It started as a question about a woman’s therapy bills, which skyrocketed unexpectedly.
She had been promised a $10 copay for therapy with a specific in-network therapist, and entered a relationship via Alma, the venture-backed mental health practice management company. Then her bills rose sharply — to $127.52 — setting off a months-long back-and-forth about payments. The payment amount changed; multiple bills were issued for several dates of service; several different Alma reps came in to respond to dozens and dozens of emails requesting relief from both the client and the therapist.
But then it took a strange turn. Alma offered The Client a spot in an out-of-network payments pilot inside the company, using her personal health information to do so. Around the same time, Alma said repeatedly that it could not give the patient her records for her treatments — saying that’s not their responsibility because they are not a “covered entity” governed by the Health Information Portability and Accountability Act (HIPAA), but rather a “business associate” with different obligations.
It started innocently enough: In September, The Client (she asked that her name not be used because she doesn’t want her personal health information all over the internet) got assurance from Alma that The Therapist (she asked that her name not be used, to protect relationships with other clients and insurers) is in network for her with her insurance, and that she would pay an estimated $10 per session as a copay.
Almost immediately, The Client noticed that claims were being billed at a much higher rate, $127.52.
What followed was a long chain of communications. Both The Client and The Therapist addressed Alma, separately and on the same email chain, apparently in Alma’s system. The person at Alma answering questions changed frequently, meaning the two had to start over again with a new person. Often they would ask two or three questions in one email and get only one answer. (Many responses seemed suspiciously like AI, or an extremely thick customer service representative.)
Eligibility confusion
Months and months went by. Dozens of emails and replies ensued. Sometimes both The Client and The Therapist were on the same chain; sometimes, one was inexplicably dropped. Alma said the problem had been solved, but it hadn’t; new problems arose.
At one point, Alma said The Client had not met her deductible and thus the $10 estimate was wrong. Then, almost immediately, they changed their mind: “The latest eligibility check shows a $10 copay and the deductible is waived. This means the client’s only estimated cost for service moving forward is a fixed $10 at the time of treatment; they do not need to meet their annual deductible first.”
But the problems continued. And no refund was issued.
We asked Alma for comment, but they did not respond. If they do, we will update this post. (If you have information to contribute, email jeanne@clearhealthcosts.com or call Signal 914-450-9499.)
At one point, The Client noticed that the claims were attributed in some cases not to The Therapist, but to another entity: Alma Community Health Network. Her insurance company told her that the claims filed with this as the provider could not be paid properly — Alma Community needed to be removed and a corrected statement needed to be filed with The Therapist’s name on them.
The Client also wrote to Alma: “My records, including the ones that Alma just sent me, show that the same therapy sessions on September 2, September 9, and September 16, 2025 were billed twice — first at the in-network copay rate of $10.00, and later again at the full
session rate of $127.52 — resulting in an improper duplicate charge of $382.56. In addition, identical sessions were billed at inconsistent amounts ($10.00, $17.50), indicating misapplication of network status and improper claim processing.”
She asked for 1) a refund of the $382.56; 2) a written explanation of the inconsistent billing, and 3) confirmation that her account had been fully corrected.
More confirmation
For months, Alma confirmed that The Therapist was in network, and that the billing had taken place properly. In frustration, in January, The Client wrote:
“This is no longer a simple billing question. The documented, contradictory representations coming from Alma are now directly interfering with my care and my financial obligations.
I strongly support [The Therapist’s] request for a coordinated call — including the insurance company if necessary — to identify precisely where this breakdown is occurring and to ensure that it is promptly corrected. In addition, I am formally confirming my expectation to receive all requested HIPAA records related to my billing and payer information in electronic form, including but not limited to:
- claims submitted by Alma
- eligibility verifications
- benefit determinations
- internal billing notes
- communications with the insurer
- and all records used to determine my financial responsibility”
In January, after months of back-and-forth, Alma notified both that it had made a mistake, and that The Therapist was out of network for The Client.
The two pointed out that Alma had erred and should fix the problem — suggesting that The Client should get a refund and The Therapist should get a full payout. But the confusion continued, with both pointing out repeatedly that clinical needs were being affected.
Alma wrote in trying to explain in a question-and-answer format:
“Why does Alma appear in-network in some places (insurer portal, Alma website) if it is not? Because [The Therapist] had independent credentials this information was picked up.
“Why was the client told in writing that care was in-network in September and December if
that wasn’t true? At this time, a system error flagged multiple providers as falsely OON, so it was believed your provider was affected as well.
“Why did Alma previously state the payer was reprocessing claims due to incorrect OON
designation if claims were never in-network? At the time, we believed the provider was in-network based on the above.”
Time and money
Both The Therapist and The Client pointed out repeatedly that Alma’s mistakes were costing them time and money.
