This is an exclusive BHB+ story.
Amid rising rate pressures, some small-scale, independent therapists feel pressured by payers to relinquish their independent contracts with insurers and join enablement platforms like Headway or Alma to secure better rates.
In theory, these platforms aim to solve problems similar to those franchisors face: take care of administrative burdens and time-consuming business logistics, and provide tools like credentialing, payer networks and billing workflows to free up therapists so they can spend more time on care instead.
However, with the challenging rate environment already in place, providers told Behavioral Health Business they feel nudged toward joining platforms like Headway or Alma. But once they do, pay is only marginally better and the platforms’ promised business acumen is not as supportive as they were led to believe.
Dr. Ajita Robinson, executive director of Bethesda, Maryland-based Friends in Transition Counseling, said in addition to recent reimbursement issues with CareFirst Blue Cross Blue Shield (BCBS) of Maryland, she has felt pushed toward these solutions during rate negotiations.
Robinson said that when she has requested rate increases from CareFirst in the past, she has been told they would not review an increase, but that if she contracted through Headway, her rates would go up by $17 per session. But that would mean her organization would have to give up its independent contract with CareFirst and become contractors under a 1099 with Headway.
The last rate increase she received from CareFirst was for $1, she said.
“I think it’s unethical, but it absolutely should be illegal for them to say we will pay you more if you give up your privately held contract that we’ve had for 14 years… to subcontract over 200 clinicians under this third-party agency is the only way we can get an effective increase,” Robinson told BHB.
Joining Headway also did not make sense from a logistics perspective, Robinson said, since her organization already has practitioners, a billing team and compliance officers in-house.
CareFirst and Headway have had a partnership since 2022, but CareFirst does not have any members on Headway’s board or an investment in the company, a Headway spokesperson told BHB.
“Headway’s mission is to expand access to affordable mental health care, and we do that through a provider-centered model that gives clinicians the technology, tools, and operational support they need to succeed, while absorbing the administrative and financial burden of working with insurance,” a spokesperson told BHB. “Independent practices face real structural barriers when it comes to getting credentialed, managing claims and getting paid reliably. Headway exists to solve that. When reimbursement delays or claim denials occur, Headway absorbs that risk: providers on our platform are paid on a regular biweekly schedule, regardless of when or whether an insurer reimburses us.”
CareFirst was contacted for comment on this story and directed BHB to BCBS for comment, which is included further down in this story.
Alma has also been cited as a platform that small or independent providers have felt pushed toward by payers, sources told BHB.
Yet, recently, Alma providers have faced some challenges. The company announced on May 21 that Aetna will reduce the rates it pays therapists via Alma’s platform, beginning July 15, which is something providers already feared. Alma was contacted for comment on this story but did not return a response.
A spokesperson for Aetna, the national health plan that just reduced the rates it will pay therapists on Alma, shared that at their core, these platforms are intended to scale access and connect patients to virtual care.
“Our rate policies are based on the level of care provided with an emphasis on shared and measured outcomes aided by technology, not how providers connect with members, allowing them the flexibility to join one or stay independent,” Aetna’s spokesperson told BHB.
Neither BCBS or Aetna commented on whether or not they encourage small or independent providers to join platforms in rate negotiations.
BHB also reached out to Cigna for its perspective. Their response has yet to be received. This story may be updated.
The promise of therapist enablement platforms
Ghost networks have plagued payers for decades and have come with serious legal and financial implications. A 2023, secret shopper study by the Senate Committee on Finance found that over 80% of mental health provider listings on Medicare Advantage directories are inaccurate or unavailable.
Therapist enablement platforms that offer a consolidated, up-to-date view of in-network providers are often pitched as a potential solution to payer’s access issues. The platforms also offer ways for independent therapists to get in-network with more payers, creating an enticing proposition for payers who are frequently looking to expand their behavioral health capabilities.
“Access to quality mental health care remains a challenge for many Americans,” a spokesperson for The Blue Cross Blue Shield Association told Behavioral Health Business. “Some Blue Cross and Blue Shield plans may use these platforms to help improve access to care, provide a better user experience for members and to support provider administrative costs.”
As a result, these platforms have also attracted attention from many health plan’s investment arms.
For example, Headway has received investments from Health Care Service Corporation (HCSC), an independent licensee of BCBS and the largest customer-owned health insurer in the U.S. In 2023, HCSC participated as a lead investor in Headway’s $125 million Series C round.
Alma, an enablement platform that was recently acquired by SpringHealth, also has ties to insurers. Both Optum Ventures and Cigna Ventures – the investment arms of the respective insurance giants – participated in Alma’s $130 million Series D fundraise in 2022.
