Mastering Single-Case Agreements for Medical Providers: Requesting, Negotiating and Billing

September 4, 2024

Mastering Single-Case Agreements for Medical Providers: Requesting, Negotiating and Billing

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Dr. J is a Physician, MBA graduate, AAPC Certified Coder (COC), and ASQ Certified Six Sigma Black Belt (ASQ CSSBB) with 20+ years of experience in the Healthcare Industry. His key expertise areas include coding in multiple specialties, end-to-end RCM, multiple market segments, product and process innovation for the healthcare business, lean six sigma management, and process design and improvement.

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Healthcare providers and insurers enable out-of-network patients to access specialty care through single-case agreements. In this guide, our experts explain how the agreements work and how to negotiate and secure one. Plus, get our list of request forms.

Inside this article:

How single-case agreements work
List of the top 50 insurer’s agreement request forms
Single-case agreement approval process
Single-case agreement billing and reimbursement
Managing single-case agreements
Single-case agreement best practices for medical providers

What Is a Single-Case Agreement in Insurance?

A single-case agreement is a contract between an insurance company and a healthcare provider that enables treatment for an out-of-network patient. They are useful when a patient needs specialty treatment unavailable in their network. Other times include when a patient changes insurance carriers or requires a closer provider.

Importance of Single-Case Agreements in Healthcare

Single-case agreements in healthcare are crucial for ensuring patients receive care from out-of-network providers when in-network options are unavailable or inadequate. The agreements provide access to necessary treatments while negotiating coverage and cost, offering a lifeline for patients requiring specialized or urgent care.

Differences Between Single-Case Agreements and Standard Insurance Agreements

Single-case agreements differ from standard insurance agreements. Standard insurance agreements offer a provider network with pre-negotiated rates applicable to all policyholders. Single-case agreements involve out-of-network providers with customized terms, payment arrangements, and reimbursement rates.

Key Takeaways:

Single-case agreements are requests for patients to receive care from out-of-network providers.
Single-case agreements work in place of prior authorizations.
The agreements, including reimbursement rates, differ for each patient.
Rate negotiations are flexible because in-network rates do not constrain them.

Situations Where Single-Case Agreements are Typically Used

Single-case agreements come into play when there’s no good option in the network. There can be a few reasons. One common one is that the provider is a specialist. Others include the patient switching insurers or needing a closer provider.

Balaji Ramani, Vice President of Business Development at Plutus Health, explains how single-case agreements enter the process.

"Prior authorizations are required to provide treatment for in-network patients,” he says. “An out-of-network clinician cannot obtain a prior authorization because there is no formal contract with the payer. This is where single-case agreements come into play. Single-case agreements replace prior authorizations when the practice or provider is out-of-network."

Bala, who specializes in Applied Behavior Analysis (ABA) and behavioral health, says single-case agreements are vital in this field to allow patients access to treatment under special circumstances.

When Would a Patient Need a Single-Case Agreement?

Many scenarios could cause a patient to need a single-case agreement. The patient’s insurer may not offer a particular specialty in their network. Or the patient may have a gender or religious preference. Or the patient may want to keep a provider who’s no longer in the network.

Here’s a full list of the reasons for a patient needing a single-case agreement:

Out-of-Network Payer: The provider has chosen to be out of network because the payer is small or the provider doesn’t see many patients from that specific payer. This can be challenging when negotiating single-case agreements because there is little incentive for the payer to provide one.
No In-Network Options: The patient's insurance carrier lacks in-network providers who specialize in the treatment the patient needs. This situation is particularly common with Medicaid and Medicare patients, who may have limited network specialist options.
Specialty Not Available In-Network: The patient’s insurance carrier does not have providers who specialize in areas such as addiction, eating disorders, or trauma. Or they don’t offer treatment such as group therapy, family therapy, or school counseling.
Age, Gender, or Religious Preference: Patients may have preferences that are unavailable in-network. These reasons include comfort levels, culture, or needing a specialty for specific age groups like pediatric or geriatric.
Long Processing Times: The credentialing process is long for out-of-network providers, up to 100 days. If an out-of-network provider can see new patients, they may request a single-case agreement to start the services.

Bala says, “In cases when a kid desperately needs immediate services, the single-case agreement is usually granted because the insurance provider doesn’t want the patient to suffer, and they can see that the healthcare organization is in the process of joining their network.”
Insurance Carrier Change: When patients switch insurance carriers, their current provider may no longer be in-network. To ensure continuity of care, a single-case agreement is requested to allow treatment to continue with the same provider. This arrangement alleviates the patient’s burden of finding a new in-network provider and reduces the risk of a disruption in care.

