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.
For those seeking help from a therapist with a specialization or specific level of experience, this can make it more difficult to use insurance benefits. Because of this, it may be helpful to determine whether insurance may pay for services using a Single Case Agreement.
Determined on a case-by-case basis, a Single Case Agreement allows somebody to be treated as though he or she has in-network benefits by a therapist who is outside their insurance network of providers. The agreement is usually specific to therapeutic treatment within the current window of care.
Many insurance companies accept either a Single Case Agreement or have provisions for Out Of Network care. It may be helpful to contact the insurance company to discuss what options may be available to you that are based on the insurance plan.
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.
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:
Your particular speciality needs to be relatively unique in the area or specific to the patient’s needs. This might include language or cultural competency.
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 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.
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.
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.
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.
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.
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