When two big digital mental health platforms cut pay rates for therapists using UnitedHealth’s Optum insurance recently, the action stirred a debate among therapists about the overall value of the platforms.
Therapists’ initial responses were angry. Now, a few weeks later, they are still upset, saying things like “it is devastating,” “it is unsustainable,” “it is insulting” and — in one case — “it isn’t a big deal.”
The two platforms, Alma and Headway, are among several that contract with insurers to get pay that is usually better than what solo practitioners can get. Therapists can sign up and pay fees or give a cut of their pay to the company, becoming a 1099 independent contractor and gaining aid in billing and access to assets like credentialing, an electronic health record, a telehealth platform, a scheduler and so on. They have grown quickly in the past few years because they promise to alleviate the burden of practice management, offer higher pay, and also because they promised answers to telehealth procedural questions that sprang up early in the pandemic.
The rate cuts for therapy for people insured through UnitedHealth’s Optum, though, shocked therapists, and brought to the fore other concerns about the platforms, where thousands of therapists now conduct business. The cuts, announced in late October, range in size from a few dollars, to $7 a visit, to $43 a visit, or a cut of 30 percent, therapists said. Headway and Alma said they were a result of contract renewals with Optum.
Some who are cautious about or opposed to the platforms note they have access to patient and clinician data, raising privacy concerns. Giving up solo control is undesirable for many therapists. Others who never joined say they think the platforms will always act in their own self-interest, and that they set contract terms and negotiate with insurers, so can dictate terms to members.
Barbara Griswold, author of the blog “What Every Therapist Should Know About Insurance” and the book “Navigating the Insurance Maze,” is a therapist who advises other therapists on the business of a practice. She wrote in an email: “So, this brings up an important reminder: Large, multi-state digital platforms like Alma, Headway, or Grow Therapy may be able to credential you faster with a health plan, and get you higher rates than you could get as an individual provider. But you do not hold the contract with the health plan — the platform does. This means you have no power to negotiate reimbursement rates or raises with the plan, or to fight it if the rate drops.”
As we were reporting about the rate cuts, we heard a lot from therapists who were having second thoughts about these platforms and others. Almost all of the therapists here spoke or wrote on condition of anonymity, saying they did not want to draw retaliation from the platforms or from insurers. Most also noted that their contracts forbid them from revealing rates.
Headway, founded in 2019, says it works with 40,000 providers; Alma, founded in 2018, says it has 22,000 providers in its directory, though its LinkedIn says 8,000.
Service sagging
One Brooklyn licensed clinical social worker said in a Zoom interview that the service from Alma has become worse since he started in 2021.
“The benefit of Alma is that insurance companies are horrific to work with. It is nothing but headaches. I mean, it’s like, they won’t pay you,” he said. “Working with Alma, at least I know I’m going to get paid. They’ve always paid the amount that they say they’re going to pay on time.
“But the quality, over the years I’ve been working with them has gotten obviously worse. It used to be so friendly, great customer service. Any issue arose, I would email them, they’d email me back within 24 hours, problem solved.
“But the service is significantly worse. Like, we said that this client’s copay was going to be $0, and then they’re like, ‘Oh, we got that wrong.’ So 12 weeks later, they come back to me and the client and send an email saying, ‘We estimated incorrectly. It turns out the copay is actually $75 per session. So you owe $75 times 12.
“Clients have agreed to participate in the therapy knowing that it is the cost that has been quoted to them, and then Alma will change it. What they don’t do is change my pay, at least not yet. They haven’t done that to me, but they have started doing that on the client, and that freaks me out.”
Once, it felt “it’s therapist-centered, like they work for us, or we are their customer at least, kind of, so it seems like a good idea. But now it feels like they’ve gotten so many therapists in,” and the service is much less.
“My goal is to get out of the whole thing soon. But that sucks too. The further you go in your career, the more expertise I’ve been able to develop. I’ve also become much, much less accessible, which was never my goal. I didn’t go into social work to be charging $200 an hour, and you better be able to pay out of pocket. That was never my goal.”
Challenges in pushing back
Another Brooklyn licensed clinical social worker wrote in an email about “the challenges of pushing back as a group as we’re 1099s and if I’m not mistaken, unable to unionize. Combine this with the fear of posting on the Alma community forum, we find ourselves divided and conquered.”
