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New California Law Limits
Workers' Compensation Visits to Chiropractors

Stephen Barrett, M.D.

Chiropractors are notorious for "keeping their patients coming back." Many advise everyone to have their spine checked for "subluxations" and "adjusted" throughout life. Many chiropractors advise people whose symptoms have stopped to keep coming back for "preventative maintenance. Some chiropractors are networked with attorneys (and even medical doctors) to provide unnecessary tests and treatment to injured works and auto accident victims. Partly as a result, in many states, workers' compensation programs has become so expensive that employers have asked their state legislature to limit the amount of chiropractic coverage.

In 1992, Florida Trend magazine published a cover story on "why chiropractors get blamed for fueling the cost of workers' compensation." The author concluded that, "Workers' compensation is fraught with abuse, but no other players in the system rile business more than the chiropractors." A spokesman for the American Insurance Association even said that, "Sometimes I think of workers' comp as the chiropractic full-employment act." Some health-insurance companies called for limits on chiropractic treatment, and some wanted chiropractors out of the WC system altogether. The main complaints were about exaggerated diagnoses, overtreatment, and aggressive marketing aimed at patient retention from cradle to grave. The author also noted:

Less scrupulous attorneys turn to chiropractors, hoping they will give injured workers the highest impairment rating and extend treatment for as long as possible. The chiropractors who play the game are then rewarded with a steady stream of clients provided by their unspoken lawyer/partners.

The payback for a lawyer comes in the medical expenses: The larger the expenses, the more the lawyer can expect, with legal fees paid by the insurer. . . . If a carrier disputes a claim . . . the lawyer can rack up hefty costs for time-consuming depositions and pre-trial appearances. Meanwhile, the chiropractor continues to provide treatment [1].

Two studies have focused attention on the problem in California. The first one, published by the Workers Compensation Research Institute of Cambridge, Massachusetts, analyzed 28,539 workers' compensation cases involving back strains and sprains in California and four other states and concluded:

The second study, published a few months later by the California Workers Compensation Institute (CWCI), analyzed data from 134,312 cases in which a chiropractor was identified as a service provider on work injury claims from accident years 1993 to 2000. The Institute reported:

In 2003 , the California legislature held a hearing on a bill (SB 354) that called for limiting chiropractic care without special authorization to 15 visits per claim. This provision was subsequently removed by an amendment, but a representative of the California Chiropractic Association made an interesting comment about the hearing:

Unfortunately, many of our arguments fell on deaf ears when an advertisement touting a chiropractic seminar to "double or triple" workers' compensation income from the "high profit" market, with testimonials bragging of increases of income of "over $30,000," was passed around by Sen. Speier. The effect of the ad was immediate and devastating [5].

California Senate Bill 228, which took effect on January 1, 2004, states that for injuries occurring on or after that date, an employee shall be entitled to no more than 24 chiropractic and 24 physical therapy visits per industrial injury. The law, part of a 6-bill package intended to curb runaway costs, was passed in the wake of two reports which concluded that the costs of treating back strains and sprains for injured workers with physical medicine services, such as manipulations, exercise, hot and cold packs and massage were greater when the care was directed by chiropractors than when it was managed by physicians.

In 2005, the California Worker's Compensation Institute (CWCI) concluded that SB228 had sharply reduced the cost of chiropractic and physical therapy. The CWCI study found that since January 2004, the average number of chiropractic visits per case has been about 50%% lower and payments per chiropractic claim have been nearly nearly 60% lower than they were in 2002. For physical therapists, the average number of visits per claim dropped about 44% and the total cost per claim dropped about 48%. At the time implementation began, payments for physical therapy and chiropractic manipulation together comprised 37% of all California workers' compensation outpatient costs [6].

In 2006, the Workers' Compensation Insurance Ratig Bureau of California concluded that [7].


  1. Coletti RJ. The manipulators. Florida Trend 35(2):32-36, 1992.
  2. Patterns and Costs of Physical Medicine: Comparison of Chiropractic and Physician-Directed Care. Cambridge, MA: Workers Compensation Research Institute, Dec 2002.
  3. Chiropractor-directed costs more than when physical medicine care is managed by physicians, says WCRI study: Chiropractic care could achieve lower costs by limiting visits. WCRI media release, Jan 23, 2003.
  4. Changes in Utilization of Chiropractic Care in California Workers' Compensation, 1993-2000. California Workers Compensation Institute, March 21, 2003.
  5. Whalen WM. California DCs face Workers' Compensation dilemma: SB 354 would require MD authorization after 15 visits. Dynamic Chiropractic 21(12):23, 2003.
  6. Swedlow S. The Utilization & Cost of Physical Therapy and Chiropractic Manipulation in California Workers’ Comp Following Implementation of Mandatory UR and 24-Visit Caps. California Worker's Compensation Institute, 2005.
  7. 2006 Legislative Cost Monitoring Report. San Francisco: WCIRBCalifornia, Released Sept 27, 2006.

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This article was revised on December 28, 2005.