Holding steady: How does your practice compare to results from the 2020 chiropractic fees and reimbursements survey results?

In 2018-19 we saw an overall leveling of chiropractic fees and reimbursements, and this trend has generally continued in 2020 among our survey participants.

The biggest potential influence on this year’s Fees & Reimbursements Survey is undoubtedly COVID-19. When the spread of the coronavirus exploded in mid-March, we didn’t know what to expect to happen to the chiropractic industry, as so many businesses of all types were forced to shut down. Would DCs be able to practice? If so, how would practice have to change? If not … what would happen to those millions of chiropractic patients our readers serve?

By the end of March, one of those questions was answered: Chiropractors would not have to close their doors. Christopher C. Krebs, director of the Cybersecurity and Infrastructure Security Agency (CISA) under the U.S. Department of Homeland Security, in a “Memorandum on Identification of Essential Critical Infrastructure Workers During COVID-19 Response,” named chiropractic care as an essential service. That classified chiropractors as essential workers, one of many professions “needed to maintain the services and functions Americans depend on daily and that need to be able to operate resiliently during the COVID-19 pandemic response.”

With that, personal protective equipment (PPE) requirements changed for both medical offices and other essential businesses. You’ve probably dealt with some challenges brought on by proper use of masks, face shields, hand sanitizer and more, as well as reassuring nervous patients — and employees — that chiropractic can be practiced safely in your office.

The results from our survey show slight declines and upticks here and there, but for the most part chiropractic is holding steady as it has during the past couple of years. This comes after a slow decline up until 2019, when average fees settled at $61; this year’s average fee is $60.38. Reimbursement averages increased from $39 last year to $40 this year, for a reimbursement rate of about 67%.

According to the data collected from chiropractic school enrollments, it’s apparent that more women have started entering the industry. Over the past few years, we have seen those numbers trend positively in our survey, as more women have responded to our calls to take the survey. This year we had a high number of women respondents, 28%, a bit of a dip from last year’s all-time high of 30%. Statistics point to more women entering the chiropractic field in coming years and closing the gender gap.

As always, our survey is subject to statistical variation, and all figures herein presented should be considered as 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 several key points from this year’s Fees & Reimbursements survey:

West, South lead reimbursements again this year

The West led regional reimbursement rates in last year’s survey, and that trend continues this year; the West reported the highest reimbursement rates in 2020 at 71%. The South followed close behind at 69%.

Specialists vs. going solo

As usual in this survey, when asked what type of specialists they work with in their practice, the largest number of chiropractors said “none” (48%), indicating that going solo continues to be the arrangement for about half of our respondents. The other half reported a variety of specialists, the most popular being licensed massage therapist (34%) and acupuncturist (11%).

Cash-only fluctuations

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 last year to 16%. This year the percentage of cash-based practices bounced back almost all the way from that dip, coming in at 19.8%.

Payment plans

According to our 2020 data, 49% of chiropractors offer patients payment plans; pre-payment plans are offered by 29%. Discounts for cash continue to be a popular option; our survey results showed that about 28% of DCs currently offer this type of plan.

Regional Fee Comparisons

Across the nation, average fees and reimbursements among chiropractic practices continue to vary by region. Like our findings from last year, the West reported the highest reimbursement rate in 2020 at 71%. Also the same as last year, the South followed close behind at 69%, trailed by the Midwest at 64% and the East at 53%.

While overall fees ($60) decreased this year, reimbursements increased slightly from last year’s $39 to $40. The reimbursement rate is 68%, which is an increase from last year’s average reimbursement rate of 64%.

The West reported the highest average reimbursement rate at 71% (down from 73% last year) and also had the highest average fees ($75).

Chiropractic Fees and Reimbursements

From 2018 to 2019 we observed a decrease in fees and reimbursements among our survey participants. This year, fees slightly decreased while reimbursements showed a slight increase among our 2020 survey participants.

Our 2019 annual survey showed that fees decreased from $72 in 2018 to $61 in 2019. Reimbursement followed a similar trend, with a $45 average in 2018 to $39 in 2019. The overall reimbursement rates ticked up from 63.9% last year to 67% this year.

The last three years’ reimbursement rates have hovered between 64-70%; this year we saw the numbers remain among those averages. While only time will tell how major changes in health care will affect the industry, this year’s results show a consistency that indicates a fairly stable chiropractic market for the time being.

Team Play

Among our survey participants this year, 24% reported operating in a group setting. This rose slightly from 2019, where 21% reported working in a group.

We had slightly more responses from associates this year, which made up for a total of 6% of responses, and about 5% indicate they’re working as independent contractors in a practice. At 65%, a bit down from 2019’s 69%, 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. This year group practices had average fees of $64 and average reimbursements of $40, while solo practices had average fees and reimbursements of $59 and $42, respectively.

Reimbursement rates in group practices increased from last year’s 52% to 62% this year, and solo practices increased from 67% to 71% 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 42% of solo practices and 27% 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 code 99201 (evaluation and management for new patients) and its variations including 99202, 99203 and 99204.

