The Mega-Platforms Controversy: A Biller’s Perspective

I admit it! With my biller’s perspective, I mentally cringe when someone says they have a “biller” or “credentialing service” but then cites Alma, Grow, Headway, Rula, Sondermind, Talkiatry, Talkspace, etc. That’s like saying a life coach is a psychotherapist.

For example, I saw this while scrolling Reddit.

Apologies to abdog5000, if you’re reading this: you’re far from alone in identifying the mega-platforms as “billers.” The entities position themselves as such.

Alma’s self-description, from a 2021 press release.

From Rula’s Provider FAQ:

Does it matter what the platforms call themselves?

If claims are being paid, of course not. Other than that…from a biller’s perspective, there are a few minor differences between the platforms and a billing/credentialing service.

A. Few. Minor. Things! (Too many to list here – they’re in the next blog!)

Am I worried about my business or biller colleagues being made redundant? Nope! Insurance is difficult. There’s plenty of work for people with the skills to help practices thrive – skills I teach!

So why am I sharing my biller’s perspective?

I intentionally wrote this blog to serve as a biller’s perspective, as a counterpart to Barbara Griswold’s discussion of the mega-platforms and the concerns associated with them. Third-party billers are part of the environment from which the platforms emerged.

That’s why I think the biller’s perspective is something to examine. The mega-platforms will have consequences for clinician support industries. Of primary concern to me is professionals who choose not to affiliate with the platforms, but who accept insurance. If they need or want a billing service, will it be hard to find a competent and affordable one?

The landscape of independent billers contributed to the rise of the platforms.

Smaller, independent billing/revenue cycle management (RCM) and credentialing companies – the traditional support systems for private practices – have faced tough challenges in the last decade.

• The mega-platforms rely on proprietary technology. Developing technology at this level requires substantial investment. Only venture capital has that kind of funding available.
• Clearinghouse, software, labor, cybersecurity, compliance, continuing education, errors & omissions insurance, and other operating costs are escalating. They may soon be beyond what small billing businesses can reasonably afford. What are the likely outcomes?
  • Billers stay small. But that limits the number of practices they can manage. Which keeps their income modest (at best). As costs of living escalate, billers burn out or close down, reducing the accessibility of good billing services to clinicians in need.
  • Raise prices. In this economy?! Let me know how that works out…!
  • If you’re a good biller, contracting with more practices than your company’s size can reasonably manage is a real risk. (Yes, even in the age of the mega-platforms!) While that keeps income levels up in the short run, in the long run it risks poor results, a bad reputation, possibly eventual closure.
  • Sell to a larger entity who can afford better technology, additional labor, and economies of scale. But getting in bed with the big boys, or venture capital, may not produce the desired result. Larger billing conglomerates usually service multiple specialties. It’s impossible to handle the special nuances of behavioral health the same way as you’d serve cardiology or pediatrics. I often hear from clinicians using bigger RCM services that they don’t feel valued or adequately attended to. The reason could be that mental health practices are usually much smaller than most of the large RCM company’s accounts, thereby not generating as much revenue (and being viewed as expendable).
• Labor is especially problematic for smaller companies:
  • Payroll / taxes.
  • It’s difficult to offer wages – and benefits! – that are competitive with entities who have much deeper pockets.
  • There’s not much room for growth in a smaller RCM company. Good employees who desire growth won’t stay long.
  • Continually training new employees is hard – you still need to conduct daily business.
  • The knowledge requirements are huge. If billing were easy, we wouldn’t be having this discussion!!!
  • Offshore outsourcing where labor is cheaper is an option. But that has other issues. (I won’t be discussing this further. Not today, anyway.)

These trends shaping billing/RCM firms have been decades in the making, and in my biller’s perspective, have contributed to the proliferation of the venture-capital platforms in behavioral health. However, the platforms may also become the catalyst for the further decline of small behavioral health third-party billing services.

This biller’s perspective on the future.

I often say two things:

1. I failed Divination at Hogwarts.
2. I hope I’m wrong! But…

I’m already seeing:

1. Clinicians on social media make points that are unfortunate, but 100% true:
   • I’m uncomfortable with the platforms, but
     • I can’t find a good biller
     • Billers are too expensive
     • The platforms give me more than a biller can, and I don’t have to pay for this stuff: EMR/clearinghouse, payment processing, fast credentialing, marketing/referrals.
   • All for (usually) higher rates than insurance would pay the same clinician in private practice. Is it any wonder third-party billers can’t compete?
2. Billing services who survive will be unable to accept smaller practices as clients. While a hybrid of private practice and working with a platform can provide therapists with acceptable income, billing services can’t survive on half-practices.
3. Clinicians may feel stuck with the platforms in order to work with clients needing to use insurance, because they don’t know how to manage revenue cycle management on their own. (I exist to disrupt that!)
4. The end result: insurance-owned mega “value-based care” practices.

Value-Based Care? Huh?

