Arete Healthcare LLC
Independent Practices | Shared Infrastructure | Clinician-Led Governance
Independent Practices | Shared Infrastructure | Clinician-Led Governance
Arete Analytic Brief
A sensitivity analysis of spinal CMT utilization in a provider tiering appeal
The chart below is the core financial argument of this brief: the intermediary’s prior-authorization remedy costs the practice roughly twenty-eight times what it could plausibly save the insurer.
Figure 1. Illustration of the financial impact of requiring a chiropractor to participate in a prior authorization based on a determination that the chiropractor’s use of the 98941 spinal CMT code exceeds the intermediary’s “benchmark.” While all 98941 services provided during the measurement period were appropriately documented in the medical record, on submitted claims, and claims were adjudicated and paid, the “excess” 98941 code use according to the intermediary is estimated to have an approximate $250 financial impact, of which the patient who sought the treatment is responsible for over 50% through a copay and/or deductible. With the intermediary’s prior-authorization process applied to all patients — and notably not addressing the visit-specific CMT code level for which the intermediary is concerned — the minimum total administrative cost to the chiropractor’s practice will be approximately $3,500. The chiropractor’s overall utilization (visits per patient and services per visit) is very low. Visualization was human generated.
This case illustrates the difficult economic environment chiropractors practice in.
A chiropractor with 25+ years’ experience serving a local community with high-value conservative care, at exceptionally low cost to the commercial insurance company, is identified by an intermediary chiropractic network as an “outlier” due to the mix of spinal chiropractic manipulative treatment (CMT) services. The resulting “down-tiering” would be associated with the chiropractor having to participate in a prior-authorization process for all patients treated, for 12+ months.
For the time being, we will set aside methodological questions about the intermediary chiropractic network’s provider “profiles” and “tiering” criteria; these will be topics of future Arete Original Research and Analytic Briefs.
The intermediary chiropractic network based the “down-tiering” on the chiropractor exceeding the intermediary’s “benchmark” of no more than 60% of spinal CMT billed at the 3–4-region (98941) level.
The chiropractor’s medical records document the necessity of all services, including all 98941 services.
Claims submitted to the insurance company were properly supported, including all 98941 services, and all claims were paid.
The intermediary’s clinical representative did not evaluate any patient treated, did not review any medical records, and did not identify a single patient for whom the intermediary believes a 98941 service was unnecessary.
The combination of the intermediary’s low fee schedule, the small reimbursement difference between a 98940 and 98941 CMT code, and an administratively burdensome prior-authorization process results in:
The “down-tiering” determination being associated with the practice incurring more than $3,550 in annual administrative cost.
A maximum potential financial “benefit” to the insurer of $250, of which patients are responsible for over 50% — resulting in a net “benefit” to the insurance company of less than $125.
7 unusual patients out of 142 patients treated explain the entire “outlier” designation.
For these 7 patients, more than $3,500 in annual administrative burden is placed on a small practice to “save” $125 for the insurance company — for services that are necessary, supported, and that patients value, seek, and are willing to pay for.
Finally, the intermediary chiropractic network’s prior-authorization process does not actually address the issue for which the chiropractor is being “down-tiered.” It applies an unnecessary and costly “solution” to a “problem” that, seemingly does not exist.
Why are high-value providers of all types electing to go out of network?
| Measure | All patients | Without 7 | 7 patients |
|---|---|---|---|
| Unique patients | 142 | 135 | 7 |
| Patient age, mean | 47.7 | 47.5 | 51.4 |
| HCC RAF, mean | 0.287 | 0.286 | 0.308 |
| Visits | 610 | 480 | 130 |
| Units | 1,135 | 911 | 224 |
| Spinal CMT units (98940/1/2) | 612 | 481 | 131 |
| 98940 units | 194 | 194 | 0 |
| 98941 units | 418 | 287 | 131 |
| 98942 units | 0 | 0 | 0 |
| Visits per patient | 4.30 | 3.56 | 18.57 |
| Units per patient | 7.99 | 6.75 | 32.00 |
| Units per visit | 1.86 | 1.90 | 1.72 |
| % spinal CMT — 98940 | 31.7% | 40.3% | 0.0% |
| % spinal CMT — 98941 | 68.3% | 59.7% | 100.0% |
| % spinal CMT — 98942 | 0.0% | 0.0% | 0.0% |
| 98941 visits with ≥3 expanded regions on same visit† | 96.9% | 96.9% | 96.9% |
| 98941 visits with ≥3 expanded regions in patient 12-month profile‡ | 99.5% | 99.3% | 100.0% |
Rolling 12 months after filtering to Insurer 1, Insurer 2, and Insurer 3: September 17, 2025–September 16, 2026. Age and HCC RAF are patient-weighted.
†Expanded spinal-region mapping is an analytic sensitivity heuristic, not a payer coverage rule.
‡Longitudinal concordance counts a 98941 visit when the patient had ICD-10 diagnoses spanning at least three mapped spinal regions anywhere in the same 12-month measurement period; it is not a visit-level medical-necessity determination.