In 2020, in a survey conducted by Medical Economics, a business journal for medical doctors, their data indicated that 38% of physicians thought their practice was doing “about the same” financially; in the previous year’s survey, 34% provided that response. The number of doctors reporting their practice was doing “better than five years ago” and “worse than five years ago” also remained consistent, differing by a very small number of percentage points. (Of course, it is worth noting that

Medical Economics’ data was collected in early 2020, prior to the explosion of the coronavirus pandemic, so it may provide a look at the medical field through a different lens than does our survey, conducted this summer.

In 2020, DCs (per this survey) and MDs (according to 2020 insurance company estimates, the latest figures available) reported mixed reimbursements on average for all four codes. MDs were seen to be reimbursed at a higher rate for all four codes.

While both industries bill for these codes, the results consistently illustrate a cleft dividing the industries. Because the MD data we obtained applies solely to reimbursements, our comparisons will be limited to DC reimbursements as well. The breakdown of specific codes in 2020 is as follows:

For code 99201, DCs averaged reimbursements of $44, while MDs’ reimbursements were $47. For code 99202, MDs’ reimbursements were $77, and DCs reported an average of $67.

For code 99203, MDs’ reimbursements averaged $109, while DCs’ reimbursements averaged $88. For code 99204, MDs reported a reimbursement average of $167, while chiropractors reported an average reimbursement of $103.

Specializing pays off

In spring 2020, 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 $164,000, compared to the $105,000 reported by strictly solo operations.

In addition, multidisciplinary practices participating in this survey reported higher fees, but slightly 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%).

Franchise Facts

Although we saw an increase in survey participants reporting as franchises over the three years prior, we saw the percentage drop slightly in 2018 and again in 2019 to about 5%. This year, less than 1% of survey respondents identified their business as a franchise.

The very small number of responses for this category may suggest that the popularity of franchise ownership is waning, but it is impossible to tell without a larger survey sample. For this reason, we are unable to draw any conclusions about chiropractic franchising from the results of this year’s survey.

However, in our 2019 survey, the average franchise owner was a 50-year-old male in practice for about 20 years, owning one practice and licensed in one state. For the last two years, 80% of franchise-owning chiropractors were men, indicating a male-female ratio similar to that of the chiropractic profession at large.

Cash, please

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 back to 19.9% this year. Those DCs who did report operating a cash-based prac-tice fared well in their collections.

For cash-based practices, average fees were reported at $60, the same amount as overall average fees. In 2018, cash fees came in at $74, then decreased to $61 in 2019, so this year’s data serves as an indication that cash collections are about the same as 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 $60 are up compared to an overall average reimbursement of $40.

This year we asked what percentage of your collections is cash-based to dig deeper into this type of practice. About 37% answered that their practice had less than 25% cash income. Twenty-five percent had 26–50% cash, 17% had 51–75% cash, and 21% had 76–99% cash collections.

Your typical cash-only practice respondent is male (72%), with women making up 28% of this group. Of cash-based survey participants:

• 38% offer homeopathy;
• 24% offer acupuncture;
• 21% offer nutrition;
• 20% offer kinesiology taping;
• 20% offer instrument assisted soft
tissue mobilization;
• 17% offer instrument adjusting;
• 15% offer physical therapy;
• 13% offer electrotherapy;
• 13% offer exercise programs;
• 13% offer massage therapy;
• 13% offer laser therapy; 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%.

Female chiropractors reported slightly higher average fees than male DCs ($64 compared to $59), along with higher reimbursement averages ($42 to $40). However, female practitioners reported slightly lower reimbursement rates than male DCs (66% to nearly 68%).

The 68% reimbursement rate for men is up from 56% last year, and reimbursement rates for women are up to 66%, compared to 63% last year.

Women respondents reported an average younger age (47), compared to men (52), which is the same as last year for both. In addition, female DCs reported being in practice for fewer years (16), while male respondents have been in practice for an average of 22 years.

+Interestingly, when asked about which additional modalities they offer, both men and women reported the same top three modalities: instrument adjusting (56%), ultrasound (52%) and electrotherapy (48%) were the most popular. Rounding out the top five were flexion distraction (44%) and kinesiology taping (43%).

The reimbursement rate for men is up to nearly 68%, and up to 66% for women.

How patients pay

The number of DCs offering payment plans to patients this year decreased a bit (49% in 2020 compared to 58% in 2019). Historically in this survey, this percentage fluctuates up and down, but is always around 50%.

A significant number of chiropractors also offer discounts when patients pay in cash. Last year, DCs saw 30% offering discounts for cash, and this year 28% of DCs have this type of plan in place.

The remaining responses were “prepay” (29%), “down payment” (15%), “patient financing” (10%), “discount medical plan organization” (6%) and “other” (12%).

A final response choice, “negotiation per case,” came in at less than 1%.

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 $32, while average reimbursements were $23 — a reimbursement rate of 72%.

Average fees for muscle testing were $23, with an average reimbursement of $11 — a reimbursement rate of 48%.

Average fees for physical-performance evaluation were $31, with an average reimbursement of $20, and a reimbursement rate of 65%.

About this survey

During August 2020, 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.

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 260 respondents.
• Regional distribution: Participants hailed from the South (35%), the Midwest (26%), the West (25%) and the East (14%).
• Averages: Unless indicated otherwise, all numbers are given as 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.

Allison M. Payne is the associate editor of Chiropractic Economics and MASSAGE Magazine. She can be reached at apayne@thedoylegroup.com.