He said he had considered leaving Alma, but added: “It’s important to me that I be able to participate in insurance programs. It doesn’t mean I don’t want out-of-network clients. But it does mean I help the throngs of insured customers access mental health care. It’s an ethical issue in part for me. Now I’ve taken all Optum insurers off of my profiles (Alma and Psychology Today) and after confirming with Optum that I am not in-network with them under my NPI, I can begin to see Optum clients out of network.
“Many therapists are talking about this kind of boycott of Optum across the many groups popping up on Facebook. As we can’t unionize, this might be our best option. I’ll add that I’m keeping my credentialing status with Alma active. Things may change.
“I almost forgot—I expect to lose between 12 and 14k next year.”
The Current Procedural Terminology (CPT) codes most frequently mentioned as marked for cutbacks were the common 90834 (psychotherapy, 45 minutes with patient) and 90837 (psychotherapy, 60 minutes with patient), though both Alma and Headway also included several other mental health codes.
‘Corporate greed’
A therapist with a PsyD degree who practices in New Jersey with a group using Alma wrote: “My practice in NJ will be affected by the rate cut, and I fear Alma being a venture capital backed company means it will get gradually worse from here.”
He also referred to Optum Ventures’ part ownership position in Alma: “It puts us (clinicians) in a difficult spot; if I get credentialed with Optum independently (not via Alma) I have heard that their payout rate is significantly lower than being credentialed with Optum through Alma (by about $20 per session), but staying with Alma feels like a frog in boiling water situation/it is hard to give my tacit approval to corporate greed given Alma and Optum’s ouroboros situation with one another.
“However, I will say that Alma has been a great service…at least until the last few months when they decided to no longer offer a free Zoom pro subscription as part of their offerings and then the recent reimbursement rate cut, with no intention of decreasing our yearly/monthly subscription fees. Again, feels like the water is starting to get a bit hot…”
‘Not sustainable’
An MS, licensed marital and family therapist in Brooklyn, who is with both Alma and Headway, wrote: “These cuts are not sustainable. The minimum I need to have financial stability is $125 per session at 25-30 clients a week and all my insurance reimbursements are well below that (for 45 min codes which we are pressured to bill rather than 60 min codes).
“Venture capital backed companies are hurting and will continue to hurt this field. I am deeply worried about the future of my career and if I will be able to stay in business.
“I also worry now that UHC and other insurers are offering in house mental health care that is drastically driving down the cost of therapy (UHC offers $60 a month for mental health care – session frequency determined by provider). I believe these companies are well into the territory of anti-trust and monopolization and I fear that private therapists are soon to be outpaced and run out of business by these corporations.”
She sent a link to UHC’s Mental Health Complete Plus, which offers unlimited mental health and other services for $59.99 a month, via Teladoc.
Notes platform
A New York PsyD who practices with Alma wrote: “There is a different, though related, issue that is arising as well. Alma is pushing providers to use a new AI note-producing platform (for which providers will have to pay extra). They are saying that to be compliant with insurance, providers have to write progress notes that are 2-3 pages in length.
“This would be virtually impossible for us to do manually for every session, given the time it would take (which translates to loss of income), and is something that has never been required previously. It can be done through AI, but that involves AI recording the session and generating the note automatically.
“I and other providers have significant concerns about client confidentiality (although the recordings are supposedly deleted immediately after the note is generated, it is difficult to trust that the client’s information would not be used in some way). There is a concern about insurance companies using these recordings to essentially listen to sessions — we have no idea what data or meta-data is scraped from the sessions.
“The notes ‘required’ for insurance include ridiculous information that we would normally never include in a session progress note, such as ‘the client appeared his stated age’ — this is something a provider might record in an intake note, but certainly does not need noting in every session. If a 40-year-old appeared to be his stated age during the intake, it’s very unlikely that he would appear older or younger in subsequent sessions, and anyway, why would that matter? Other therapeutically useless information is also required to be noted.
“It makes me wonder if the ‘requirement’ for longer notes is simply a way that insurance companies are trying to ensure that all notes are eventually produced by AI, which would essentially mean that all sessions would need to be recorded.
