Billing Practices Overview

Overview

Alma Integrity Standards promote our mission by:

Creating clear expectations for providers in terms of how to use the Alma platform and tools.
Establishing an environment of safety and respect, while supporting providers in maintaining autonomy of their practices.

To learn more about our integrity standards as a whole, please see What are Alma Integrity Standards?

This article covers Alma’s policies around Billing Practices:

Rendering Provider Accuracy
Client Accuracy
Coding and Session Accuracy
Timely Filing of Claims
Supervision
Balance Billing

1. Rendering Provider Accuracy

Providers must accurately bill services to payers in terms of the rendering provider and are not permitted to bill for services of other providers, whether the provider is independently licensed or not.

The Alma Insurance program does not currently support supervision. Supervision with insurance payers requires an additional contractual agreement with the payer as well as additional field requirements on the CMS 1500 form.

Currently, any claim submitted through an Alma account is processed to insurance as being rendered by the Alma account owner. If a claim submitted through the Alma Insurance Program is not rendered by the Alma account owner, the claim will be considered a violation of Alma's policies, and may subject an individual to legal or disciplinary actions.

2. Client Accuracy

Providers must accurately bill services to payers in terms of identifying the client receiving services.

This includes ensuring that the details entered into the client’s profile accurately reflect the client who is receiving services, and if they are dependent on the insurance, the information of the primary subscriber is entered underneath (see the image below). Failure to enter the client’s legal name in the insurance details section may lead to improper billing and can be viewed as fraudulent billing by the insurance payer.

To designate someone as the primary subscriber on your client's insurance policy, like a parent or partner, scroll down while you enter your client's insurance details. Click "No" under the question, "Are they the primary subscriber?" to open up a space for the primary subscriber's name and date of birth.

3. Coding and Session Accuracy

Providers must accurately bill services to payers in terms of coding accuracy and session accuracy.

4. Billing Integrity Monitoring

Alma is committed to supporting providers in maintaining compliant billing practices and protecting the integrity of the claims submitted through the Alma platform. As part of this commitment, Alma conducts ongoing monitoring of claims data to identify billing patterns that may indicate potential fraud, waste, abuse, or non-compliance with payer requirements, applicable law, or the terms of this Billing Practices Integrity Standard (collectively, "Billing Irregularities").

What Alma Monitors

Alma's Clinical Operations team reviews claims data submitted through the Alma platform on an ongoing basis. Billing patterns that may trigger review include, but are not limited to:

Use of CPT codes at rates that significantly exceed network averages or expected clinical norms
Billing patterns inconsistent with the provider's license type or scope of practice
Claims volumes or session frequencies that exceed typical clinical practice parameters
Temporal anomalies
Use of add-on codes, modifier codes, or code combinations at atypical rates
Any other pattern that, in Alma's reasonable judgment, suggests Billing Irregularities

Alma reserves the right to modify the specific billing patterns subject to monitoring and to add new monitoring scenarios as payer requirements, regulatory guidance, and clinical standards evolve. Providers will not necessarily receive advance notice of the specific patterns being monitored, as prior notification could compromise the effectiveness of Alma's compliance efforts.

Provider Cooperation

When Alma identifies a billing pattern that warrants further review, Alma may contact the provider to request additional information, including clinical documentation, progress notes, or other records supporting the claims in question. Providers are required to cooperate fully with any such review, including by:

Responding to Alma's inquiries within the timeframe specified in the request (typically five (5) business days, unless a different timeframe is stated)
Providing requested clinical documentation and records promptly and completely
Participating in discussions with Alma's Clinical Operations team regarding billing practices and documentation, if requested

This cooperation obligation is consistent with and in addition to the provider's existing obligations under Section 2.8 (Records) of the Participating Provider Agreement, the provider's agreement to comply with Alma's Integrity Standards, and the provider's agreement to fully participate in applicable Alma IPA programs under Section 2.2 of the Participating Provider Agreement.

Outcomes of Billing Integrity Review

Following review of a provider's billing patterns and any supporting documentation, Alma may take one or more of the following actions, depending on the nature and severity of the findings:

Education and Guidance: Alma may provide the provider with educational resources, documentation guidelines, or best practice recommendations to support compliant billing going forward.
Corrective Action Plan: Alma may require the provider to complete a corrective action plan addressing identified deficiencies. The provider will be given a reasonable timeframe to implement corrective measures, and may be re-audited following implementation.
Enhanced Monitoring: Alma may place the provider under enhanced monitoring, which may include pre-submission review of claims prior to billing.
Claims Adjustment: Alma may cancel, reverse, or adjust claims that Alma reasonably determines were submitted in a manner inconsistent with payer requirements, applicable law, or this Billing Practices Integrity Standard, and may deduct associated amounts from the provider's payouts.
Payout Freeze: Alma may freeze the provider's payouts pending resolution of the review.
Integrity Standards Violation: Alma may issue an Integrity Standards violation, which will be documented in the provider's record.
Referral to Payer: Where Alma determines that identified billing patterns may constitute fraud or a violation of payer contract requirements, Alma may report its findings to the applicable Participating Plan(s).
Government Notification: Where Alma determines that the nature of the identified conduct requires government notification, Alma may report its findings to the appropriate government authorities.
Platform Access Suspension: Alma may suspend the provider's access to the Alma platform pending completion of a review, investigation, or corrective action.
Membership Termination: Alma reserves the right to terminate the provider's membership and Participating Provider Agreement in accordance with the terms of those agreements, including for failure to cooperate with a billing integrity review, failure to complete a corrective action plan, or findings of fraud, intentional misrepresentation, or repeated non-compliance.

