How to Negotiate a Single Case Agreement as an Out-of-Network Provider

ABA Therapy Provider

As an ABA Therapy provider, you might consider negotiating a Single Case Agreement (SCA) to offer services to a patient. These agreements occur between insurance companies and Out-of-Network (OON) providers in which the OON agency is recognized as an In-Network (INN) provider.

While it is usually the patient who asks their insurer for the SCA, on the basis that there are no other INN providers available for ABA therapy in their area, your agency will still have to come to agreement about terms and rates for the services that will be provided. Since insurers are not legally required to provide an SCA, it will be vital for you to present to them the merits of granting you this opportunity.
Remember, however, that when providing the reasoning behind the need for an SCA, remain honest and justifiable. Embellishing means fraud.

Requesting an SCA usually falls into two categories: new client or current patient. When attempting to obtain an SCA for a new patient, consider including the patient’s (family’s) need for your speciality and the advantage of your proximity to them. If you are helping a current patient to request an SCA from a new insurer, justify the need for the agreement by emphasizing the continuity of care.
Also keep in mind that until an SCA has been granted, you will need to have defined your patient’s financial responsibilities to your agency. You may decide on not providing services until the SCA has been authorized or you may agree on a financial arrangement for sessions that will not be covered by the agreement (just because an SCA is okayed does not mean it will be backdated).
Always request an SCA for OON plans that you are working to obtain authorization for. Consider the following strategies to help you obtain a Single Case Agreement:

Because it is the family that needs to ask for an SCA, you may need to provide parents with guidance on how to phrase a request letter that demonstrates why your agency offers services that other INNs cannot. (i.e. Patient John Doe will be forced to start over with a new (in network) therapist and thus lose valuable progress because the family cannot afford out-of-network services).
Be sure to ask for the SCA at the the same time you request an Initial Assessment Authorization.
Prior to the contract being signed, you will need to negotiate fees based on your fee schedule. It is recommended that you accept rates that are at or close to your fee schedule.
An insurance representative will seek out providers in your area so be prepared to substantiate your argument.
You may be required to be currently working through the INN process.
An SCA may be allowed under “pay at highest in network rate”, which means you will be able to provide service, but not negotiate your own rates.
If an SCA is granted, pay attention to the date range that is applied to it and be sure to schedule in the request for a renewed SCA the same time as a new Authorization.
Make sure to ask about any changes to claims reporting for payments if you obtain an SCA.
Take note that some insurers require the SCA be in the Rendering Provider’s name which can affect information on a 1500 claim form.

Let WebABA Professional help you with your medical billing and insurance credentialing.

WebABA Professional not only understands the requirements needed for your agency to obtain a Single Case Agreement, we also recognize how vital it can be to get your insurance credentialing, so that you can increase your patient-load, receive payment for your claims, and do what you do best – provide meaningful, quality ABA therapy services.