Value-based care (VBC) refers to the concept of structuring healthcare delivery to pay for outcomes rather than per procedure. It’s a new name, but not a new idea. And in theory, it’s attractive. It can reduce fraud, over-utilization, and maintain quality – what could be better? But measuring quality and outcomes in behavioral health has always been difficult. (To say nothing of tying reimbursement to quality and outcomes!)

Until now. The rise of the platforms has created an unprecedented ability to leverage AI on large sample sizes.

Now for the really creepy part. As already mentioned, the platforms market themselves as billing services. Perhaps this was deliberate. Do they really want to highlight the fact that some of their venture capital comes from insurers?

Yes – you read that right!

Sources:

Alma-Optum

Alma-Cigna

Headway – HCSC

Octave – Evernorth

Rula – Blue Venture Fund

The end goal of the platforms has been theorized as creating giant “value-based care” monoliths.

This isn’t just my view. Nor that of disaffected clinicians or billers on social media. It’s not a conspiracy theory. Want evidence?

• Grow Therapy requires notes to be submitted with every invoice. No note? No payment. Even insurance doesn’t conduct 100% audits.
• From a Grow press release dated April 8, 2024:
  • “… the launch of its enhanced measurement-informed care system …will allow it to elevate the care experience for clients and providers and make value-based behavioral care accessible for all patient populations…”
• Alma APA webinar October 20, 2024: Making Value-Based Care Models work for Mental Health Care Providers.

While researching, I created a fake email address & profile to get a sense of the client experience. Even as a self-pay client, to get a list of names and available appointments, I was required to complete the PHQ-9 and GAD-7. Real clients might be distressed enough that they wouldn’t think much about answering, but it was alarming to me. What’s done with that data? What if I’d used my real name, insurance information (if I had any!), and email address? Let alone added my credit card information?

I don’t pretend to be a cybersecurity expert, but I know “creepy” when I encounter it. It was May 26th when I created the fake profile – and in the two days since, I’ve received daily “Still searching for a therapist? We’re here to help!” emails from the platform.

Everyone’s suffering but the millionaires: why I wanted to write this blog

Most individual clinicians I work with confess that they’d prefer not to have to work with the platforms. They feel as if it’s the least awful of the many bad choices available to them. They know that middlemen are making millions in profits, and that clients with deductibles are having to pay more. They sense the ethical dilemmas every time they must make a decision in which client welfare is contrary to what’s best for their business. And if therapists’ professional lives are one moral injury after another, is it any wonder that burnout rates are so high?

Meanwhile, more fortunate colleagues are quick to judge their choices on social media. While it’s understandable that feelings are running high, seems to me that judgment should be directed at the millionaires profiting off a sick system – not our colleagues who are just trying to survive as best they can.

Traditional group practice owners are definitely feeling the bite also. Once licensed, it’s hard to expect a 1099 therapist to accept a 65-35 split when the platforms are there, dangling full reimbursement rates that are better than a small local group can negotiate. Groups who have switched to W-2 models and pay their clinicians more generously operate on dangerously thin margins if they don’t have substantial percentages of self-paying clients. Not a great recipe for a steadily-worsening economy.

Meanwhile, from the biller’s perspective, burnout rates are surging among us also. I’ve seen comments like these among billers on social media:

• “I can’t afford to have clients give me only the hard cases that take hours to resolve while putting easy claims through Headway or Alma.”
• “Seems like if the platform can’t resolve the claim, I get it sent over to me. What good are those services then?”
• “Doesn’t seem fair that it takes us months or a year to credential and contract someone but the platforms get it done in a couple weeks because they have preferential delegated arrangements and insider connections. It makes us look incompetent. Therapists don’t understand what’s really going on.”
• “Therapists expect to give me nothing but hard claims and Medicaid and still charge only 5%?”

Understanding the predominant way in which billers charge (a percentage of collections) might help. Billers spend time and effort setting up systems to prevent errors and/or correct them quickly. From the biller’s perspective, we set up a system to ensure as many claims as possible pay on the first submission. The profits from the “easier” claims balance the losses on claims which take months of phone calls and/or appeals to resolve. Giving the “easier” claims to a platform causes the carefully-constructed equilibrium to fall apart.

In the world of mental health service delivery, the platforms are like Amazon, who irrevocably changed the book publishing business and caused the death of independent bookstores. Or like Wal-Mart, who put small Main Street stores out of business with their economies of scale. (UGH – that Wal-Mart reference is showing my age!)

I’m only one voice. Yes, I’m speaking truth to power and using my accumulated knowledge to empower clinicians to manage insurance independently. And to teach billers the tricks of the trade so that everyone gets paid for their work and clients get served. But it’s up to ALL of us: individual clinicians, group practice owners, in-house billers/administrators, and third-party billers, to stand together if we want to effect change.

Want more discussion on this topic? I’ll be discussing the platforms TOMORROW with Sarah O’Brien, LCSW, Thursday, May 29th, at 8am pacific/11am eastern on The Healing Hour podcast.

Or check it out on YouTube afterwards!