“There are many other problems that arise when notes are produced by AI, including incorrect inferences, inability of AI to take into account body language and non verbal cues, inability to record non-verbal interventions such as facial expressions and gestures of therapist, and therapists not thinking sufficiently through what occurred in session (this is something one often does when writing notes manually).
“The therapist community is divided about AI notes – some see it as an easy way to do a part of our job that most of us dislike – it’s tedious to write in insurancey language. But what we are trained to do, and what really helps the client, is likely not going to happen as well if we are all required to do therapy in an automated way.”
‘$8,000 next year’
A New York City PsyD who is with Headway wrote: “As of January 2025, which is when the newly renegotiated contract is supposed to be active, I’ll be seeing a loss of $19.69 on each 90837 and of $40.99 on each 90834. (I will also add that family/couples sessions – 90847, which I occasionally will do with parents of child patients – will see a decrease of $45.52).
“I exclusively conduct 90834/45-minute sessions and this is roughly a 30% loss of income per appointment. Even in my relatively small private practice, I stand to lose about $8,000 next year for doing the same work as before.
“I’ve been working with Headway for almost three years and, until very recently, have had a great experience with them and would have recommended them to any of my fellow providers who asked. As it stands now, I’m feeling alone and betrayed by the whole system.”
‘It isn’t a big deal’
Alexandra Mejia, a licensed mental health counselor who said she is credentialed with Optum through Alma in New York, Delaware and Florida, was one of the few who is not concerned.
She wrote in an email: “I’m responding to the article you’re writing on the fee changes through Alma. While I was initially worried about it, after looking at the changes, it really isn’t a big deal.
“I am credentialled in three states and in all three the only rates affected are for 60 minute sessions, which most clinicians don’t use when taking insurance due to the risk of being audited, and the additional service change for complex sessions (with collateral, couples, family). For my practice, that only does individual sessions, this will not make an impact at all.
“These changes also have less to do with Alma and more to do with Optum itself.”
‘It is insulting’
A PhD licensed psychologist in Minnesota wrote: “As a trained mental health professional with lots of student debt, it is insulting to not only NOT have our reimbursement rates stay current with the times (like other medical professionals), but it to be reduced even further.
“My Alma story: I interviewed them in January of 2024 and was quoted the following reimbursement rates:
“90791: $152.19
“90837: $152.19
“90834: $132.08
“When I finally signed on in August, I was told that I could not get credentialed with Optum (through Alma) because of contract negotiations that would take an unknown amount of time, so I only got credentialed with Aetna because they were the highest payor. After a month and still not hearing anything (and not getting any Aetna referrals) I inquired about the Optum contract negotiations and I was told that the new rates would be around $140 for 90791 and 90837 – roughly a $12 decrease per session. (Unfortunately, I deleted that email outlining the specific rate differences because I was mad).
“I said this was unacceptable and terminated my contract immediately. Thankfully I was still within the first 30 days of my contract so I was able to get a full refund. (I had paid for a full year).
“Now, for some, this might be a great reimbursement rate. But the fact that Optum is REDUCING payouts is what makes me so mad. We have years and years of data outlining that mental health professionals are not being compensated to keep up with the times on par with other medical professionals and now they are cutting payouts even more? I also have a sneaking suspicion this is just the beginning…so I’m out.
“I have also interviewed Headway and Rula. Rula was absolutely insulting at reimbursing only $90 per 90837. No chance in hell was I signing on for that….
“I wrestle all the time with choosing not to accept insurance in my practice because I know it limits access to care. But as an advocate for myself first, I cannot work with a system that chooses to put me down and devalue me in every way from crap payouts to clawbacks to denials. The system is so broken. Insurance as a business has ruined healthcare.”
‘I am devastated’
A Central Texas therapist working with first responders and veterans wrote: “I am an LPC in Texas and am devastated by Alma’s announcement. Optum/UMR/United Healthcare are the main payors for my caseload. I see primarily first responders who cannot afford private pay, so walking away from Alma is not an option for me (My independent credentialing with Optum pays at an even lower rate).