At one point, The Client’s access to her Flexible Spending Account funds was cut off by the F.S.A. administrator because of the dispute, she said.
But the dispute ground on, with no resolution. Several times, different Alma reps noted in their emails that they had done all they could, and were effectively closing the case, a tactic familiar to anyone who’s been in a dispute with a service provider that is tired of the conversation. In each case, The Therapist and The Client said effectively, “Nope, we’re not done here.”
The Client found Better Business Bureau complaints about Alma that caught her attention. Multiple complaints mirrored her experience: Alma customers complained of lack of support, random sudden out-of-pocket charges from a therapist previously confirmed to be in-network, and endless disputes. One person wrote: “This is a service that is supposed to help people with their mental health, not cause them distress.” Another: “Alma charged me $375 after claiming I could see my provider in network. My plan states that my responsibility is $0. Alma has not refunded me for this charge despite it being incorrectly charged to me.” A third: “Alma is not responding to me, I cannot reach a human being. Their billing department is grossly incompetent and breaking the law.” A fourth: “I was told I would have a $0 copay. For the first few months, my appointments were completely covered and I didn’t get charged. I had an appointment with my provider on July 3rd and on July 5th I received an email from Alma insurance that I would now have a copay of $260-380 and that I would owe this amount for my July appointment.” A fifth: “I’ve had to make 3 separate support tickets in the past 30 minutes. I cannot upload my insurance, and now the ai chatbot is blocking me from completing other tasks and I cannot close the window. I cannot start therapy because of these issues. I fear someone will eventually harm themselves while seeking help because of the friction of their processes.”
Multiple reviews had similar sentiments.
(Alma was recently bought by Spring Health, an employee assistance program company.)
No to records requests
Related to the billing dispute: The Client repeatedly requested a full set of her claims from Alma. Alma refused to turn them over, and a new “Alma rep” wrote that the partial records a colleague had “shared on January 30th represent the absolute maximum I and the rest of my Client Experience organization are permitted to release. I have to trust and enforce the strict boundaries set by our legal team, so those are the final records I am able to share.”
The Client asked in notes of surprise if this was a denial of her request for records, adding that “my request was made pursuant to 45 C.F.R. § 164.524.” (This is the section of the HIPAA privacy rules stipulating that patients should have access to their own records.) She added: “Please let me know if Alma will be issuing a formal written denial under HIPAA with the specific basis forwithholding the requested records.”
Both The Client and The Therapist pointed out that HIPAA does not allow a provider to deny access to claims.
They continued pressing for a claims history, and the “Alma rep” wrote: “Please consider my direct emails detailing the boundaries of our documentation as Alma’s official, written notice on this matter. Because Alma functions primarily as a billing and payment processor rather than a traditional medical facility, we do not generate standard denial letters.”
In March of this year, The Client requested her full set of claims from her insurer. These arrived around the same time that Alma finally agreed to send her her records.
(If you have information to contribute, email jeanne@clearhealthcosts.com or call Signal 914-450-9499.)
A surprise on PHI
Then, The Client wrote that she had been invited to enroll in an Alma pilot program for out-of-network clients. The purpose of the pilot is murky, but the correspondence includes an Alma rep saying “Clients would be invited to the Out-of-Network Pilot because they may be a good fit based on factors such as being a cash-pay client and having commercial insurance that may include out-of-network benefits.”
The Client asked several questions, and an “Alma rep” told her she’s free to opt out of the pilot.
The Client answered: “I understand that participation in the pilot is not mandatory and that I can opt out at any time. That’s not really the issue. What’s concerning is how I was identified and targeted for this in the first place. The criteria you’ve described — looking at payment status, insurance eligibility history, and recent care activity — makes it pretty clear that my P.H.I. is being used for internal analytics and outreach in a way that goes beyond what I would reasonably expect from a billing entity handling claims and payment.”
The Client also wrote: “As a billing entity, HIPAA obligations don’t change just because something is labeled a pilot. P.H.I. is supposed to be used for specific purposes and under the ‘minimum necessary’ standard. Using it to segment and target people for a program like this — especially one that seems at least partly business-driven — doesn’t obviously fit within that. …
“Even if I don’t participate, my information was still used to evaluate and target me for this. That’s the part that doesn’t sit right. At a minimum, it raises questions about whether this kind of use — especially if it ultimately benefits Alma — edges into something like unjust enrichment.” The minimum necessary requirement states that only the most minimal use of personal health information is allowed.
When asked if she had signed any contract, which perhaps would have stipulated something about use of her data, The Client said she had no record of anything similar. She did say that when she gave her payment information to Alma, she might have clicked to accept “terms of service,” as we all often do without reading every word. But she has no record of any contract.
The Client is now continuing to see The Therapist, out of network.
