Verisk Analytics Reveal $2M in Suspect Chiropractor Billing

October 14, 2025 / 5 min read

A well-known property and casualty (P&C) insurance carrier—who just this year excitedly onboarded provider analytics to complement their existing fraud, waste, and abuse efforts—was both shocked and pleasantly surprised to discover the findings. The carrier was thrilled to see their new analytics in action and to discover how fast the tool revealed the risk. They were also alarmed by the degree of the surfaced exposure.

The provider in question, a chiropractor, operates out of a tiny East Coast office which from the outside looks a bit run-down, with obvious peeling stucco and severely cracked awning tiles. The equally tiny parking lot is littered with cracked, broken asphalt, and potholes. Its size suggests a maximum capacity of nine vehicles, presumably to accommodate both staff and patients.

Despite the outward appearance and physical size of the location, in only three years, across just twenty-one patients, this chiropractic office billed the carrier over $2M!

Provider Analytics-1920x1280-100kb

While the atypical outward appearance of the office would not necessarily have any direct impact on the quality of chiropractic care delivered inside, what was unusual was the level, frequency, and duration of patient treatment and procedures the office billed.

Further leveraging their recent provider analytic capabilities, the carrier discovered granular data metrics that compounded the potential for fraud, waste, and abuse.

Highlights of major intelligence and billing behaviors exposed through the analysis

Over $2M billed in the last 3 years across just 21 patients
Over $96K in average billing per patient
Over 150 average visits per patient
Over 795 average procedures per patient
Over 25 unique billing threat issues surfaced
Over 280 days billed with up to 18 hours of supposed treatment
Over 378 instances of up to 9 carrier-specific patients billed in a single day
Over 17 of 48 repetitive procedures submitted were billed to up to 100% of patients
Over 50% of patients had treatment durations of up to 3 years
Over 38% of patients were billed excessively (up to $285,630)
Over 65% of patients were continually billed subjective diagnoses throughout their treatment duration
100% of the over $2M was identified as having at least some form of billing issue(s)

Keeping in context that the provider in question is a chiropractor, the type, volume, frequency, and duration of treatment from a multi-carrier or industry perspective would itself be troubling. But when we realize that the above chronicled billing behaviors were perpetrated against a lone carrier, across just twenty-one patients, the potential risk level is significantly heightened.

Excessive treatments and subjective diagnoses

In private insurance and in the federal systems—such as Medicare, Medicaid, etc.—chiropractic treatments would usually be capped at eighteen visits. Yet here, in the P&C space, this provider billed an average of over 150 visits per patient. Similarly, the patients’ continued treatment for up to three years! Further, a significant percentage of repeat procedures were billed to 100% of the patient population regardless of the true injury at issue in the claim.

Speaking of the true injury, the carrier doesn’t have the benefit of knowing through the billing what those true injuries are. Why? Because the provider continuously applied subjective diagnoses across the patient population for what in most instances was the entire treatment duration.

Subjective diagnoses are those identified as being vague, ambiguous, unspecified, and/or pain-related. The application of a subjective diagnosis within perhaps the first thirty days of treatment may be appropriate. This scenario would assume that the provider would ostensibly perform additional assessments, run further tests, and/or secure diagnostic evidence in an effort to help evaluate the cause and origin of the patient’s issue(s). However, once determined, those subjective patient diagnoses should be appropriately updated to specific ones. What would then typically follow is an equally appropriate and updated treatment plan designed to address the patient’s more accurate injury type or condition.

Providers are required to apply the most specific diagnosis. Unfortunately for payers, without specific diagnoses determined and applied to patients, providers are able to generate a greater number of treatments and procedures they bill for. Such occurrences unnecessarily drive up claim costs. These are needless expenses that otherwise would not be possible when such treatments are assessed against more specific diagnoses.

Turning analysis into action

Armed with the results of the provider analysis performed, SIU management at the carrier made the decision to operationalize the surfaced intelligence. They initiated their effort to conduct further investigation into the chiropractor’s billing practices—including a review of documents. This will provide the ability to effectively identify, assess, collect, and preserve potential evidence. Undertaking such steps is crucial to mitigate, and hopefully abate, both current and future exposures.

Leveraging lessons learned from analytically surfaced behavioral intelligence like that revealed in this case example aids carriers in multiple ways. Not the least of those include identifying other providers who may be engaged in the same or similar behavioral practices, as well as sharing the discoveries via training and awareness campaigns among the carrier’s integral anti-fraud personnel.

Contact your Verisk representative or visit verisk.com/products/provider-scoring to schedule a demonstration and learn how advanced analytics can empower your fraud detection capabilities.

Verisk’s comprehensive claims solutions suite is designed to help you detect fraud faster and protect your bottom line.

Learn more

Verisk’s Provider Analytics Uncover Over $2M in Suspect Chiropractor Billing Generated from Tiny East Coast Office

Highlights of major intelligence and billing behaviors exposed through the analysis

Excessive treatments and subjective diagnoses

Turning analysis into action