Where the pressure is being felt
While therapist enablement platforms offer ease of use, the platforms have the power to negotiate rates with payers, taking away some of the power from the individual providers.
“I’m really disillusioned with insurance companies and then to add in these intermediary [entities], it almost feels disguised as an auditor of sorts,” Dr. Stephanie Steele‑Wren, owner of PsychologyWorks in Bentonville, Arkansas, told BHB. “They just have more control and hands in what you’re doing, and they love to audit, so it kind of feels like being audited in disguise in some way.”
Steele-Wren said she was previously approached by Lyra Health, another enablement platform in the space, about a 1099 contract offer. Ultimately, she decided against onboarding because of low rates. Overall, she sees these platforms exacerbating issues across an already challenging reimbursement ecosystem and also emphasized the loss of provider autonomy when joining one. She said this is something she has watched colleagues grapple with across the field as well.
John Puls, the owner and founder of Full Life Comprehensive Care, a practice in Boca Raton, Florida, said over the last year he has witnessed what he feels like is an uptick in payers more directly steering providers onto platforms like Headway and Alma.
“If the eventual goal from a lot of these payers is they want the majority of their providers credentialed with Alma or Headway, then what I would wonder is when that happens, what would stop Headway and Alma from then reducing what they pay providers?” Puls told BHB. “Because if it’s at a point where they really have no choice but to be on Headway and Alma, why would they continue to pay these higher rates? If they don’t lower the rates of reimbursement, will they just keep them stagnant while, on the back end, negotiating higher rates with the payers?”
Puls initially joined Headway, not because of payer pressures, but actually in an aim to take advantage of referral bonuses at the time. However, he left the platform due to additional requirements and frustrations with billing errors. He also previously worked with Alma and saw its active referrals as a real added benefit. However, once his practice was filling up, he no longer felt that way.
Aaron Martin, a San Francisco-based therapist with an independent practice in his name, Aaron Martin Therapy, shared that often even the platforms’ advertised to help reduce administrative burdens actually increase them. He said there have been several discrepancies with billing or other issues that have caused him to be on the phone or chatting with a support bot for hours, instead of providing care.
He first joined Headway out of financial necessity to get more volume into his practice with a goal of weaning off eventually and holding direct contracts with payers instead. At its best, he is paid on time. At the worst, he said it feels like dealing with another insurance company — time-consuming, confusing and bureaucratic.
“I don’t like middle people kind of capitalizing on my emotional labor and actual labor, so that’s kind of [what] geared me to try to wean off a lot of these platforms. …,” Martin told BHB. “As a provider, [it] makes me wonder who has vested interests in these companies, and is it a pseudo insurance company now? And if they are also investors in Headway, Alma … then they have an interest in keeping prices as low as possible and funneling everybody through Headway or whatever.”
Stakes and solutions
If these platforms monopolize the market, providers worry that independent and small provider autonomy could fade further.
“I feel like these venture‑backed intermediary companies popping up are really — I don’t know if it’s their intention — but trying to take away more of our autonomy in private practice, so that we can’t survive,” Steele-Wren said. “I don’t want to be pushed to have to contract with one of these companies. I mean, we go into private practice to have autonomy and do things the way that we see fit… I really hope it doesn’t come to that.”
While these platforms do broaden access, they also threaten local network diversity and clear higher-acuity care pathways.
From his vantage point, Puls sees the real issue as a power imbalance that favors platform-based contracting and erodes autonomy. If things persist in this way, he anticipates the platforms will actually hurt themselves and start to see higher attrition rates from therapists as a result.
“The risk is that they lose more and more therapists on their platforms and without the therapists on the platforms, they can’t operate, right? So there’s a risk to the business there,” Puls explained. “The other risk I would say is more macro, which is that their whole shtick, so to speak, is that they wanted to increase access to care… I think the end result would be that there’s even less providers than there were prior to these platforms, because they leave Headway and they’re just disenchanted by insurance in general. So then, they either go back to work at an agency or go fully private pay. The more macro risk is that there actually ends up being less providers ultimately that are in the network.”
To return to a table that feels more balanced when negotiating rates with payers as a small or independent provider, Steele-Wren said she views the ultimate solution as overhaul of the system coupled with continually coming to the table with better outcomes .
“If we can do the work that matters, they’re actually going to be paying out less claims, because people will not need as many services,” she said. “They’re going to get the help they need… and that is going to be less money that the insurance companies are paying out, because those folks are not going to have to come back to treatment again or continue with treatment that’s not working.”
Ultimately, less time navigating middlemen platforms and more time negotiating with payers around outcomes is what would feel most valuable to her as a provider, clinician and small practice owner in the interim.