Is Your Practice Profitable — Or Just Busy?

The Wake-Up Call: Alma–Aetna Is Just the Latest

On July 15, 2026, Alma is cutting reimbursement rates for clinicians on the Aetna network. Specifically, CPT 90837 — the 53+ minute psychotherapy session code that many clinicians use as their default — will now be reimbursed at the same rate as CPT 90834, the 38–52 minute session code. Across the Aetna network on Alma, panel rates are coming down.

If you see Aetna clients through Alma, your effective hourly rate just dropped.

But even if you don't — even if you've never used Alma, even if you don't take Aetna, even if your practice is mostly self-pay with a panel or two on the side — this should still be on your radar. Because Alma–Aetna isn't an isolated event. It's part of a much bigger pattern that every mental health clinician needs to be paying attention to.

Reimbursement rates across the industry have been quietly compressing for years. CPT codes get re-bundled. "Telehealth parity" gets walked back. Platforms renegotiate with payers and the clinician is the last to find out. Whether it's Alma–Aetna this July or another payer–platform combination next quarter, the direction is the same: less money per session for the same work.

This isn't a story about one platform. If insurance reimbursement is any part of your practice — even a small part — you are exposed to changes you don't control. And they are happening more frequently, not less.

The reality is that running a private practice means running a small business in an industry that doesn't really teach the business side. Graduate programs focus on clinical training. Continuing education focuses on clinical training. The financial and operational side of running a practice is something most clinicians end up figuring out on their own, in real time, while also seeing a full caseload. It's a lot. And it leaves most practice owners working with less visibility into their numbers than they'd actually want.

Which is exactly the kind of position you don't want to be in when the industry changes underneath you.

That's what this post is about.

Busy and Profitable Are Not the Same Thing

Here's the trap.

When you go solo or build a practice, the first metric you track is your caseload. How many clients you're seeing. How many sessions per week. How booked your calendar is.

And those numbers feel like progress. A full caseload feels like success.

But a full caseload only tells you one thing: your time is occupied. It tells you nothing about whether you're making money — and it tells you nothing about how vulnerable your income is to changes outside your control.

I've sat with clinicians pulling in $425,000 a year in gross revenue who were stressed about money. And I've sat with clinicians pulling in $140,000 who were saving, investing, and sleeping fine.

The difference wasn't talent. It wasn't hours worked. It wasn't even the size of the practice.

The difference was that one group had clear visibility into their numbers. The other group didn't — and the bigger the practice got, the more that visibility gap cost them.

The Three Numbers Every Practice Owner Should Know

Forget the spreadsheets your bookkeeper sends you. If you only track three numbers, track these.

1. Revenue Per Clinical Hour

Your rate matters — it sets the ceiling for what you can earn. Especially in private pay, where there's no payer setting that number for you, your rate is one of the most important decisions you make.

But your rate and your revenue per hour of work are two different things.

Take your total revenue for the last 90 days. Divide it by the total hours you actually worked — not just the hours you billed, but the documentation, the admin, the insurance follow-up, all of it. That's your effective revenue per clinical hour.

Let's run two quick examples with easy numbers:

Let's assume a private-pay session at $250 runs about an hour of clinical time plus 30 minutes of documentation. That's 1.5 hours of work per session, which puts your effective revenue at roughly $167/hr.

Now take an insurance session at $130. Same hour of clinical time, same 30 minutes of documentation — plus another 30 minutes per session, on average, spent on claims, re-submissions, and payer follow-up. That's 2 hours of work per session. Your effective revenue drops to $65/hr.

Same clinical hour. Less than half the take-home.

(If you're on a platform that handles claims for you, that admin tax shrinks — but the platform's cut comes out of your reimbursement instead. Either way, the gap between your stated rate and what you actually earn per hour is real.)

This is the number that tells you what your time is actually worth — and whether your rate is doing the work you need it to.

2. Overhead Ratio

Add up everything you spend to keep your practice running. EHR. Liability insurance. Bookkeeping. Phone. Website. Professional dues. Marketing. CEUs. Office rent, if you have one.

Divide that number by your gross revenue. That's your overhead ratio.

For a fully virtual solo practice with lean operations, this should land around 10-20%. Add a leased office and you're typically in the 20-30% range. Once you're paying for a coaching program, paid ads, a marketing consultant, a premium EHR, and a virtual assistant on top of everything else, you can quietly drift to 30-40% without realizing it.

Group practices run higher. Operating overhead alone — rent, admin payroll, supervision time, additional liability, EHR seats — typically lands in the 30-45% range. Associate compensation runs separately on top of that (more on that in the hiring section below), and that's where the math gets really important to model out before you commit.

The principle is the same regardless of practice size: the higher your overhead ratio, the harder every session has to work for you.

This is one of the most common places I see profitable-looking practices quietly bleed money. The revenue looks fine. The take-home doesn't match it. The gap is overhead.

