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. Timely Filing of Claims
Providers must submit claims within 45 days of service with necessary information.
5. 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.