Insurance companies frequently do not cover visits to certain types of medical professionals. You and the patient both lose patience when anything like this occurs. In other cases, all it takes is for the client to find a new occupation and change insurance providers. This could be very negative news for your patient. A single-case agreement may allow you to continue treating a patient whose insurance doesn’t cover your practice.
What is a single-case agreement with insurance?
An insurance company and an out-of-network provider can enter into a single case agreement (SCA) to allow a patient to obtain care while analyzing in-network benefits. The patient will only pay their usual in-network session co-pays after meeting their deductible (if any). An SCA is generated when a patient must see a physician not covered by their new insurance or cannot receive equal care from an in-network provider. Individual SCAs may cover a service for a set time and cost. SCAs reduce the patient’s financial burden and allow the physician to continue treatment.
What are Single-case agreement insurance requirements?
Insurance companies and non-participating providers can negotiate a “single case agreement” (SCA); therefore, a single patient can receive care from the provider at a predetermined price. A SCA is created when a patient cannot locate an appropriate in-network provider or must switch insurance plans and continue treatment with an out-of-network provider.
Different services and insurance providers may have additional minimum requirements for single-case agreements. Present are, nevertheless, some universal requirements that should be met.
The out-of-network supplier must provide a specific service that cannot be obtained from a source within the network. This may involve a particular treatment method, fluency in a language or culture, or both.
The out-of-network physician must be more convenient than the in-network alternative, or the patient must experience significant obstacles in seeing an in-network doctor, such as a long commute.
Cost to the patient:
The patient’s out-of-pocket expenses will be reduced if the non-network provider can demonstrate that their service will prevent hospitalisation, minimise medication utilisation, or improve the patient’s quality of life.
The client needs help finding the same level of care:
If the client cannot identify an in-network provider who can donate the same or comparable level of care as the out-of-network physician, the insurance company will not pay for the treatment. Examples include recommendations that went nowhere, lengthy wait times, or unhappiness with previous physicians.
Continuity of care:
The patient must demonstrate that they have an ongoing relationship with the out-of-network provider and that switching providers will interfere with their treatment goals or harm their mental health to receive coverage for continuing care with that provider. Present should indicate improvement, familiarity, or confidence in the current provider.
The out-of-network provider must typically contact the insurance company and submit proof of the above conditions to request a single case agreement. Following submission, the insurance company will decide whether to grant coverage. The insurance company will determine the agreement’s pricing, length, and other details if accepted.
How does a Single-case agreement insurance work?
A “single case agreement” is an option for providers whose services are not covered by their patients’ insurance. A legally enforceable agreement outlines the service’s duration, cost, and benefits to the patient. A patient may need specialized or long-term care from a provider outside their insurance network or want to keep seeing their current provider after switching plans. If so, a single-case agreement may work. A single case agreement lets the practitioner bill the insurance company instead of the patient.
A single-case agreement usually requires a provider to prove that their service is medically necessary and appropriate for the patient’s condition and that no other network options are better. The provider may also need to show that their service would lower the patient’s healthcare costs. The supplier contacts the insurance to negotiate the agreement’s terms, which can vary depending on the payer and service. The practitioner may require a treatment plan, progress notes, or outcome measures to justify their request and costs. The insurance company can approve, refuse, or counteroffer the manager and put conditions to the service. If all parties agree, a single case agreement contract is signed.
Single case agreement vs. letter of agreement
An SCA or LOA is a contract between an out-of-network provider and an insurance company that allows a patient to obtain care from that provider even though that provider is not in the insurance’s network. There are, however, distinctions between the two.
A SCA often only applies to a patient during a single care episode. The patient has a severe or rare ailment that calls for extended, specialized care from a specialist outside the insurance company’s network. When the patient is too far from the nearest in-network provider, a SCA may be employed instead. Per diems, fee schedules, and billed expense percentages are only a few examples of reimbursement rates that might be negotiated as part of an SCA.
An LOA is more comprehensive, as it can apply to more people and more treatment sessions at once. It’s common practice when the insurance company and the out-of-network doctor have an established rapport and desire to work together. A LOA may also be employed if the provider is in the process of joining the network or if the network is undergoing expansion or change. An LOA will typically detail the agreement’s duration, scope, payment method, and dispute resolution process.
