Do you know that a single case agreement, or SCA for short, enables a patient to continue treatment with an out-of-network clinician without the need to pay extra charges?
But what exactly is it? It is a customized, one-time contract between an out-of-network healthcare provider and an insurance payer. It enables a patient to receive care from an uncovered provider while retaining their in-network benefits. While it helps the provider secure in-network rates from the payer, it also prevents denials because of being an out-of-network provider.
This guide covers everything you need to know about these one-time contracts, from their importance to key requirements. So, continue reading!
Significance of SCA for Healthcare Providers
Let’s review how the SCA contract helps healthcare providers:
Secures In-Network Reimbursement Rates
What happens when an SCA insurance contract is in place? Even if you are an out-of-network provider, you can still ensure that you receive a fair and negotiated rate directly from the payer. This rate typically matches the standard in-network reimbursement levels.
The benefit? This protects you from arbitrary out-of-network payouts or complete reimbursement rejections.
Minimizes Financial Burden on Patients
Single case agreement in insurance billing ensures that the payer treats the care as in-network. This means the patient only owes the practice their standard co-insurance, co-pay, or deductible.
How does it benefit the provider? It prevents the practice from having to balance-bill patients for out-of-pocket costs. The outcome? Reduced unpaid bills and improved patient relationships.
Expands Patient Access & Retention
Do you know that with a single case agreement, you can treat more patients with complex and rare conditions who otherwise could not afford out-of-network care?
The result? Your practice enjoys a broader patient base without forcing individuals to seek alternative, in-network competitors.
Guarantees Continuity of Care
Is your practice treating critical or long-term conditions, such as behavioral health or specialized medical therapies? With an SCA contract, you can guarantee care continuity.
How? It enables treatment to continue seamlessly without forcing the patient to find a new in-network clinician.
Safeguards Practice Revenue
An SCA in insurance billing establishes legally binding payment terms, explicit billing codes, and pre-authorization before you deliver the care. This prevents administrative confusion, lowers the risk of post-care claim denials, and ensures a smoother billing cycle.
Requirements for a Single Case Agreement
Typically, payers qualify healthcare practitioners for an SCA contract only if the following requirements are met:
- There is an absence of qualified in-network providers in the patient’s geographical area who can treat the specific condition.
- The out-of-network clinician possesses a specialized skill set, treatment method, or clinical expertise necessary for the patient’s care that existing in-network healthcare providers lack.
- In case a patient is transitioning to a payer or a clinician is leaving a network mid-treatment. Besides, switching providers would be harmful or disruptive to the patient’s health mid-treatment. Note that this situation is more common in behavioral health or complex medical treatments.
- Out-of-network providers must submit detailed clinical documentation to establish medical necessity and secure prior authorization before the payer negotiates the single case agreement.
- The payer and the clinician must agree on a set reimbursement rate, the exact procedural code to bill, and the specific number of allowed sessions or timeframe.
- The out-of-network provider must fulfill the insurance payer’s standard requirements. That is, you must maintain active state licensure, specific professional credentials, malpractice insurance, or any other requirements set by the payer.
Single Case Agreements with Payers
Discussed below are some insights about how different payers see SCA contracts:
Medicare
If you have been tired of looking for how you can secure an SCA with traditional Medicare, stop now! But why? Because it neither offers nor utilizes a single case agreement.
The reason? Traditional Medicare does not operate via restricted provider networks. Simply put, Medicare beneficiaries can seek care from any healthcare practitioner nationwide who accepts Medicare. As a result, an out-of-network contractual exception is unnecessary.
For context, a healthcare provider’s relationship with Medicare is strictly binary. That is, you can have either of the following statuses:
- Participating (PAR): A provider who is enrolled with Medicare and accepts the program’s approved amount as full payment for all covered services.
- Non-Participating (Non-PAR): These providers are also enrolled with Medicare. However, Non-PAR providers may choose per claim whether to accept assignment.
- Opted Out: Any healthcare provider who opts out of Medicare is completely outside the Medicare program for at least two years.
Medicare Advantage
Medicare Advantage plans may agree to SCA contracts. Note that private insurance companies, such as Aetna, United Healthcare, and Blue Cross Blue Shield, manage Medicare Advantage. Besides, they have a limited network of providers. As a result, they can and do sign SCA contracts with providers.
However, there is a catch! Private payers frequently refer to an SCA as a network gap exception because it is issued due to network deficiencies.
Also, getting an SCA under a Medicare Advantage plan is generally more challenging than it is with private insurance carriers. The reason? Medicare strictly audits whether a true gap in network coverage exists before agreeing to an out-of-network exception.
Medicaid
Single case agreements are very common in Medicaid plans. The reason? There are often no in-network options, and out-of-network benefits are unavailable.
So, how can you get an SCA contract?
- Justify that the specific case meets the criteria:
- Continuity of care (mid-treatment insurance changes)
- Specialization (rare clinical expertise)
- Network inadequacy (no local in-network options)
- Document the diagnostic codes, targeted procedural codes, and clinical proof explaining why an in-network clinician cannot provide this care.
- Submit the packet to the payer’s authorization department through an online portal or fax, and have the patient request an internal case manager to expedite the process.
- Negotiate the reimbursement rate.
- Obtain a formal, written contract with complete details before starting treatment to prevent claim denials. These include approved procedural codes, exact payout rates, and authorization dates.
Single Case Agreement vs. Gap Exception
The table below offers an at-a-glance view of the key differences between a single case agreement and a gap exception:
| Gap Exception | SCA | |
|---|---|---|
| What does it entail? | It is an internal insurance policy approval that temporarily treats an out-of-network provider as in-network. | It is a specific, negotiated one-time legal contract between a payer and an out-of-network provider for a single patient. |
| When does it become applicable? | When the insurance plan lacks any local or qualified in-network specialists to fill a gap (network deficiencies). | It focuses on provider-centric qualifications. That is, when continuity of care with a trusted clinician or highly specialized treatment methods is needed. |
| Who negotiates it? | Requested primarily by the patient or case manager via member services. However, the payer decides standard in-network pricing. | The payer and provider mutually decide on agreeable rates. |
| How long does it stay active? | The agreement stays active for a strict, temporary window until the payer can contract an in-network provider to fill the gap. | The duration is primarily tied directly to the length or course of the specific treatment plan. |
Streamline Your Billing Operations with MediBillMD
To summarize, single case agreements are an integral tool that enables you to accept and treat patients while being an out-of-network provider. However, you must fulfill the specific payer requirements to secure one.
In case you are experiencing a high denial rate or unsteady cash flow, it is time you consider onboarding professionals to help you with your billing cycle. At MediBillMD, we have a team of certified professional coders and billing specialists. We audit the practice’s billing operations, identify root causes, tailor a specialty-specific solution, and achieve quantifiable results.
Thus, if you want to experience all that and more, feel free to opt for MediBillMD’s medical billing services.
