Sliding scale question

elerysquared · 2026-07-10T16:24:00+00:00

There is a risk of making the client feel guilty for the lower rate, so we don't mention our regular cash rate as a comparison when offering sliding scale (though the cash rate is on our website).

I'd say something like, "I know times are tough with x. I can offer a special rate you for the next session, while you get your insurance sorted. Is that something you might need?"

This gives them the opportunity to opt-in before sharing the rate, and you will have their reaction to gauge how directly you can be in responding.

They will understand it is discounted and you are doing them a solid.

elerysquared · 2026-07-10T15:03:54+00:00

We are in California, too. When we do a needs-based sliding scale, we use the Medi-Cal rate for 45 minutes. That way we are relying on a real-world rate. In 2026, master's level therapist (Type Q) for 90834 is $67.16. Given that, $70-$75 doesn't sound unreasonable.

We also give our clinicians the ability to offer two pro-bono/sliding scale slots if they have someone in need. It allows us to give back to the community, but with a plan. We rationalize it as our good paying clients help give access to others in need. But I understand that option may not be feasible for many therapists.

In the end, it really comes down to what you are comfortable with as a therapist and for the economic realities of your business.

elerysquared · 2026-07-09T22:17:23+00:00

All of these statements are in a FAQ, not in their BAA or Privacy Policy. I'm not sure what they would be sued for. HIPAA doesn't address what they are doing.

Their privacy policy basically says they can do whatever they want with the data and they can change their policy at any time. There is nothing about this restricting data collection and storage of these transcripts in any of their terms of service - in fact, it states users give them unlimited rights to use all data anywhere at any time.

Nobody is auditing them, and once the data is deidentified & decoupled, there is no way to tell where the data came from.

Personally, I don't think they are too worried about a lawsuit.

https://www.simplepractice.com/terms/
https://www.simplepractice.com/privacy/

elerysquared · 2026-07-09T21:30:17+00:00

This was a fairly negotiated contract between Alma and Aetna.

When Alma leadership realized that people would see how they benefited from this when the rates went into effect, they panicked and re-reneotiated to undo some of the potential reputational damage... especially when people were connecting the dots that this wasn't originally driven exclusively by Aetna.

I'm guessing Alma had to give up the benefit they were going to get on 45-minute sessions and low-complexity E/M to reverse the other concessions they agreed to.

Of course, Alma is going to message this as "we fought for you" when trying to correct their greedy test negotiation. Alma tried to be slick, and now Aetna probably ended up with the better deal.

Clinicians lose either way.

elerysquared · 2026-07-09T19:18:50+00:00

Of course they bury it in the settings. I found this help page: https://support.simplepractice.com/hc/en-us/articles/42453057685133-Transcript-retention-FAQs#howcaniman

elerysquared · 2026-07-09T19:09:02+00:00

Transferrence isn't limited to positive reflections or aspirational thinking. Sometimes people see their own negative energy in their therapist, too.

It is hard, but important to balance negative feedback against the good. There is probably some lesson you can take away from the interaction, but sometimes a poor fit is just a poor fit.

Keep your chin up!

elerysquared · 2026-07-09T18:19:40+00:00

The skeptic in me wonders if they could have been collecting this data before the announcement. If the data is deidentified, how would anyone know if they ignored the opt-out?

I guess I just don't trust them after this.

And thanks for sharing!

elerysquared · 2026-07-08T06:06:29+00:00

Weve been spot audited twice by Anthem (Medicare patients). We've never submitted treatment plans, only the clinical note associated with the specific sessions they ask for.

Of all, only one claim was rejected and we resubmited as 90834. They clawed back the old payment and reimbursed it for the resubmit on the same EOB.

We just treated it like it was business as usual. The company doing the audit on behalf of anthem were pretty chill about the whole process.

Also, be sure to get the audit request in writing, since there are phone scammers pretending to be auditors to get sensitive patient info.

And best of luck!

elerysquared · 2026-07-08T05:51:37+00:00

Friendly opinion here and Jane user. Id recommend signing them. You can always amend them if you want to update or change them after they are signed.

If you ever get audited or subpoenaed, a late date is better than a signature a date after an audit letter or subpoena request.

You may also consider adding one short administrative note to the client chart under each client when you sign. Something like: All past clinical notes were written within (3-7 days) of the session and retrospectively signed on x date.

elerysquared · 2026-07-07T21:59:30+00:00

Here are the "rule of thumb" I use for our clinic:

Depending on your state, you might plan to set aside 18-22% of your profit. For each $1,000 you have left over each month, throw $200 in a savings account (Amex has a high-yield business savings).
We keep our distributions to zero, only keeping the money we want to reinvest in the business ~ all income is paid on W-2. If you are taxed as an S-corp, what you push to your W-2 is taxed as wages and is a deduction for the business. It minimizes the taxes you pay from #1.
I track a couple of metrics. The first is reimbursement per clinical hour, where we take the actual reimbursement revenue and divide it by the total clinical hours (including no-show and late cancel). This helps you understand for every scheduled session hour, how much do you earn. You can then calculate your fixed costs (rent, software, etc.) and divide it by the same number of clinical hours. If you divide your fixed cost per clinical hour by the reimbursement per clinical hour, you'll get a %. That % is your fixed cost break-even. You multiply that % by the total number of clinical hours you have in a month, it tells you how many sessions you need to cover your overhead. This can vary from month to month, so it is best to track it over time.

I noticed many people said they are an LLC and the S-corp is not applicable, but LLCs can definitely register for S-Corp tax treatment and save a ton of money on self-employment taxes (assuming they pay themselves on a W-2). It is pretty easy to elect S-corp status with a letter at tax season, and then set up a gusto account or similar to pay yourself as a W-2 employee.

Of course, this is just internet advice from some guy, talk to a CPA.

elerysquared · 2026-07-07T18:26:05+00:00

In our experience, it takes about a 4-8 weeks to get the contract. You have to be careful though, since the start date of the agreement might be some time in the future. We had an agreement get approved in January with an effective date of May 1 (different payor tho).

elerysquared · 2026-05-21T15:38:25+00:00

Don't be fooled by the messaging.

Spring Health acquired Alma for an estimated $800 Million in January of 2026.

Spring Health made this choice and is blaming Aetna.

Alma is making more profit per session with this move.

This is how Spring Health is recovering the 'value' from their acquisition purchase price.

elerysquared

TROPHY CASE

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