The SCA will also describe the permitted CPT codes, the start and end date of the treatment and the number of sessions. You can request an extension of the SCA if there are only a few authorized sessions left (2 to 3). It is also important to note that some insurers have standard protocols for negotiation on a case-by-case basis. Some have a “Pay At The Highest Rate”, as if you were a network provider. This is based on their tariffs without the need for negotiation. In an off-grid scenario like this, it`s possible to use a case-by-case agreement to ensure your client has the coverage they need to get the care they rely on from you as a practitioner or therapist. Even though your agency may be out-of-Network (OON) in a specific insurance company, you may still have the option to negotiate a single case agreement (SCA) to be recognized as an in-network provider (INN). For ABA services, the criterion is that there are no INN providers near you for the same services. For every OON plan you`re working on to get permission, ALWAYS ask for an SCA – there`s never a hard time asking, right? Follow these steps and you can get an SCA for the best payment. Some insurers require that the case-by-case agreement be that of the rendering provider, which must be submitted on claim form 1500. In the case of a patient who needs to move from your care to a new network provider or a patient who prefers to remain in your care, you may need to help the patient address their request to the insurance provider.
Sometimes an insurance company may have a “payment with the highest intra-network rate” policy, in which case you cannot negotiate the rate. You always have the option to refuse the SCA if the rate and conditions are not acceptable to you. If the patient has recently changed insurance providers, the insurance company may arrange a limited number of meetings (approximately 10) and a period (.B e.g. 60 days since the change of insurance) to allow the patient to continue treatment with the current provider outside the network, while switching to a network provider. If there is evidence that the person could pose a danger to themselves or others, or if it affected the patient psychologically/mentally (e.g.B. returns during treatment) if necessary to switch to a network provider, a case could be made for increased continuation of care with the current provider. Examples: a patient has an uncertain bond and it is very difficult to trust others. The already existing therapeutic relationship with the current provider can be considered as a factor in the allocation of sca. If you receive an ACS for a current patient for continued treatment, the negotiated rate is based on the patient`s informed consent and consent at the start of treatment with you. Rate increases will be consistent with your pricing policy in informed consent. You can`t charge the patient a lower mobile rate out of pocket and then charge the insurance company your normal full rate if the SCA is back to cover past meetings.
A case-by-case agreement is designed to meet the patient`s essential treatment or therapy needs and the cost benefits to the insurance company, without having to switch to another provider in the network. To lead the negotiation process, the following criteria must normally be met. These include the following factors: one of the things to remember is that insurance companies are legally required to properly treat patients by properly trained professionals. Therefore, if the insurance plan does not cover out of network services and there are no networked providers with the indicated specialization, you can, as a trained provider, negotiate your usual full fees as a meeting rate for new patients. . . .