I have noticed a lot of new providers struggling to develop a workflow and system that they feel is simple and effective for both them and their clients if they choose to maintain their own electronic health record (EHR) outside of the corporate group practice/billing platform (Alma, Headway, Uplift, etc) they use to process insurance claims. While some providers choose not to do this and either maintain paper files or utilize the embedded and available tools within those platforms, many of us prefer having our own EHR and I wanted to share my personal rationale along with the workflow I feel is best for me and my clients.
Please feel free to use whatever is helpful, modify whatever you need to, and discard whatever doesn’t add value.
As a provider who utilizes Alma to provide a way for my clients to utilize their insurance benefits, I maintain my own clinical EHR through Simple Practice. While I wont get into why I chose to work specifically with each here, I do want to start off with the reason why I pay for these two separate services (which average around $100 and $90 a month respectively), which is autonomy and personalization.
By keeping the entirety of my client’s record in one place (my EHR) I have complete control over how I protect their personal health information (PHI) and maintain their confidentiality.
The only information I have shared with Alma regarding my clients is what is necessary for insurance claim submission: Client’s Name, DOB, Address, Phone Number, and Insurance Policy Information along with ICD-10 and CPT codes for services provided along with the date of service. If the initial client referral came through Alma, the client shared a short narrative about what is going on that they are seeking support for along with their name, location, and insurance carrier (so Alma has this narrative, but I did not supply it). The only other piece of information Alma has regarding my clients are their payment information as I have all my clients enroll in autopay, but I send them an invitation and they input their own HSA/FSA/CC information rather than give me access to it. Alma (and therefore insurance) has no access to intake questionnaires, progress notes, psychotherapy notes, correspondence, documents shared, assessment measures administered, treatment plans, secure messages exchanged, or any payment that is processed or stored within my EHR.
By using my EHR which is highly customizable, I am able to easily create and update templates for documentation, streamlining the process to reduce the time it takes to complete each note while ensuring I show medical necessity. I have a lot of options and tools within Simple Practice that allow me to customize reminders for clients, how I share information, and the way I allow them to self schedule appointments, among other things. It also allows me to have a separate way to manage payments for my clients that I have chosen to not process through Alma.
Since I offer clients to use their FSA or HSA cards with Alma, I have them keep a regular credit card on file with my EHR in case there are any non-healthcare related fees they are responsible to pay that cannot be charged to a health based account (like no-show fees). Thankfully, I have very few clients whom I have to charge these fees for, but it’s a simple way to separate types of cards and the processing fees between Alma and Stripe (the company Simple Practice uses for payments) aren’t significantly different.
Additionally, having this credit card saved in my EHR can also come in handy if I need to do a manual charge on behalf of a client. While my insurance based clients all enroll in autopay with Alma, occasionally they won’t have available funds in their account or their card has expired or is canceled. When this happens, they will be invoiced for a session, requiring them to have to directly submit payment for co-pays or deductibles (as well as having to re-enroll in autopay). In these situations, I offer clients the option to ignore the invoices from Alma and I can manually charge them for the invoice through my EHR so when Alma deducts their unpaid invoice from my pay out, I’m not financially impacted. My insurance clients still have invoices generated in my EHR for record keeping, but I just indicate that they have no financial responsibility here as payment is handled via Alma and they can get receipts for their copays or deductibles there. For my OON clients, I choose the option that Simple Practice offers of “External Card: Payment processed elsewhere."
I have chosen to use Alma for all insurance clients, whether INN or OON, because I find it simpler to have Alma automatically generate superbills for OON clients on a monthly basis and have them be the point of contact for documents clients need for insurance reimbursement. However, any client who I work with who are paying my full fee and NOT using their insurance in any capacity as well as clients who have a sliding scale agreement with me, I bill through my EHR. In the case of full fee clients, the processing fee is about a dollar less through Stripe and I get the payment within 2-3 business days rather than have it applied to the next pay period. For my sliding scale clients, the motivation to keep their payments outside of Alma is a way to withhold my sliding scale rates from insurance, who will use them in considering fair market rate for provider reimbursement (and therefore, I see it as a small act of therapeutic advocacy). If clients are not using their insurance at all, they do not need a superbill, and therefore my EHR is set up to only issue basic invoices and statements.
Now for the big question people tend to have… how does all of this work with your appointment calendars since they don't sync? My EHR client portal functions as the primary interface between myself and my clients and I make this very clear to them from the very beginning. I keep all my client appointments here whereas only insurance (again, both INN and OON) clients go on my Alma calendar. I want my INN clients on my Alma calendar because Alma will re-verify client coverage before the first appointment each month and inform us of any changes in financial obligation. Including my OON clients on there means I have a claim automatically generated, just like with INN clients, so I don’t forget to submit it.
I do not have any clients who are not using insurance anywhere in Alma so if I just look at my Alma calendar, there are appointments that won’t show up there. Most of my sessions are recurring weekly or biweekly, so they don’t require much maintenance in the Alma portal except for the occasional cancelation or reschedule due to a conflict and I try to add individual appointments when I add them to Simple Practice by having multiple windows open on my computer.
However, at the end of every week, I take a few minutes to ensure that my Alma calendar matches my Simple Practice one for the week ahead and delete any appointments from Alma that I may have missed to reduce the likelihood that a client gets an incorrect reminder (since they do get them from both portals). At the end of the day, I am only human and I do occasionally forget to do this so sometimes clients have gotten reminders from Alma when they don’t have an appointment in their client portal. They know to disregard them as I’ve explained my client-facing practice workflow, though sometimes they will email me just to confirm. While this does create some additional administrative work, I feel the few minutes it takes each week is worth being able to provide as much financial informed consent as possible to my clients since re-verification is an amazing service Alma offers.
I tried to address most of the questions or concerns I've been seeing providers raise as they navigate balancing these different platforms and develop their own processes. If this was helpful or if you have additional questions, please feel free to share in the comments!