Business norms
Such concerns over HIPAA restrictions and other basic business norms are not uncommon in the world of these companies — like Alma, Grow, Rula, Octave and others — that say they’re smoothing the way for therapists and clients by reducing the administrative burden, said Barbara Zabawa, a wellness lawyer and law professor at the University of Missouri-Kansas City.
She said such relationships are common in healthcare now: In many cases, a management services organization takes over business functions while leaving the practice of, say, a dermatology or dentistry or mental health business to the provider. Sometimes the M.S.O. buys the practice outright, she said. That M.S.O. might be backed by private equity or venture capital, with a goal of making a lot of money and then selling in 5 to 7 years. But HIPAA still needs to be observed, she said — even as those M.S.O. groups cast themselves not as a practitioner but as a business associate of a practitioner.
“Just because they’re a business associate doesn’t mean they’re not subject to the HIPAA laws,” she said. “If, like in your example, this client is seeking access to their P.H.I., and they have to go through the M.S.O. to get it, then even if it’s a compliant Business Associate Agreement, they have to provide that access to the client. And as a business associate, they can’t be using P.H.I. for any purpose that wouldn’t be permitted by the covered entity that they’re contracting with.
“Alma is supposed to only be a vendor of services that the therapist hires for helping manage their clinic, and not the other way around. They end up looking like it’s the private equity-backed firm is the one that is hiring the therapists and dictating to the therapists how things are going to go, when legally it needs to be the other way around — the therapists need to be the ones in the driver’s seat and hiring Alma to manage services and then pay them a fee for doing that service, making sure that Alma is signing business associate agreements and complying with HIPAA as the therapist needs to comply, as a covered entity.
‘So opaque’
“I suspect that is not how it’s operating in practice in this situation. And so Alma has it has it in its head that they’re a business associate, not subject to the privacy rules. There could be an exception for healthcare operations if they were using the P.H.I. of this client for purposes of improving quality, and they wouldn’t have needed to get that client’s authorization to do it. But I don’t know if that’s what’s actually happening here, and because they’re being so opaque about it, it’s not helping their case.”
Has she heard of similar cases? “It’s happening all over the healthcare industry,” she said.
So who’s the cop here? “Technically, the cop should be the state licensing board, state legislators, because this would be mostly a state issue,” she said. “The reason why these arrangements exist the way they do is because of state ‘corporate practice of medicine’ laws. Of the 50 states, very few states don’t have a corporate practice of medicine law. But they have varying levels of enforcement and scrutiny, and so for a lot of these businesses, there’s not really oversight. Medical examining boards or licensing boards are typically not looking to get involved with these kinds of arrangements. But they should. Having more teeth in these corporate practice of medicine laws would definitely help — but so far, it has not gone well for enforcement.”
It’s also true that a Rhode Island regulatory decision is not binding in any other state, so, as so often happens in healthcare, the regulatory patchwork leaves enforcement spotty. And there doesn’t seem to be an appetite in Congress to address such matters on a federal level.
As far as regulation on the Personal Health Information matter, and the compliance with HIPAA, she said, “It could be not only a complaint to the Office of Civil Rights for potential HIPAA violation, but the Federal Trade Commission on improper use of data, especially if there is not any transparency on how they’re using data and why they’re collecting data — or if it conflicts with what it says on their website about their use of data. The F.T.C. has been active in this space under Section Five of the Federal Trade Commission Act, so that could be an avenue as well.” The Federal Trade Commission explained this here.
One other aspect of this matter is the question from The Client if she signed something that had an acknowledgement that Alma can do whatever it wants to do with her data. She recalled that she might have signed something, and opined that any opt-in for such matters might be on Page 23 of a 25-page “terms of service” document. We are all familiar with these documents, which Zabawa said are called “adhesion contracts.” This is the take-it-or-leave-it document you have to click on to advance in a process of signing up for a tech service, agreeing to a download and so on.
Speaking of such contracts, Zabawa said Congress is “aware of the problem, but the tech companies are so powerful that nobody’s doing anything about it.” (If you have information to contribute, email jeanne@clearhealthcosts.com or call Signal 914-450-9499.)
Unclear information
Linda Michaels, a PsyD and M.B.A. who is the chair and co-founder of the Psychotherapy Action Network and a psychologist in private practice in Chicago, said that PsiAN had surveyed therapists and done other research about these companies, which they refer to as Practice Management Companies.
“A lot of financial information is hidden, or unclear to therapists,” she said. “One of the most alluring claims of these P.M.C.’s is that they say that therapists will make more money if you sign with us. We can get you a better deal with companies. In our research, we found it was 50-50 – 50 percent said ‘yes, I am making more,” but a third are making less. The whole financial piece is very murky.
