Are you or your agency Out of network with insurance? Do you feel like you are left out? Here are the tips that come handy to negotiate an in-network single care agreement for out-of-network providers.
What is a Single Case Agreement (SCA)?
A Single Case Agreement (SCA) is a contract between an insurance company and an out-of network provider for a specific client, so that the client can see that provider using their in network benefits. The fee per session that will be paid by the insurance company is negotiated by the insurance company and the provider as part of the SCA.
What are the criteria’s for a Single Case Agreement (SCA)?
An SCA has to basically address the unique needs of the client and the cost benefits to the insurance company of the client seeing you, rather than an in-network provider. The following are some of the conditions that must be met for an SCA to be granted:
1) You have a clinical specialty that is not available with any of the in-network providers (can include cultural competency)
2) Client location- in-network providers are not available locally
3) Treatment you provide will keep the client out of the hospital, or will reduce the cost of medications
4) If the client has had no luck finding an adequately skilled in-network provider, then the client makes the case for an SCA with the out-of-network provider BEFORE commencing ABA therapy treatment.
For a current client who has obtained a new insurance:
· Continuity of Care
When can one make the case for Continuity of Care?
If the client has recently changed insurance providers, then the insurance company can agree to a limited number of sessions and period to allow the client to continue the ABA treatment with the current out-of-network provider, while transitioning to an in-network provider. If there is evidence that the individual might be a danger to him/herself or others, or if it would adversely affect the client psychologically/mentally (such as setbacks in the progress made in ABA therapy), Examples: a client has an insecure attachment and finds it very hard to trust others. The therapeutic relationship that has already been established with the current provider may qualify as a factor for granting the SCA.
How does one negotiate the rates of payment and terms of the contract?
One thing to keep in mind is that insurance companies are legally obligated to provide clients with adequate ABA treatment by properly trained professionals. Therefore, if the insurance plan does not cover any out-of-network services, AND there are no in-network providers with the given specialty, then you as a trained provider will be able to negotiate your customary full fee as the session rate for new clients. This is because the client is not simply choosing to see you, but is being forced to, with inadequate in-network providers. In this case, the client usually makes the case with the insurance company for an SCA with you, before commencing ABA treatment.
If you are obtaining an SCA for a current client for continuation of care, then the rate negotiated will be based on the client's informed consent and agreement when beginning ABA therapy with you. Fee increases will be consistent to your fee policy in the informed consent. You cannot charge the client a lower out-of-pocket sliding scale rate, and then charge the insurance company your regular full rate, if the SCA is back-dated to cover sessions in the past.
Sometimes an insurance company may have a policy of "pay at highest in-network rate", in which case you will not be able to negotiate the rate. You always have the option of declining the SCA if the rate and terms are not acceptable to you.
The SCA will also spell out the ABA CPT Codes authorized, the start and end dates for ABA treatment, and the number of sessions. One can request for a renewal of the SCA when there are only a few authorized sessions left.
Reach out to us for more success on obtaining SCA. You can also write an email to credentialing@amromed.com