Single Case Agreements, also known as SCAs, are contracts between an insurance company and an out-of-network provider. These types of contracts typically cover a specific client receiving a service for a designated amount of time at an agreed upon rate. Until more recently, most payers took on the role of negotiating rates for SCAs; however, many payers are now no longer negotiating these case basis rates, and as a result, are paying the highest in network level costs.
Take a look at some of the more frequently asked questions we at Missing Piece hear regarding SCAs:
When would a patient need a Single Case Agreement?
Single Case Agreements may be established when a patient cannot receive the same or comparable service from an in-network provider. If a patient needs a specialized service and an in-network provider is not available within a reasonable amount of time or proximity from the patient, a SCA can be considered to make up for the lack of availability. These agreements may also be allowed if a patient has recently changed insurance providers and is in need of ongoing treatment with a specific provider that is out-of-network with the new insurance company.
Why would a provider want a single case agreement?
A provider may want to continue working with a patient even after they have switched insurance providers that fall out-of-network. Two examples of general qualification include the temporary transitional period until a specific provider is contracted as in-network with the new insurance, or until a patient is transferred to another in-network provider. When a provider is in the final stages of transitioning to an in-network status, they may obtain a SCA for a few months until contracting is completed.
It has not been uncommon for single case agreements to compensate for services in ways much more appealing than those available by in-network providers. Now, many payers offer SCA compensation at the highest network rate, but allow patients continued access to their in-network benefits thus resulting in less financial responsibility for the patient.
If a provider can be granted Single Case Agreements, why would they want to become in-network providers?
Typically, insurance companies have a pool of contracted providers within a geographic area; and the payer will not offer single case agreements, if they feel that enough providers are already available to meet their patients’ needs. Other payers such as Medicaid or additional government entities only offer in-network benefits, so SCAs are less likely to be an option. For small providers with fewer clients, it can be advantageous to be selective about which payer networks you wish to contract with.
It is important to note, that payers can be very slow and/or difficult to work with in the processing of out-of-network claims. Slow payment or difficulty with payment even with documented contract are not unheard of. Generally speaking, these issues are eventually resolved, but it is important to be mindful of deadlines and take into account that extra time, attention, and administrative work will be needed to reach a point of reimbursement.
What else do I need to know about single case agreements?
Single Case Agreements can be a helpful alternative for patients and/or guardians to help facilitate with insurance companies. If a patient’s request for an SCA can explain and support in detail why a specific provider is better qualified to meet their medical needs than an in-network provider, this can help to justify the need for a SCA. Common reasons that can support the need for an SCA include: extended wait times for services, distances that are too far away from where the patient resides, or that there is not a provider specialized enough to provide adequate treatment.
It is necessary that you obtain all paperwork and have a clear understanding of the conditional terms of the SCA, some of which aspects include authorization requirements or prior approval of services, billing requirements, payment terms, and the duration of services allowed.
Note that not all insurance companies provide a physical version of a SCA document, this extensive clinical information needs to be documented and maintained as part of medical necessity. In the chance that justification is needed in advance to services, or for post case audits you want all the bases to be covered in terms of protection.
Finally, be prepared for the extended periods of time that are needed to obtain a SCA. As a provider, you will want to plan out and coordinate the services in advance to request an approval of the SCA; this way once approval is granted a plan of action is already set in place. If an agreement to provide services during the time of SCA consideration is set, you will want to have a clear and well written financial agreement with the patient should the insurer come back and not cover the services provided.
Missing Piece is experienced in helping providers obtain compensation for Single Case Agreements. We provide guidance in clinical documentation and handle the remaining administrative aspects to make sure that you can focus on your patients’ care while we focus on obtaining your reimbursements. We can also help provide you with insight into when it is more advantageous to remain out-of-network versus when it might be better to remain in network.
Contact us today to learn more about the advantages of outsourcing your billing and revenue cycle management to Missing Piece at
765-628-7400 or firstname.lastname@example.org.