“In my area, Alma is implementing a $10 cut for 90837, the main CPT code I use. For me that will mean about $700/month or $8400/year loss. This is the only time I’ve experienced rate cuts. I’ve had several increases from insurance companies I’m independently credentialed with without me even asking! …
“I’m a solo private practice in Central Texas…. I already work unsustainable hours and was hoping to cut back soon, so this was a gut punch. Here’s something that makes me extra angry. The Alma rate cut for psychiatrists in my area is only $2-4! Their rates are already astronomically higher than masters level therapists, and I don’t have a problem with that. But if Alma feels the need to make a cut, $10 for MD’s and $2 for LPC’s makes a lot more sense. Why stick it to the little guys?
“I know that Alma gets more than $20 for every claim I file, plus monthly membership fees from all providers. I think those run about $150/month. I paid for the whole year last December in order to get a discount.
“I’m already working 60+ hours a week, 40-45 of those are actually counseling hours. I don’t know how I could possibly add more.”
Optum investor in Alma
In 2022, Alma raised $130 million in Series D funding led by Thoma Bravo, a software investment firm, with participation from Cigna Ventures. “Existing investors Insight Partners, Optum Ventures, Tusk Venture Partners, Primary Venture Partners, and Sound Ventures also participated in the round, bringing the company’s total funding to over $220 million,” the company said in a press release.
In response to our earlier query about the size of Optum’s investment, an Alma spokesperson wrote in an email: “With respect to Alma’s funding, we have raised capital from multiple venture capital funds including Thoma Bravo, Insight Partners, Tusk Venture Partners, First Round Capital, Primary Venture Partners, Rainfall Venture, Sound Ventures, BoxGroup, Optum Ventures and Cigna Ventures. While we cannot comment on the specific ownership of any particular fund, Alma is a fully independent business and all existing investors have minority ownership stakes in Alma. You can see more information in our press release from our most recent funding round.”
Alma laid off 9% of its workforce in early October, saying it needed to “re-focus resources.”
Headway raised $100 million in July, bringing the company’s valuation to $2.3 billion.
Startups’ trajectories
The discussion about Alma, Headway and other similar platforms often touches on the fact that Startup World is focused on making money, and that goal will be paramount. That is especially true of venture-funded companies. So it might not be a complete surprise that patient or clinician takes a back seat to making money.
Some point to other companies, like Uber — the model is to disrupt the industry they are in and make money by taking advantage of the disruption. In the process, the drivers — the actual providers of the service — are often squeezed. Are Alma and Headway mental health companies, or are they tech companies that do business on mental health?
It is also true that mental health practitioners find the drudgery of insurance paperwork to be repugnant and time-consuming, as the country battles a mental health crisis exacerbated by the pandemic — so the platforms’ offer to take on that burden is attractive. Also, an increasing number of practitioners refuse to accept measly insurance rates, along with their heavy paperwork requirements — leaving people who want mental health care to either pay out of pocket, or go without.
Many therapists feel that having an avenue for easier insurance coverage is an overall good, allowing them to bring services to those who need them and cannot pay out of pocket.
Recognizing that capital-hungry investors might deliver less-than-good services in the pursuit of returns on investment, Rep. Pramila Jayapal and Sen. Edward J. Markey (D-Mass.) introduced a bill in Congress in July to set guardrails for private equity investment in healthcare.
What can you do?
If you have information about insurance payments for mental health care, or other issues you think we might want to know about, email jeanne@clearhealthcosts.com or use our secure Signal at 914-450-9499.
For clinicians: It may be worth discussing this with a professional association, like the New York State Psychological Association or the American Psychological Association, if you are a member.
The APA Services and the American Psychiatric Association recently told Optum how onerous its “pre-payment review” policy is, and Optum said it was discontinuing this practice, though we have still heard of people who are not getting paid.
Register your objections with the insurer and the platform.
This is obvious, but the decision to use Alma, Grow, Headway or others is one only you can make: Does it make sense for you and your practice?
Regulators and legislators have an interest in helping; consider raising these issues with your elected representatives or regulators.
For patients, or, as we like to call them, people: The Consumer Finance Protection Bureau has a complaint system.
We have learned in many years of immersion into the healthcare marketplace that many therapists decided long ago not to accept insurance payments. If you’re unsure about who accepts what, the practice’s website may be informative.
Psychology Today has a find-a-therapist function, with therapist profiles including, quite often, the insurance they take and a statement of hourly cash rates. You can do a zip-radius search to find therapists close to you.
Regulators and legislators have an interest in helping; consider raising these issues with your elected representatives or regulators.