The two tables below translate Table 1 data into the brief’s central cost-benefit argument.
| Measure | All patients | Without 7 | 7 patients |
|---|---|---|---|
| Unique patients | 142 | 135 | 7 |
| Spinal CMT units | 612 | 481 | 131 |
| Actual 98941 units | 418 | 287 | 131 |
| 98941 units at 60% intermediary “benchmark” | 367.2 | 288.6 | 78.6 |
| Difference vs. 60% “benchmark” | +50.8 | −1.6 | +52.4 |
| Excess units above “benchmark” (floor at 0) | 50.8 | 0.0 | 52.4 |
| Assumed reimbursement differential | $5 / unit | $5 / unit | $5 / unit |
| Estimated annual reimbursement exposure | $254 (~$250) | $0 | $262 (~$260) |
Estimated annual reimbursement exposure by patient group, from the 60%-benchmark sensitivity analysis above; figures were independently recomputed from the sensitivity workbook.
| Scenario | Estimated provider labor |
|---|---|
| 100 prior authorizations × $25 | $2,500 |
| 142 prior authorizations × $25 (1 per patient) | $3,550 |
| Cost vs. ~$254 gross reimbursement exposure | 9.8x / 14.0x |
| Annual visits per patient in 3-insurer cohort* | 4.30 |
Estimated annual provider-side labor cost under two prior-authorization volume scenarios, compared with the gross benchmark-relative reimbursement exposure; figures were independently recomputed from the sensitivity workbook.
An Arete Network chiropractor appealed a tier reduction associated with spinal CMT coding above an intermediary network benchmark; during follow-up, the intermediary requested patient-level examples. Complete claims across Insurer 1, Insurer 2, and Insurer 3 were analyzed and found a recent rolling 12-month 98941 rate of 68.3%, with seven of 142 patients accounting for 21.4% of spinal CMT and 31.3% of 98941 utilization; a counterfactual removal of this minimum seven-patient set reduced the rate to 59.7%.
The high-impact seven-patient cohort averaged 18.7 visits per patient versus 3.6 for all others and was modestly older with slightly higher HCC RAF. 99.5% of all 98941 visits — and 100% of visits in the seven-patient cohort — occurred in patients with ICD-10 diagnoses spanning at least three spinal regions during the same 12-month period, illustrating how patient concentration can materially influence a crude visit-weighted provider profile while the underlying diagnosis history remains highly concordant with multi-region CMT.
Using illustrative reimbursement and administrative-cost assumptions, benchmark-relative 98941 use represents approximately $250 in annual reimbursement exposure ($125 net of patient cost-sharing), while 100 prior authorizations would require at least $2,500 in provider labor and one authorization per 142 patients would require $3,550.
De-identified EHR/RCM claim-line data for one chiropractor were filtered to three insurers managed by the intermediary network (September 17, 2025–September 16, 2026), using all 12 ICD-10 diagnosis positions.
Visits were unique patient-date-payer combinations; spinal CMT comprised codes 98940–98942.
A sensitivity analysis identified the minimum patient set whose counterfactual removal reduced 98941 use below the intermediary’s 60% benchmark.
Diagnosis concordance was assessed at the same-visit and 12-month patient-profile level using strict and expanded anatomic-region definitions.
Financial sensitivity valued benchmark-relative 98941 units at an illustrative $5 each; prior-authorization burden was modeled at $25 in provider labor per authorization.
Single-provider case study. Findings describe one provider and are not intended to estimate network-wide performance or establish a general utilization benchmark.
Intermediary specifications were unavailable. The exact profiling interval, attribution logic, denominator, risk adjustment if any, sensitivity analysis if any, exclusions if any, and benchmark-development process were not provided; this brief therefore does not attempt to reproduce or validate the intermediary’s methodology.
Sensitivity analysis is counterfactual. The seven patients are not proposed exclusions from profiling; their removal is used only to quantify how strongly a small high-frequency cohort affects the aggregate rate. Multiple minimum-cardinality seven-patient sets may exist when patients have similar influence.
Claims diagnoses do not establish medical necessity. Same-visit concordance shows whether the claim contains codes anatomically consistent with multi-region CMT; the broader longitudinal measure shows whether the patient’s diagnosis history across the measurement period spans at least three spinal regions. Neither measure substitutes for chart review of documentation and clinical appropriateness.
Financial analysis is illustrative, not a payer financial audit. The $5 CPT reimbursement differential and $25 provider-labor cost per prior authorization are scenario assumptions. Actual reimbursement, authorization frequency, administrative cost, and any change in coding after prior authorization may differ; intermediary administrative expense and patient burden are not included.
HCC RAF is a general risk measure rather than a musculoskeletal-specific severity measure, so modest RAF differences should not be interpreted as complete clinical risk adjustment.
Claims history may differ from an intermediary’s adjudicated dataset because of eligibility, attribution, run-out, product mapping, timing, or other administrative differences.
Data Source: De-identified operational claims data. Provider and patient identifiers are omitted from this publication; the internal reproducibility file retains the source-level linkage required for review.
AI Use Disclosure: AI-assisted analysis and drafting were used to independently recompute the source data, structure the sensitivity analysis, and prepare this document, including the Analytic Exhibit tables.
Figure 1 (In Pictures) was human-generated.
Scope: This brief supports a provider-specific tiering appeal. It intentionally does not assess the intermediary’s profiling methodology, benchmark validity, or decision-making process.
Recommended Citation: Arete Healthcare. Patient Concentration and Provider Profiling: A Sensitivity Analysis of Spinal CMT Utilization. Arete Analytic Brief ARETE-AB-2026-001 (provisional), Version 0.7. Approved for Release, September 2026.
1. Arete Healthcare. Athena EHR/RCM provider-profile claim-line extract, complete 12-position ICD-10 coding; service history through September 2026. Internal de-identified analytic source; not publicly distributed.
2. Arete Healthcare. Provider tiering appeal reproducibility analysis and sensitivity workbooks, September 18, 2026. Internal analytic materials; not publicly distributed.