Alma will exercise its judgment in determining the appropriate response and will consider factors including the severity of the findings, whether the pattern appears intentional or inadvertent, the provider's responsiveness and cooperation, and whether the provider has prior Integrity Standards violations.

Relationship to Payer Audits

Alma's billing integrity monitoring is separate from, and in addition to, any audit conducted by a Participating Plan or government agency. Cooperation with Alma's billing integrity review does not satisfy or replace a provider's obligation to respond to payer or government audits. Conversely, cooperation with a payer or government audit does not satisfy a provider's obligation to cooperate with Alma's billing integrity review.

No Limitation on Existing Rights

Nothing in this section limits Alma's rights under the Participating Provider Agreement, including Alma's right to request records under Section 2.8, to enforce Participation Policies under Section 2.7, or to terminate the Agreement under Article 5. This section is intended to supplement, not replace, those provisions.

5. Timely Filing of Claims

Providers must submit claims within 30 days of service with necessary information.

6. Balance Billing

What is Balance Billing?

Balance billing occurs when a provider bills a client for the difference between an insurance company’s allowed amount and the provider’s fee.

Providers who are in-network have agreed to accept the insurance company’s allowed amount as payment in full (excluding any applicable copays, deductibles, or coinsurance) for a covered service. Because of this, providers are not permitted to charge clients an amount that is not covered by the insurance company.

Examples of Balance Billing

1. When an in-network therapist bills a client for the difference between the therapist’s charge and the allowed amount for a covered service (ex: individual psychotherapy). For example, if the therapist charges $100 and the allowed amount is $70, and the therapist bills the client for the remaining $30.

2. When a provider charges a client for additional non-covered services. For example, the client and provider meet for a 90-minute session, and the client is charged an additional amount for the extra 30 minutes not covered by their insurance.

Alma’s Stance on Balance Billing

Providers can only bill for eligible services for in-network clients and can’t collect the rest out-of-pocket, even if a client signs a patient service agreement agreeing to the additional charges. Charging additional fees for covered services is considered “balance billing”. If it’s a non-covered service (such as ketamine therapy etc.), the provider can bill on an out-of-pocket basis.

Covered Services

Individual psychotherapy is typically a covered service, so in-network providers must abide by the contracted rate. A client’s insurance plan determines the amount of time that will be covered so even if a provider chooses to extend the time of the session beyond what insurance allows, that is still a covered service and the provider cannot bill the client for additional time.

Non-Covered Services

Service types that are not covered through payer contracts (for example, ketamine therapy, writing letters to school districts, collateral time with other providers, etc.) can be billed on an out-of-pocket basis.

For non-covered services, providers should abide by the following best practices:

Notification: Providers should clearly inform clients in advance that a service is not covered by their insurance and that they will be responsible for the full cost.
Consent: Providers should obtain the client’s written consent to receive and pay for non-covered services before providing them.
Transparency: Providers should be transparent about the costs of non-covered services upfront, ideally providing a good faith estimate.

Deduction Policy

If an insurance claim processes differently than our initial estimate suggests, we’ll take the necessary steps to ensure you receive and retain your full insurance payout rate. To learn more about how Alma supports our providers against deductions, please see Deduction Coverage Guidelines.

As a reminder, if we receive notification of claims denial or updated client payment responsibility, your payout from Alma will not change so long as your client pays their Alma invoices in a timely manner. However, you’ll remain accountable for client invoices left unpaid after 60 days. In the event that your client has not paid their Alma invoice within 60 days, we will deduct the amount of that invoice from your next insurance payout.

There are several situations in which you may be subject to payout deductions:

1. Failure to respond

Failure to respond to billing-related questions from the Alma team in a timely manner may lead to the cancellation / reversal of impacted claims.

If you don’t respond to such an inquiry, we will always notify you that as a next step, we will be canceling the impacted claims. Doing so is necessary in certain situations in order to comply with our payer contracts. Please keep in mind that, due to timely filing constraints, Alma cannot guarantee that claims can be resubmitted once canceled.

2. Unpaid Client Invoices

Any client invoices left unpaid after 60 days will be deducted from your upcoming payout because we paid this portion to you in advance of us receiving it from the client.

If we do not receive reimbursement from the client, we will ask that you work with them directly to ensure payment for outstanding sessions.

3. Inadequate Documentation

Failure to provide adequate documentation in the event of an audit may lead to a denied claim and payout deduction.

In the case of an audit, Alma will request medical records from you. The records will then be assessed for adequacy.

If a provider’s documentation is deemed inadequate and the claim is subsequently denied, Alma will deduct the denied amount from the provider’s next payout. To learn more, please see What to Expect with an Insurance Audit.

4. Medical Record Requests

You must respond to a medical records request from the Alma team within 30 days from the date of the message. Failure to send records within this time period will result in a freezing of your payouts.

If you do not respond with all outstanding records within an additional 30 days (60 days from the original message), your membership will be terminated and the associated claims will be deducted from your final payout.