Complete Story
05/06/2026
TPA Practices Undermine Providers and Patient Safety
By Jeff Trinka, DC AAC Reimbursement Fairness Committee Member
A growing concern in musculoskeletal healthcare is the role of third-party administrators (TPAs) in shaping care through policies that may not align with clinical science. Nowhere is this more evident than in the management of chronic pain.
Despite well-established guidelines recognizing chronic pain as a condition requiring ongoing, individualized care, some TPA systems continue to apply acute care medical necessity criteria—expecting rapid resolution, limiting treatment duration, and restricting visit frequency. These frameworks are fundamentally mismatched to the clinical realities of chronic neuromusculoskeletal conditions.
The affected population is large. With 50 million Americans living with chronic pain and millions relying on insurance plans subject to utilization management, the downstream impact of these policies is significant¹. Patients who require sustained care are instead subjected to episodic, truncated treatment plans that fail to meet their needs.
For providers—particularly doctors of chiropractic—this creates a dual burden. Financially, reimbursement is constrained by visit caps, denials, and documentation limitations. Some systems restrict the number of diagnosis codes (often to four), despite the complexity of chronic cases, effectively under coding the patient’s condition and weakening the justification for care.
This has a direct impact on practice sustainability. Clinics are forced to either absorb financial losses, reduce care to meet arbitrary limits, or engage in administrative appeals that consume time and resources. Over time, this erodes morale and contributes to burnout.
More concerning, however, is the impact on patient safety. When appropriate conservative care is restricted, patients are more likely to seek alternative interventions, including pharmacologic management. The CDC has repeatedly emphasized the risks associated with opioid therapy and the importance of non-pharmacologic approaches². Limiting access to evidence-based conservative care may inadvertently increase reliance on higher-risk treatments.
Additionally, these practices raise questions regarding compliance with established standards. The National Committee for Quality Assurance (NCQA) requires that utilization management criteria be evidence-based and appropriate to the clinical condition. Applying acute care standards to chronic pain may fall short of this requirement.
Takeaway:
- Current TPA policies are prioritized over scientific research. One example is using acute care criteria when authorizing chronic pain treatments.
- A significant segment of the population suffer from chronic pain and are subject to TPA policies which force them into pharmacological or higher risk alternative treatments creating a public safety concern.
- Current TPA policies result in financial, administrative, and ethical challenges for providers.
- Current TPA practices may fall short of nationally established standards and criteria.
Ultimately, this is not merely an administrative inefficiency—it is a systemic issue affecting clinical integrity, provider viability, and patient outcomes. Addressing it will require greater transparency in TPA criteria, stronger provider advocacy, and alignment of policy with the substantial body of evidence supporting chronic pain management.
Footnotes
- Dahlhamer J, et al. CDC MMWR: Chronic Pain Prevalence Data.
- CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022).
- AHRQ: Noninvasive Nonpharmacological Treatment for Chronic Pain.
- CMS Medicare Benefit Policy Manual, Chapter 15.
- National Committee for Quality Assurance (NCQA): Utilization Management Standards.
You wont want to miss the Insurance Update at the AAC's Annual Convention June 12-14 at the Wild Horse Pass! Have your breakfast and hear about the latest on Sunday, 8:00-9:00a with members of the Reimbursement Fairness Committee.
To find out about reimbursement fairness, or about how to get involved contact Dr. Jeff Trinka at jefftinka@gmail.com.