When would a patient require a Single Case Agreement?
When an out-of-network provider cannot provide a patient with the same or equivalent care, a SCA may be necessary. For instance, if the patient requires a speciality service not covered by their insurance plan or has just switched insurance plans but desires to maintain treatment with their existing out-of-network provider. For a limited time or until an appropriate in-network provider is located, patients may utilize in-network benefits by signing an SCA with their insurance company and their out-of-network clinician.
Example of a single-case agreement
The following is an Example of a case-by-case agreement:
If you’ve been seeing the same therapist for a while, you trust them. You’re seeing a cognitive-behavioral PTSD therapist. Your company switched insurance carriers, and your new plan doesn’t cover your therapist. You must spend more to keep or locate a therapist outside your insurance network.
Your current therapist is useful and acceptable, so you don’t want to switch. You prefer paying only what is necessary. You ask your provider for a single-case agreement to keep seeing your therapist while receiving your insurance’s in-network benefits.
Your therapist will negotiate a single-case agreement with your insurance provider at your request. CBT for PTSD is a specialised service that is hard to find from other in-network providers, they say. They say maintaining continuity of care is vital to rehabilitation, and interrupting treatment could affect your mental health. A reasonable session charge that matches in-network expenses is recommended.
Your insurance company approves your therapy claim. They will sign a contract with your therapist defining the single case agreement’s criteria, including the number and length of sessions, billing and reimbursement, and treatment success evaluation. The contract states that the single case agreement applies only to you as the designated patient and not to other services or patients.
The single-case agreement lets you see your therapist while using your insurance’s in-network benefits. The copayment for each session is your out-of-pocket price after your deductible. You may relax knowing you won’t have to find a new therapist or pay more for treatment. The result is satisfactory and you appreciate your therapist’s efforts.
Tips For Obtaining a Single Case Agreement Insurance
Here are some suggestions for securing insurance using a single-case agreement:
Request the SCA while you submit your IAA application for approval. You can save time and prevent approval delays by doing this.
Prepare a fee schedule and be willing to negotiate depending on that. If asked, you should be prepared to show proof of your prices and disclose why they are fair, given your expertise and geographic location.
Ensure the patient and the insurance company know how much they will gain from using your service. You can highlight how your service will benefit the patient by decreasing their out-of-pocket expenses, keeping them out of the hospital, or enhancing their quality of life.
Provide evidence that specialised or ongoing treatment is required. Justify the requirement for out-of-network care by detailing why the patient would not benefit from seeing a doctor inside their insurance’s network.
Maintain consistent contact with the insurance company and keep detailed notes on every interaction. You may have to talk to multiple people or departments to receive the SCA approval. Make a note of when you spoke with each person and what was covered.
Gap exception vs. single case agreement
Gap exceptions and single instance agreements can cover non-network providers, but they differ. If no one in your insurance network meets your needs, you can request a “gap exception,” which lets you use an out-of-network provider at the in-network rate. An out-of-network doctor strikes a “single case agreement.” with your health insurance provider to assist you.
A gap exception may be granted based on specialty treatment, patient location, patient expenditure, and client inability to seek equivalent care. In a single-case agreement, continuity of care, long-term therapy, and the risk of damage or setback if changing providers may be considered.
Are CPT Codes Used For Single Case Agreements?
An insurance company and an out-of-network practitioner use CPT codes to prohibit patients from switching providers as single case agreements. Medical practitioners utilize the CPT code set to code their work. Service-specific reimbursement discussions with insurers are facilitated.
Services containing both professional services (“26”) and technical services (“TC”) require a separate median contractual rate estimate from the CMS. Simply expressed, whether the provider invoices for professional or technical services may alter the QPA for a single case agreement.
A sample single-case agreement from CountyCare Health Plan provides CPT codes for services, fees, and units of payment. Upon notification, the sample document lists billing-related code updates (CPT, HCPCS, ICD-9, DRG, revenue codes, etc.) and their effective dates.
However, not all health insurance plans are equal, and some businesses may be limited to seeing only a select group of doctors. If you want to satisfy your patients and give them the best service possible, you should familiarise yourself with the single case agreement procedure.