When it comes to our health, we need the best possible care. This includes knowing how to negotiate a single-case agreement, commonly called an SCA when your health insurance provider can’t provide for your needs.

Even with the best insurance policy in place, occasionally, you may need a one-off agreement to cover an unexpected event or occurrence. SCAs cater for off-the-menu or bespoke procedures not covered by your regular health insurance for several reasons.

What Is a Single-Case Agreement or SCA?

A single case agreement is a one-off contract between a healthcare provider (psychotherapist or similar specialist service, for example) and an insurance company that deals with and outlines specific terms of cover for a patient’s treatment.

Insurance companies can make single-case agreements when a patient needs care not covered by their insurance plan or when their insurance provider (the company that provides the insurance) is not in-network with the healthcare provider. Any agreement is made on a case-by-case basis and is designed to provide coverage for a specific patient’s needs.

SCAs cover contracts that typically cover a specific client receiving a service for a designated time at an agreed-upon rate. Or client + service or procedure + time = SCA.

What Is an In-Network Provider as Opposed to an Out-Of-Network Provider?

In-network means that your healthcare provider agrees with your health insurance provider to accept a discounted rate. And out-of-network implies that there’s no discount agreement and can charge you the total price. The rate is usually much higher than the in-network discounted rate.

Why Should You Seek an SCA?

Previously, most patients would negotiate the rates for SCAs, but many payers are no longer doing so. They are instead paying the highest in-network level costs, which seems ludicrous when an out-of-network SCA can be good news for patients as it means they can access the care they need without having to pay high out-of-pocket costs.

The agreement may also be financially beneficial to the insurance company.

What Conditions Must You Meet for an SCA To Be Accepted?

A successful SCA agreement must address the unique needs of the patient while providing cost benefits to the insurance company rather than an in-network provider. Specifically, the patient must have particular needs or requirements that a verified insurance healthcare provider cannot service.

The following are some of the conditions that must align for an SCA to be granted to patients if they have a clinical specialty that is unavailable with the in-network providers.

• Medical Necessity: Your in-network healthcare provider does not provide the treatment you require, which is medically necessary and not just a preference or convenience.
• Availability: Your in-network healthcare provider does not provide the treatment you require within a reasonable distance from your home or work location.
• Qualification: Your in-network healthcare provider is not qualified or not licensed to provide the specific treatment you require.

All of the above are grounds for an SCA, but you must get an agreement from your insurance provider before any treatment can occur. If you have changed health insurance providers mid-treatment and your new provider cannot offer you what you need, you may continue with the out-of-network treatment provider for continuity of care.

How To Negotiate SCA Terms

The first thing to remember is that insurance companies must, by law, provide patients with adequate treatment by properly trained healthcare professionals who specialize in the specific care you need. Therefore, if your insurance plan does not cover the out-of-network services you need, and there are no in-network providers with the given specialty, then you can insist on an SCA with an out-of-network provider who can see to your needs.

You must remind the insurance company that you, the patient, are not simply choosing to see an out-of-network provider but are being forced to because of the inadequate in-network providers’ healthcare provision. In this case, the patient usually makes the case with the insurance company for an SCA before commencing treatment.

Suppose you are obtaining an SCA for continuation of care. In that case, the fee is negotiated on the patient’s informed consent at the beginning of the therapy with the out-of-network provider.

Fee increases will be consistent with the out-of-network fee policy in the informed consent before treatment commences. Sometimes, an insurance company may have a policy of “paying at highest in-network rate,” in which case this rate is non-negotiable. If this happens, the out-of-network provider could decline the SCA if the rate and terms are unacceptable.

More Things To Know About Single Case Agreements

SCAs can be a valuable alternative for patients to help insurance companies play their part. A patient’s request for an SCA must explain why a specific out-of-network provider is better qualified to meet the medical needs than an in-network provider. In that case, this increases the chances of successfully obtaining a Single Case Agreement.

As mentioned earlier, common reasons supporting the need for an SCA include extended wait times for services that could worsen a condition, distances too far away from the patient’s home or work, or lack of in-network providers specialized enough to provide adequate treatment.

Securing an SCA Is a Win-Win for All

Finally, getting an SCA can take time, as the care provider will need to coordinate the action plan so that when approval is granted, there will be no break or delay in service. It’s also essential to have a clear and well-written financial agreement with the out-of-network provider should the insurer refuse to cover the services provided.

If you cover all bases, securing an SCA shouldn’t be complicated and should leave all stakeholders satisfied with the arrangement but, more importantly, facilitate the most appropriate healthcare for your situation.