Single-Case Agreements: A Guide for Healthcare Providers

Single-Case Agreements: A Guide for Healthcare Providers

Maximizing revenue and streamlining the operational flow are usually the primary concerns of healthcare providers and practices. However, there is one major factor that causes increased administrative hassle. It’s being an out-of-network provider for patients.  

As a healthcare provider, landing in such a situation can be challenging from an operational point of view. On the other hand, patients may find it difficult to continue receiving care. So, the concept of single-case agreement comes into consideration.  

Single case agreement (SCA) allows a patient to continue treatment with an out-of-network provider without the need to pay excessive charges. Whereas healthcare providers receive adequate revenue and continue rendering care to the patient.  

In this blog, we will understand single case agreements and explore ways for single case management. Read on to dive deep into the concept and learn to deal with such conditions.  

What Is a Single Case Agreement?  

Definition -  

When a healthcare provider is an out-of-network provider, but the patient needs ongoing treatment, they can consider a single case agreement insurance.  

Type of Agreement -  

It is a one-time contract between the insurance provider and the healthcare provider. Under this contract, both parties negotiate insurance terms and decide on a reasonable charge for the treatment. The charge can be between the out-of-pocket cost and the original cost.  

Need for Such Agreement -  

This is a great way to let the patient continue with the existing healthcare provider, and the healthcare provider avoids some medical billing hassle.  

Single case agreements become necessary when patients require urgent care from a specialized provider.  

Unusual Aspect SCAs -  

Insurance single case agreements are very different from usual insurance agreements. Standard insurance agreements are pre-decided, and healthcare providers get reimbursement according to pre-negotiated rates.  

However, single-case agreement insurance allows healthcare providers to set fresh payment plans, customize terms, and establish reimbursement rates.  

Common Situations for SCAs -  

When a healthcare provider is a specialist or when a patient is not able to find a healthcare provider within the network or a patient wants a nearby healthcare provider.  

Necessary Criteria for Single Case Agreement  

Continuity of Care -  

There are various treatment processes that require continuity of care, such as ABA therapy, cancer treatment, mental health care, physical therapy, and many more. Because they require continuity of care, patients with these ailments are eligible for single case agreement insurance.  

Medical Specialization -  

If a patient finds a specialist in the field who is out of network, they can negotiate for SCA. Also, if there is an unstable patient or one with potential risk of danger, SCA is negotiable. 

Location of Patient -  

When a patient stays closer to an out-of-network provider and requires regular treatment, the insurance single case agreement becomes valid.  

Cost of Treatment -  

Entering into a single case agreement reduces the liability of out-of-pocket costs for the patient. Due to this, healthcare providers can establish better patient relationships.  

The Process of Single Case Agreement  

This process takes place between the insurance provider and the healthcare provider. Both parties follow certain steps to reach the stage of agreement, and then finally healthcare providers can acquire reimbursement.  

Here are the steps:  

Step 1 -  

Healthcare providers or patients: Anyone can initiate the SCA and request the same from the insurance payer. However, there must be a valid reason behind initiating such a request highlighting the requirement of this agreement.  

Step 2 -  

Once the request is initiated, the next step is negotiation between the healthcare provider and the insurance company. This step includes discussion regarding the terms of SCA.  

Step 3 -  

The third step is when the agreement comes into place, and it is officially drafted and signed by both parties.  

Step 4 -  

The last step is claim management under SCA, which involves claim filing and submission to attain revenue.  

How to Acquire Single Case Agreement Insurance?  

Now that you know the steps to enter SCA, we can discuss how you can actually attain the single case agreement insurance.  

  • Always prioritize the timing of obtaining your SCA. The best time is the initial medical billing step, at the time of pre-authorization. This helps in streamlining the medical billing process and ensuring adequate revenue.   
  • Keep your research thorough and be sure of all evidence in favour of the single case agreement. In such situations, insurance providers always search for other in-network providers. That is why strengthening your case is essential.  
  • Negotiations are a part of SCA and as a healthcare provider be ready to discuss the revenue for your medical services. There are chances that the insurance provider already has fee scales. This is where professionals come into picture who help you negotiate properly. Having a cost breakdown can be ideal to attain approval for the desired reimbursement rate.   
  • Make sure your single case agreement is based on accurate details such as patient information, treatment plan and diagnosis codes. Also, don’t overlook instructions of the agreement to accelerate processing.  
  • Never neglect coding when requesting single case agreement. Mentioning appropriate CPT codes, ICD-10 codes and modifiers along with other details such as number of visits and treatment period.   
  • Single case management is also vital and for this you must keep all records of your agreement and communication regarding negotiation including related documents and confirmation proof.   

Conclusion  

Single case agreement has the capacity to transform the healthcare landscape. While patients get access to top-level medical services, healthcare providers can improve their revenue cycle.  

However, this whole process can be a challenge for many healthcare providers and practices. Partnering with professionals can help you navigate through the complex landscape of single-case agreement insurance.  

Eminence RCM is a medical billing company that can help you manage SCA effortlessly without any hassle. Handling the medical billing process efficiently and negotiating with insurance providers is our strength. With our services, you will never have to struggle with a single case agreement. Our team helps you maximize revenue and improve operational flow. We stay current with healthcare changes and follow a proactive approach to avoid claim denials. Our team ensures accurate coding, prevents submission delays, and avoids revenue leakages. 

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