Making The Case for Single Case Agreement (SCA) with Insurance Companies
As a psychotherapist in private practice, I have chosen not to be a part of any insurance panel. My patients pay me directly for services (out-of-pocket). I provide patients with a Superbill (a statement listing the dates, service codes and payments made) which they submit for reimbursement to their insurance company for out-of-network benefits. Most of these plans have a high deductible to be met, before any out-of-network benefits take effect.
There have been a few exceptions, in which I did contract with insurance companies for Single Case Agreements (SCAs), which were beneficial to all parties involved. Here's what you need to know about SCAs to advocate on behalf of your patients.
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 patient, so that the patient can see that provider using their in-network benefits (i.e., the patient will only have to pay their routine in-network co-pays for sessions after meeting their in-network deductible (if any)). 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 conditions to be met to ask for a Single Case Agreement (SCA)?
An SCA has to basically address the unique needs of the patient and the cost benefits to the insurance company of the patient 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:
For a new potential patient:
- You have a clinical speciality that is not available with any of the in-network providers (speciality can include cultural competency)
- Geographical location - in-network providers are not available locally
- Treatment you provide will keep the patient out of the hospital, or will reduce the cost of medications
If the patient has had no luck finding an adequately skilled in-network provider, then the patient makes the case for an SCA with the out-of-network provider BEFORE commencing treatment.
For a current patient who has obtained a new insurance:
- Continuity of Care
When can one make the case for Continuity of Care?
If the patient has recently changed insurance providers, then the insurance company can agree to a limited number of sessions (around 10) and period (e.g., 60 days since insurance change), to allow the patient to continue 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 patient psychologically/mentally (such as setbacks in the progress made in therapy), if required to transition to an in-network provider, than a case could be made for extended continued care with the current provider. Examples: a patient 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 patients with adequate 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 speciality, then you as a trained provider will be able to negotiate your customary full fee as the session rate for new patients. This is because the patient is not simply choosing to see you, but is being forced to, with inadequate in-network providers. In this case, the patient usually makes the case with the insurance company for an SCA with you, before commencing treatment.
If you are obtaining an SCA for a current patient for continuation of care, then the rate negotiated will be based on the patient's informed consent and agreement when beginning therapy with you. Fee increases will be consistent to your fee policy in the informed consent. You cannot charge the patient 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 CPT codes authorized, the start and end dates for treatment, and the number of sessions. One can request for a renewal of the SCA when there are only a few authorized (2 to 3) sessions left.