The Problems with Tech Platforms and Mental Health for outpatient providers

As a CA LMFT employer of clinicians providing outpatient care for the last 14 years, I have certainly seen my fair share of industry wide changes. I continue to feel it's important to educate those newly licensed as well as those considering using a big tech platforms to start or grow a practice. There is much to consider here about the impact they have had and the future of outpatient mental health care.

Credit: Barbara Grisold, LMFT for the following bullet points:

• Transparency: 

  • Many of these platforms seem to want to quickly sign you up, without giving a lot of information, or making it easy to ask questions first.  This means therapists may join without fully understanding the terms of their agreement.

  • Some platforms do not have therapist directories, and do not assist with client referrals, something many users had expected.

    
    

• Calendar requirement: Some platforms require you to use their online calendar so clients can schedule initial appointments.  While this speeds referrals and shortens wait times for clients, you may not be able to screen new clients for appropriateness.  

  
  

  

  Hidden concerns in Big Tech Big Platforms Such as Headway, Alma, Rula, Better Help, Talk Space and Grow Therapy

  
  

• EHR requirement: Some platforms require you to keep your notes in their program so they have access to them. This may not allow you to customize notes to your needs, and might give the platform more access to your charts than you would like.

  
  

• Artificial Intelligence (AI):  Some already offers the use of their AI program Note Assist for your notes.  However, recent articles have documented serious problems with this program. 

  
  

• Access to records: 

  • Different platforms reported varied ability to access your confidential client records.  In fact, one platform stated they will release records for Risk Adjustment (RA) audits to insurance plans without contacting the provider. If not giving the platform access to your records is important to you, you may prefer to work with a platform that will notify you when your records are released, or you might consider keeping your notes in an external EHR. 

  • At least two platforms stated that they do their own INTERNAL audits on provider files progress notes and treatment plans, to find weaknesses and make suggestions for improvement.  This is not something all their users were aware of.   If this is something you would welcome — or hate — this might be something to ask about.

    
    

• Medicare requirement: Some platforms will not accept therapists who have opted-out of Medicare.  Since there are some real benefits to opting-out of Medicare, and there can be consequences if you don’t, this can block your ability to see older and disabled cash-pay clients in your private practice.

  
  

• Dependence on platform: 

  • If you credential through one of these plans, you are only credentialed under their Tax ID number.  You won’t get a copy of any provider contract of any insurance plan they credential you with.  The contract is between the platform and the health plan.  This means you have no document outlining what you are agreeing to, and your responsibilities as an insurance provider.  If there is an insurance problem, you must rely on the platform to troubleshoot with the health plan – you can’t contact the insurance plan yourself.  You must also rely on the platform to submit your resignation to a health plan.

  • A big complaint from users was that many of these platforms don’t offer phone support, and also didn’t respond quickly or knowledgeably to emails, making it difficult to resolve more complex issues.

  • The platform may handle financial issues differently than you would.  For example, if the insurance plan does not pay as expected, the platform could send your client a large bill for the balance, when you might have tried to negotiate something with the client.  I have also heard of a case where the platform did not inform the therapist when the client wasn’t paying their copayments.

  • One clinician told me her clients abruptly lost their coverage to see her because the platform did not let her know that the insurance plan needed an updated copy of her license and malpractice.

  • Because you do not hold the contract with the health plan, you do not have the ability to ask for a higher reimbursement rate.  You also can’t fight it if the rate drops, which recently happened with all therapists on one of these platforms who were contracted with United HealthCare / OPTUM.

    
    

• Fee issues: 

  • While the presumption exists that you can get a higher reimbursement rate from going with one of these online panels, this may not always be the case, particularly with Headway.  Several therapists reported they were paid significantly more when contracted directly with a health plan than they would be paid by Headway. 

  • Several therapists told me they did not know the exact amount the platform was billing the health plan for their services.  This became a problem when, during the deductible period, the client was handed a bill for each session for an amount that was higher than the therapist’s full fee.

    
    

• Practicing in other states:  If you are a member of PsyPact or another interstate compact, the platform may not accept this.  Just because these platforms operate in other states doesn’t mean you can do so legally.  Remember, to see a client in another state, you must be licensed (or permitted by the licensing board) in the state where your client is located at the time of the session.

  
  

• When you leave: 

  • Several platforms acknowledged that if the therapist leaves their platform, the clinician will no longer have access to the notes entered in the platform’s EHR.  This concerns me since notes are sometimes needed at a later date, such as to defend yourself in a complaint, or to support a client’s disability claim.  One platform’s provider contract stated, “any patient files and health records created by…Provider into the Company’s EHR system or telehealth platform … are and shall remain the sole property of the Company, and the Provider shall have no right or interest in such patient files or records.”  Again, this is a fact that the users I spoke with were often not aware of.   While you might be able to individually download each note as a PDF before leaving, this could be cumbersome if you work with a large number of clients.   If this is a concern, you might consider keeping your session notes (or a copy) in an external EHR. 

  • It’s important to note that if you decide to leave any of these platforms, your health plan in-network status will end.  You would have to apply to the health plan for an individual contract, which can take months, and there is no guarantee you will be accepted.  This may leave your insurance clients high and dry if you leave unless you plan in advance.

  
  

And then there are some ethical dilemmas:  

• The private-pay bind: Let’s say you are contracted with Aetna through Platform XYX, when an Aetna client comes to you in your private practice ready to pay you your full fee, out of pocket.  Is it unethical to charge them your full fee, and not tell them that you could bill for them through the platform, so they could use their insurance?

• Remember interstate therapy rules: Just because these platforms operate in other states doesn’t mean you can do so legally.  Remember, to see a client in another state, you must be licensed (or permitted by the licensing board) in the state where your client is located at the time of the session.

• Insurance plans are now investing in these platforms.  For example, United Healthcare / Optum and Cigna have invested in Alma and Headway.  This may lead to decreased provider reimbursement rates.

• Something to ponder: By participating in a trend where therapists are joining platforms to get higher pay, might you be making it harder for individual clinicians to get raises, thus forcing clinicians to have to join these platforms?  

The summary:  These platforms are growing in popularity, and can really help some therapists to build and grow their practices, but I have concerns on several fronts.  The main one:  Whenever you have a third party between you and the client, you are losing some of your control.  This sometimes leads to financial, administrative, and even ethical complications that can affect the clinical relationship. My hope is that this article serves to slow you down when joining, helps you analyze with clear vision the pros and cons of this move, and helps you ask good questions to get all the information necessary to make an informed choice.

Thank you Barbara for all those fantastic points!

After due diligence, licensed therapists need to protect both clients, records and their own license

What do to next:

My advice to outpatient therapists who want to run their own business is to avoid many of these problems is contract directly with insurance companies with your own tax ID. You maintain control and avoid many of the legal and ethical concerns outlined here. Otherwise, do consider working for locally run (by a therapist!) group practice who will know and be informed of all legal and ethical matters and be able to provide you with great clients, low risk and many additional benefits beyond pay including support, time off and a great culture. At Grow Through Life, we offer all of this to our clinicians who don't have to stress about any aspects of running the business so they can focus solo on providing great care. If this is you, we'd love to talk more about the opportunities we have available.

Please send your resume to:hiring@growthroughlifecounseling.com to learn more or visit us at www.growthroughlifecounseling.com/careers to learn more.

"Don't just go through life, grow through life." E Butterworth