3. What You Actually Pay Yourself

This is the one most clinicians skip.

What shows up in your personal checking account every month? Not your gross revenue. Not what's left after expenses. The actual dollars that make it from your practice to your life.

If you can't answer this in 10 seconds, that's the first problem to solve.

The Insurance vs. Private Pay Math

Let's actually do the math, because this question is going to matter more, not less, over the next few years.

These are illustrative numbers — your actual reimbursement and rates will vary. The point is the framework.

Scenario A: Insurance panel, 25 sessions a week

Let's say your average reimbursement is $130/session. Twenty-five sessions a week, 48 working weeks a year, that's roughly $156,000 in gross revenue.

Now imagine the rate drops by 10% — the kind of cut that Alma–Aetna clinicians are seeing in July, and the kind of cut that has quietly happened in other payer relationships over the last few years. You're now grossing about $140,000.

But your overhead didn't change. Your time didn't change. You're working just as hard for $16,000 less.

Scenario B: Private pay, 18 sessions a week

Now say you charge $250/session private pay. Eighteen sessions a week (because you're not chasing claims and you're not as drained from insurance friction), 48 weeks. That's roughly $216,000.

Fewer hours. More money. No reimbursement cuts. No clawbacks.

This isn't a pitch for everyone to drop insurance. Plenty of practices are built thoughtfully around panels and run well — and for many clinicians, taking insurance is part of how they make care accessible. But if you're already feeling stretched, the broader trend is your signal to actually look at the math.

The number of clinicians who could move 20-30% of their caseload to private pay and never look back is higher than most people think. The reason they don't is usually that no one has ever sat down with them and modeled what the change would actually look like.

When Hiring Helps — and When It Quietly Destroys Your Margin

For practice owners thinking about scaling, this is where the busy-vs-profitable gap gets dangerous.

Hiring an associate or 1099 contractor sounds like the obvious next step. More clinicians = more revenue. But here's what most practice owners don't model out before they hire:

• The associate keeps 50-70% of what they bill
• You pay payroll taxes, supervision time, EHR seats, additional liability insurance
• You take on the management work, the supervision work, the HR work — all unpaid hours
• If they leave or underperform, you absorb the cost

Done right, scaling can absolutely work — and the math gets exciting when it does. But "done right" requires actually running the numbers before you commit. Not after.

I've seen practice owners scale to 6-7 clinicians and end up taking home less than they did as a solo provider. Not because scaling is bad. Because nobody helped them figure out the break-even point before they signed the office lease.

If you're considering hiring, the question isn't "can I afford to hire someone?" It's "what does my practice need to look like for this hire to actually make me more money?"

A Simple 90-Day Profitability Review

If you've never done this before, here's where to start. This is the same process I walk clients through.

Step 1. Pull your last 90 days of revenue. Total dollars in.

Step 2. Pull every business expense for the same period. Total dollars out.

Step 3. Count your clinical hours for those 90 days. Calculate revenue per clinical hour.

Step 4. Calculate your overhead ratio (expenses ÷ revenue).

Step 5. Check what you actually paid yourself across the 90 days. Compare it to what's left after expenses.

If revenue per clinical hour is well below what your rate suggests it should be, admin time and unpaid work might be the leak.

If overhead ratio is above your practice type's normal range, you're spending too much to stay open.

If what you paid yourself is significantly less than what's left after expenses, money is leaking somewhere — usually taxes you weren't setting aside.

Do this once a quarter. That's it. Most practice owners never do it. The ones who do, sleep better — and they're not blindsided when the next payer change hits the industry.

The Bottom Line

A full caseload is not the goal. A healthy practice is the goal.

Those two things look very different on a spreadsheet, but on a Tuesday morning they feel almost identical. You're busy. You're seeing clients. Money is moving.

The difference shows up at the end of the quarter, when you look up and realize either (a) you've made significant progress on your financial life this year or (b) you've worked just as hard as last year and somehow have less to show for it.

The Alma–Aetna rate cut is the version of this conversation happening in July 2026. There will be another version next year, and the year after that. The clinicians who run their practice with their numbers in front of them adapt calmly. The ones who don't get caught flat-footed every time.

Don't wait for the next rate cut to make you look at your numbers. Look at them now. Make the changes calmly, before they're forced on you.

And if you don't know where to start, that's exactly what I do.

Want to Know If Your Practice Is Actually Profitable?

I'm Chris Marrone, a CFP and Enrolled Agent. I work exclusively with mental health clinicians — therapists, psychologists, LCSWs, LMFTs, and everyone in between — on both their personal finances and the financial health of their practice.

If the math in this post made you nervous, that's actually a good sign. It means you're paying attention.

Book a free 45-minute intro call. No pitch, no pressure. We'll talk about where you are and whether what I do is a fit.

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