The insurance companies’ investment stakes in Alma, Grow, Rula, Octave and so on are often not clear to therapists, she said: “It should not be a mystery, but it is. In the survey we asked, ‘If you knew that they were owned by an insurance company, would you use them?’ And 80 percent said no.”
The companies have a lot of power, and they can be transparent or not, she said.
“The business that all of us are in – providing emotional and psychological care to people who are vulnerable, are suffering, dealing with trauma, abuse, addiction – you know, this is not like buying a pair of jeans off Amazon. I mean, this is, this is people’s lives.
“These are fundamental questions about how these companies work. Who owns them? Who are you getting involved with? What are their responsibilities? How am I getting paid? How much am I getting paid? These should not be mysteries. A lot of therapists wrote in a lot of comments into our research survey. A lot of them reported kind of bait-and-switch tactics where they were told one thing, and then, ‘Oh no, we have this new policy.’”
Alma’s mission
Summing up the months of conflict with Alma, The Therapist said: “It’s literally going against their very mission. If the point of these platforms is to help patients access affordable care, and have for the provider an infrastructure that alleviates their administrative burden so they can focus on the priority of the clinical work — they’re doing the exact opposite here.
“If [The Client] had not been an eight-plus-year client of mine, there is no way that a client would have stuck around, right? I would have lost the client. The client would have lost my care. The client would be disillusioned with the process.
“Even so, even with the clinical alliance that [The Client] and I have built over time, it still was incredibly disruptive. We had full sessions around this, and then I would compensate, go far over, knowing that there’s a clinical component to this that we cannot ignore. We have to talk about it, but we also have to talk about other things. So then I would be doing hour-and-a-half long sessions with no compensation. Without disclosing anything about the actual work, you can only imagine the points of activation, around money, around being taken advantage of, about predatory, unjust practices on anybody who’s seeking therapy, let alone the unique considerations for each client who might be activated in really big ways as a result of this.”
In closing, she noted that Alma had recently sent an email headlined “protecting our community — compliance policy updates,” referring to new procedures on monitoring of billing, coding and documentation, and saying Alma may request charts and records, and can require education or corrective action plans and more. An entire discussion on Reddit about this email documented therapists’ apprehension about new policies, particularly considering that therapists are not employees of Alma but rather 1099 contractors.
The Therapist said, “It literally made me nauseous when I received it.”
What you can do
For therapists and clients: Read your contracts carefully, and make sure you are comfortable with the stipulations. If you have questions or are not in support of a practice — as, for example, use of P.H.I. — opt out. Or switch to another service that has terms and conditions you find acceptable.
Zabawa wrote: “I would suggest therapists and patients carefully read their agreements with these companies and know that they can and should push back on data privacy (in the case of patients) or corporate expectations that don’t meet the standard of care (in the case of therapists). They could also consider reporting data privacy violations to the F.T.C. and/or the Office of Civil Rights. Therapists and patients should also consider working collaboratively with self-funded employers to find other ways to improve health care quality and reduce costs, such as through direct care arrangements.”
Michaels recommended two PsiAN resources at Private Practice toolkit of Psychotherapy Action Network. One is a guide for managing a private practice oneself, and one is for using a platform and what questions you should ask first. “That page also includes a link to our full research report on Practice Management Companies,” she wrote in an email.
She also said therapists and clients need clarity about such issues.
“Any sort of business decision that a therapist makes is really a clinical decision. Those business decisions need to be informed by your professional values, your ethics, what you think of as good clinical care, the kind of care you want to provide. If you are very clear on all of that, I think you’re in a better position to evaluate these companies and say, ‘Am I able to provide the kind of care I was trained to do and that I want to provide to people, given how this platform operates?’ In the case you outlined at the beginning, it sounds like the answer is like no – where you know the rules of the road are not clear to the client. You know they’re getting roped into things that haven’t been fully explained.
“I think therapists really need to have more of that mentality — you don’t want to get into a position where you are sacrificing your clinical, professional and ethical standards.”
One of the fundamental problems, Michaels said: “Insurance companies discriminate against mental health care. There is not parity in how they operate. They underpay therapists relative to medical-surgical clinicians, and they overburden therapists relative to medical-surgical.”
Insurance company investments in companies like Alma, Grow, Rula and so on, she said, “let the insurance companies pay themselves. Any time a therapy session is done, the insurance company as an owner of the platform makes more money.”
As a corrective for mental health care, she pointed to a law passed in the state of Illinois, called House Bill 1085, attacking some of those problems: Underpaying therapists, long and complicated insurance credentialing, pushback from insurance companies on the use of the 90837 code for a 60-minute session, and other factors. The bill is projected to open up therapy for 2.5 million people in Illinois when implementation begins in 2027, she said.
(If you have information to contribute, email jeanne@clearhealthcosts.com or call Signal 914-450-9499.)
