What Is a Single Case Agreement

What requirements do patients need to meet for a case-by-case agreement? For a case-by-case agreement, as a health care provider, you should recommend billing your patient to the insurance company. The purpose of ACS is to meet the important needs of the patient; Billing costs primarily and not a networked provider. The following conditions make your patient`s case eligible for an ACS: Sometimes an insurance company may have a “pay at the highest rate in the network” policy, in which case you will not be able to negotiate the rate. You always have the option to refuse the SCA if the price and conditions are not acceptable to you. Single-case agreements, also known as SCAs, are contracts between an insurance company and an off-grid provider. These types of contracts usually cover a specific customer who receives a service for a certain period of time at an agreed price. Until recently, most payers took on the role of negotiating ACS rates; However, many payers no longer negotiate these case-based rates and therefore pay the highest costs at the network level. Note that not all insurance companies provide a physical version of an SCA document, this detailed clinical information must be documented and maintained as part of medical necessity. In the event that a justification is required in advance for services or for post-case audits, you want all protection-related bases to be covered. If you are a practitioner looking for a case-by-case arrangement for a current client who needs ongoing care, the negotiated rate may be more flexible depending on the client`s preferences. In such a case, the negotiated price may be influenced by the customer`s consent.

However, they must be properly informed and possibly sign official documents indicating that they are aware of the process and may be able to incur more expenses. Typically, insurance companies have a pool of contract providers in a geographic area. and the payer will not offer case-by-case arrangements if it believes that there are already enough providers available to meet the needs of its patients. Other payers, such as Medicaid or other government agencies, only offer networked benefits, so ACS are less likely to be an option. For smaller providers with fewer customers, it may be beneficial to selectively decide which payer networks you want to contract with. Once an agreement has been reached, the new terms of the FCC are valid. Since an ACS is rarely backdated, it is important that the patient understands their financial responsibility in an intermediate window between coverage or in the event that ACS is not granted. By proactively responding to the process, the time to care can be shortened, benefiting both the therapist and the patient. It is also important to note that some insurance providers have standard protocols for negotiating an agreement on a case-by-case basis.

Some have a “pay at the highest rate” as if you were a networked provider. This is based on their prices with no room for negotiation. Some insurance providers require that the agreement on a case-by-case basis be included in the rendering provider, which must be submitted on application form 1500. If the patient has not had the chance to find a sufficiently qualified networked provider, they advocate for an ACS with the off-grid provider BEFORE starting treatment. What else do I need to know about agreements on a case-by-case basis? In an off-grid scenario like this, it may be possible to use a case-by-case agreement to ensure your client has the coverage they need to receive the care they rely on from you as a practitioner or therapist. What to consider when approving agreements on a case-by-case basis Getting approval of an agreement on a case-by-case basis can be a tedious and frustrating task. Our job is to support you in this process. However, once the SCA is approved, our task is not yet complete. Here we need your help to consider the following aspects: As we go through difficult times, we need to rely on mental health professionals more than ever. Understanding the process and elements of a strong case for a single care agreement is one way to continue to serve and strengthen our local communities.

It was not uncommon for case-by-case agreements to compensate services in a much more attractive way than that of network providers. Today, many payers offer SCA compensation at the highest rate in the network, but continue to allow patients to access their services on the network, reducing the patient`s financial responsibility. Individual behavioral health agreements can be made when a patient cannot receive the same or comparable service from a networked provider. If a patient needs a specialized service and a networked provider is not available within a reasonable time or in close proximity to the patient, an ACS may be considered to compensate for the lack of availability. These agreements may also be allowed if a patient has recently switched insurance providers and needs ongoing treatment with a particular provider who is outside the network with the new insurance company. How inclusive is the case-by-case agreement We have already mentioned how you should focus on the services included in the agreement. If your patient requires multiple treatments and therapies, the contract must cover reimbursement of billing for all or the maximum number of treatments. As an ABA therapy provider, you may consider negotiating a case-by-case (CAS) agreement to provide services to a patient. These agreements exist between insurance companies and off-grid providers (OON) when the OON agency is recognized as a networked provider (DCI). Although it is usually the patient who asks their insurer about ACS, based on the fact that there are no other ICD providers for ABA therapy in their area, your agency should always agree on the terms and rates of the services provided.

Since insurers are not required by law to provide an ACS, it is important that you explain to them the benefits of offering this possibility. However, remember to remain honest and defensible when stating the reasons for the need for an ACS. Beautification means fraud. The requirement for an ACS generally falls into two categories: new client or current patient. When trying to get an ACS for a new patient, you need to consider the patient`s (family) need for your specialty and the benefit of being close to them. When helping a current patient apply for an ACS from a new insurer, justify the need for the agreement by focusing on continuity of care. Also, keep in mind that by the time an ACS is granted, you must have defined your patient`s financial responsibilities to your agency. You can choose not to provide services until the CAS has been authorized, or you can agree to a financial arrangement for meetings not covered by the agreement (just because a DSA is approved does not mean it will be backdated).

Always ask for an SCA for OON plans for which you need permission. Consider the following strategies to help you get an agreement on a case-by-case basis: This is especially true if there is evidence in the past that the person is at risk for themselves or others, or if they are at risk of suffering a significant setback to their mental health. Case-by-case arrangements are more common in patients who have identified trust issues and developed a professional relationship with their current ABA provider. If the patient has recently changed insurance providers, the insurance company may accept a limited number of sessions (about 10) and a period of time (for example. B.B 60 days since the change of insurance) so that the patient can continue treatment with the current off-grid provider while switching to a networked provider. .

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