What is A Single Case Agreement (SCA) For Out Of Network Providers?

Sometimes medical and mental healthcare providers find themselves outside of a particular patient’s insurance coverage network. This can be frustrating for you as the practitioner, as well as the patient who is relying on your care. In some cases, it might simply be a matter of the client changing jobs, and insurance providers. This can be a serious issue for a patient who is relying on your continued care.

In an out of network scenario like this, it might be possible to use a single case agreement to make sure your client has the coverage they need to receive the care they rely on from you as their practitioner or therapist.

What is a Single Case Agreement?

Sometimes referred to as SCA, Single Case Agreement is essentially a contract between an insurance company and an out-of-network provider to ensure that a client doesn’t have to change providers. It’s especially important for clients who need extended long-term treatment or therapy.

In a situation like this, a negotiation takes place between the out of network provider and the practitioner providing care. The overarching goal is to ensure that the insurance provider is paying a similar fee per session, to keep the out-of-pocket cost to the client as close to the original as possible.

What Criteria Are Needed For A Single Case Agreement?

A single case agreement is designed to meet the essential treatment or therapy needs of the patient and the cost benefits to the insurance company without having to change to a different in-network provider. To help guide the negotiation process the following criteria typically need to be met. This includes the following factors:

Specialty Service

Your particular specialty needs to be relatively unique in the area or specific to the patient’s needs. This might include language or cultural competency.

Patient Location

Your practice needs to be closer in proximity to the patient than another qualified in-network provider.

Cost To The Patient

The treatment you provide will reduce the out-of-pocket cost to your patient in some way, such as preventing them from needing hospitalization or reducing the cost of medication.

Client Cannot Find The Same Level Of Care

The client has tried and cannot find a practitioner or provider in their network that meets their needs in a manner they are comfortable with. In the case of ABA therapy, this needs to be done before starting therapy.

The Need For Continuity of Care

There are many therapeutic processes like ABA therapy where continuity of care is critical for meeting treatment goals. When a client changes to a new insurance provider, maintaining continuity of care, or establishing a transition plan to a new in-network provider, is essential. In many of these scenarios a single case agreement often needs to be negotiated.

This is especially true if there is past evidence that the individual will be a danger to themselves or others, or if they would be put at risk of suffering a significant setback with their mental health. Single case agreements are most prevalent with patients who have established trust issues and have developed a professional attachment to their current ABA provider.

How Are Single Case Agreement Rates Negotiated For A New Client?

It’s important to note that insurance companies have a legal obligation to provide clients with adequate ABA treatment by a qualified practitioner. If there isn’t an in-network provider available or you, the out-of-network practitioner, provide some type of specialty care for a new client, then you can negotiate with the insurance provider for the standard full fee. In a scenario like this, a new client may not be specifically choosing you but have no other sufficient in-network provider.

How Are Single Case Agreement Rates Negotiated For An Existing Client?

If you are a practitioner seeking a single case agreement for a current client that requires a continuation of care, the negotiated rate might be more flexible, based on the client’s preference. In a case like this, the negotiated rate might be influenced by the client’s consent. Though they need to be properly informed and may need to sign official documentation that indicates they are aware of the process and may potentially incur more out-of-pocket costs.

For a scenario like this, the fee policy might be assessed on a sliding scale. Though you cannot charge their insurance provider the standard full rate for any back-dated, past sessions.

It’s also important to note that some insurance providers have standard protocols in place for a single case agreement negotiation. Some have a “Pay At The Highest Rate” as if you were an in-network provider. This is based on their rates with no room for negotiation.

The mindset of the insurance provider here is to offer what they consider to be the fairest possible rate. Though this might still be below your standard rate. Especially if you are a specialty provider. In a scenario like this, you do still have the option of declining the terms and rates they offer, though it will mean your patient/client will be without care.

In a situation like this, many specialty practitioners will accept the possibly lower rate, for a specified number of sessions. This can then be used to help transition the patient to another in-network practitioner. In this dynamic, the patient’s continued care and treatment objectives are the highest priority.

Are CPT Codes Used For Single Case Agreements?

Single case agreements also need to use ABA CPT authorized medical billing codes. It’s important to spell these out in the negotiation process with the insurance provider. This will reduce the risk of a delayed claim. In the case of a transition to a new in-network provider, the CPT code for the SCA might be specific to the number of sessions that are left. Insurance providers might assign a specific code just for that case or patient.

Tips For Obtaining a Single Case Agreement

As a negotiation process, there are things you can do to help streamline the SCA process. Not only will these tips make it easier for the request to be considered, but it also helps ensure that the patient doesn’t have any unnecessary lapses in care.

Timing

It helps to make the Single Case Agreement request as you are asking for the Initial Assessment Authorization. This ensures that all the document origination stays together and isn’t fragmented.

Research Other Providers

You should expect that the insurance provider’s representative will look for other providers in the patient’s area. So, it might help to put in your own due diligence. This will help you be prepared to answer any questions about why you might be the preferred provider for the patient in question.

Negotiations

Be prepared to negotiate your fees. This might be on a sliding scale or the insurance provider might already have their own fee scales in place. This might be part of a “pay at highest in-network rate” protocol.

1500 Claim Form

Some insurance providers require the single case agreement to be in the Rendering Provider’s which will need to be presented on the 1500 claim form.

Documentation

In the case of a patient that needs to transition from your care to a new in-network provider, or a patient who prefers to remain in your care, you might need to help the patient phrase their request to the insurance provider.

Conclusion

It is an unfortunate reality that not all insurance providers offer the same level of coverage and may have their own limited networks available for patients. Familiarizing yourself with the single case agreement process can go a long way toward helping you retain patients, as well as ensuring they receive the highest level of care.