How to Survive Through This Tumultuous Time
A little while back, Alma made an announcement that was unsettling, upsetting, and for a lot of therapists (including myself), angering. People were all of the above — and rightfully so. It wasn’t just a billing update. It was evidence that the private practice landscape is shifting, and it doesn’t look like it’s headed in a very good direction.
I want to share my honest take on it. But mostly, I want to talk about what to do — there are tons of issues that need to be addressed. Tons of people are affected by these changes including clients and therapists. However, I want to task myself with helping you create a practice that can survive through these times. And actually, not just survive, but thrive.
The Announcement, Briefly
Here’s the news in plain terms: Alma says Aetna will stop paying more for a 60-minute session (90837) than for a 45-minute one (90834). The longer session gets reimbursed at the lower rate — not the other way around.
For quick context: there are a few main codes therapists bill — a 30-minute session, a 45, and a 60 — and historically the longer the session, the higher the rate. That’s how it’s worked. None of this has ever been all roses, either. You’ve heard about audits and recoupments for therapists who billed a lot of longer sessions. Those stories are real, but it doesn’t usually happen at the rate a lot of therapists fear. The point is that insurance has always made things difficult for therapists — but now it’s getting worse. This announcement is the proof.
I could spend the whole article there. I’m not going to, because I want to make sure your practice can survive this, so let’s get practical.
Too Many Practices Depend Entirely on Big Tech and Insurance Companies
Many therapists have built an entire practice on a single platform. All your clients come from Alma. All your billing happens in Alma. Your credentialing is there too. When everything runs through one place and that place changes the rules, you can see how fragile the whole thing is.
You don’t want your practice to ebb and flow with Aetna, with insurance companies, or with Alma. That’s not stability — it’s dependence. And dependence is exactly what gets exposed in a season like this one.
Where This Is Headed
For the longest time, people asked the obvious question about these platforms: Is this too good to be true? How is this sustainable? And we’ve started to get our answer.
In the early days, signing up with Alma often meant a steady stream of referrals — consistently, many a month — and higher rates than you could get on your own. People filled their caseloads fast. Then you started to hear the opposite: “I’m not getting referrals anymore.” “My lead quality has gone down.” Now the rates themselves are getting cut. Put those together and you can see it for what it is: a bubble that’s starting to pop.
And these changes create pressure for providers and clients. Therapists have to choose — keep seeing clients for the longer session and get paid less, or shorten the session? Those aren’t decisions we should have to make. The call should be about what the client needs. The ripple effects reach clients, too: some clinicians will move people to shorter sessions even when they’d benefit from more time, and some will get fed up and stop taking insurance altogether. That means fewer in-network options and, in some cases, shorter sessions than people need.
How to Survive: Build a Practice That Stands on Its Own
There are a lot of problems here, and we can’t fix them all at once. But here’s the first thing I want you to sit with: how do you build a private practice that’s independent?
