Have a client who wants to see you, but you are not on their insurance plan?  One option is to see if you can work out a Single Case Agreement with the plan.

What is a Single Case Agreement?  On occasion, insurance plans negotiate Single Case Agreements with out-of-network providers.  An SCA allows a client to see a provider (or continue to see a provider) who is not in their plan network. For this one case, you are usually treated as a network provider.  However, some SCAs are merely an agreement from the health plan to reimburse your out of network clients in situations when they would not normally receive reimbursement.

What is a Transition of Care Agreement?  If the client’s insurance changes and you are no longer covered, you can sometime negotiate a type of Single Case Agreement called a Transition of Care Agreement, or TOC.  With TOCs, you sign a contract with the new insurance plan to provide a certain number of “transition” sessions just for this client, even though you are not a network provider, with the goal of completing treatment or transitioning the client to someone in the new panel.

What conditions must exist for a Single Case Agreement to be made?  While some insurance plans don’t have tight restrictions, many plans require at least one of the following to be true:

• No network providers are available within a reasonable distance of the client’s geographical location
• A provider with the needed language or clinical specialty or evidence-based treatment type (ex. EMDR) is not available within the plan network.
• There may need to be evidence that the client might be a danger to him/herself or others (or that treatment might be significantly negatively impacted) if required to transition to an in-network professional

What are the steps to getting a Single Case Agreement?  This varies by the plan, but typically:

• If you are going to argue there are no appropriate in-network providers, the client usually make a reasonable effort to find a network therapist with the needed availability, specialty, or language capability within a reasonable distance. Urge the client to keep track of how many network therapists they have contacted and their names, if possible.
• If unable to find a network therapist, the client should contact the insurance plan, reporting their trouble finding a network provider.
• The client should tell the plan that they have identified an out-of-network provider that is willing to see them, or that they are already seeing.
• A care manager from the plan may attempt to call around and try to find a network provider for the client; if unable to find someone, they will typically reach out to the out-of-network therapist the client found by phone
• If you are currently treating the client, you may be asked to provide information about diagnosis, symptoms, and your treatment plan, including measurable goals and discharge criteria.  You may be asked to explain why the individual’s treatment needs cannot be adequately met by a network therapist, or why a transition to another therapist at this time might be detrimental to the client.
• If the plan representative agrees to a SCA, they will likely offer to pay what they pay their network therapists, but I encourage you to negotiate for more – you can often get your full fee. Keep in mind, you may have more power than you think.  The plan has been unable to provide what their member needs, and many states have accessibility laws that require that plans pay for someone out of network when the plan can’t provide an available provider that meets the client’s needs.
• Make sure you get the SCA in writing. You may need this down the line if there are any problems.

What should be in the agreement?  This depends what kind of SCA it is.  The agreement should make it clear how much you will be paid, what CPT codes you are permitted to bill for, when the SCA expires, the authorization number, if any, if there are session limits, who is responsible for billing, and where to send claims, if applicable.  Some SCAs have you acting for this one case as an in-network provider, where you only collect copayments from the client, and you handle claim submissions.  Others just agree to cover your services and reimburse the client, when they wouldn’t normally.  This needs to be spelled out.

Should you do this? The biggest downside about working with an SCA is that — if you have a normal SCA where you are acting as an in-network provider for this one case — you have to file insurance claims, and sometimes SCA claims are processed incorrectly.  Since you aren’t in the plan’s computer as a network provider, the claim may be processed as if you are an out-of-network provider, and either rejected, paid at the wrong rate, or the check may be sent to the client.   Another issue you might face is lack of security:  One provider told me that she set up a SCA for a client with a health plan, only to have it revoked by the health plan several weeks later when they found an in-network provider they felt the client could see.

The upside?  Sometimes things go very smoothly, and you can get paid more than if you offered a sliding scale fee to this out of network client. You may be able to continue providing services to someone you have been treating, or to make your services more affordable to a new client who perhaps couldn’t otherwise afford it.

BUT: My latest feelings:  While in the past I encouraged Single Case Agreements, things in the insurance industry these days have become so difficult and SCA providers so frequently have run into problems getting paid that I am now quite reluctant to recommend SCAs.  What often happens is that when you submit claims, they are denied or paid incorrectly, because you come up as an out-of-network provider in their system.  And when you call the health plan, often the representative who authorized the SCA no longer works there, and the plan can’t find evidence of your SCA authorization, or if they can, they promise to put though the claim correctly, but they don’t.  I hear too many stories of therapists fighting for months to get paid at all, or to be paid at the correct rate, despite having a clear contract.  Provider support isn’t what it used to be.  As one therapist put it, “the main problem really is that you can never speak to anyone who has authority and ability to fix things. You just keep…sending…emails.”

The issue is that you fall between the cracks for this case – you are not a true in-network provider nor a true out-of-network provider.   I only would consider agreeing to a Single Case Agreement if it does not involve you acting as a network provider for the client.  That is, the only time I would recommend it is if the Agreement allows you to collect in full from the client and give them a superbill, enabling the client to be reimbursed for your services when they wouldn’t normally be.  In this way, it involves no financial risk to you.  But most don’t work this way.  And even an Agreement like this could set the client up for income loss if the plan doesn’t pay properly.