursement of $18 — a reimbursement rate of 50%. Average fees for physical-performance evaluation were $45, with an average reimbursement of $13, and a reimbursement rate of 29%.

ALLISON M. PAYNE is a freelance writer, editor and proofreader based in Northeast Florida. She can be reached at allisonmpaynewriter.com.