Bala provides an example: “I’m a parent, and my child receives services from an ABA organization. In December, I had X insurance, which is in-network with the practice. But X insurance was too expensive, so in January, I changed to Y insurance. The organization is not in-network with Y insurance. Now, the responsibility to request the single-case agreement falls with the practice. Once the parent notifies the practice of the insurance change, the practice requests a single-case agreement. If the agreement falls through, the parent will have to pay cash.”
Provider Proximity: If an in-network provider specializing in a particular treatment is far from the patient’s home, obtaining a single-case agreement allows the patient to receive care from a closer provider.

Why Would a Healthcare Provider Want a Single-Case Agreement?

Single-case agreements can help healthcare providers improve their patient care and finances. They reduce claim denials associated with out-of-network services. This simplifies billing and reimbursement. The agreements also allow providers to negotiate higher reimbursements.

Since providers are not bound by fixed in-network rates with single-case agreements, they can negotiate higher reimbursement rates. “The clinician can charge what they feel is a reasonable amount,” Bala says. This flexibility maximizes revenue when providers set rates that reflect the value of their services.

Dr. Jagadeesha. G. S — Dr. Jagadeesha, physician and healthcare RCM product and process innovator at Plutus Health

Dr. Jagadeesha, a physician and healthcare RCM product and process innovator at Plutus Health, adds, “Sometimes it is 30-50% higher than the in-network rates.”

Successfully negotiating single-case agreements can enhance relationships with insurance companies, potentially leading to broader network participation opportunities. Demonstrating the ability to manage and negotiate these agreements effectively can strengthen a provider’s position when seeking formal network inclusion.

Also, providers in the process of joining a network can use single-case agreements to begin treating patients right away. This allows them to build their clients faster.

Why Would an Insurance Carrier Want a Single-Case Agreement?

Insurance carriers may want a single-case agreement to maintain customer satisfaction when there’s no appropriate provider in the network. They can retain a customer who might otherwise change companies. The agreements also reduce disputes.

Single-case agreements streamline the administrative process for the carrier, as they typically involve a one-time negotiation rather than ongoing prior authorizations or extended disputes over coverage. This efficiency can reduce operational burdens and help the carrier maintain a positive relationship with both the patient and the provider.

How the Single-Case Agreement Process Works

A single-case agreement requires coordination among the patient, provider, and insurance company. First, the patient talks to the out-of-network provider. The provider then contacts the insurance company to negotiate an agreement, which may or may not be approved.

Here’s a more detailed look at the process:

The healthcare provider initiates a single-case agreement request by contacting the patient’s insurance company and discussing the possibility of covering services at an out-of-network rate. A single-case agreement letter can initiate the request or formalize the agreement once it's negotiated.

“In an ABA setting, if the client is new, the process for establishing care with the provider requires an initial assessment to learn what challenges the kiddo is facing, such as vocal or the degree of self-harm,” Bala explains. “To complete this initial assessment, the clinician needs prior authorization from the insurance carrier.”

The clinician must be in-network to obtain this authorization, so instead, they request a single-case agreement as a substitute. It’s typically a PDF form to allow efficient handling.

“After you apply for a single-case agreement, the payer looks at several factors, including why you are requesting one,” Bala says. “For example, are you out-of-network or have you applied to be in-network and waiting on credentialing? Based on the reason and the client’s information, the request is approved or denied.”

Bala adds, “Most insurance companies will not deny a single-case agreement if they see that the credentialing process has started and it’s their processing time that’s causing the delay. They understand the requesting clinician or organization will eventually become part of the network.”

The provider and insurance company negotiate service coverage and payment and reimbursement rates. When obtaining a single-case agreement for a current patient, the rate is based on the patient's informed consent and agreement.

“We use single-case agreements to obtain payment,” says Dr. Jagadeesha.

Once a rate is established, providers bill the insurance company, which pays the provider at the agreed rate. The patient is responsible for any deductibles or co-pays.

How the Single-Case Process Works

Completing the Single-Case Agreement Request Forms

Single-case agreement request forms vary among insurance companies. The provider fills out the requested information. It commonly includes the reason for the request, provider information, CPT codes, and cost and reimbursement details.

It also typically includes terms and conditions for working with the insurance company. Specific requirements vary among insurance carriers depending on their guidelines and policies.

“It’s important to remember that a single-case agreement is not a universal contract,” Dr. Jagadeesha says. “It goes patient by patient/case by case.”

Follow these best practices for accurately filling out single-case agreement forms:

Be Accurate and Detailed: Enter patient, provider, and insurance information accurately. Include diagnosis codes, treatment details, and whether the insurance plan includes out-of-network benefits. Inaccurate or missing information can result in denials or delays in processing the request.
Provide a Cost Breakdown: Provide a detailed breakdown of the costs associated with the requested services. This information is crucial for negotiating reimbursement rates and payment terms. Clearly state what you consider fair charges for your services to make negotiation easier.
Follow Submission Instructions: Adhere to the submission instructions provided by the insurance company to avoid processing delays.
Maintain Records: Keep copies of completed request forms and related communication. This includes keeping a record of all correspondence with the insurance company, supporting documents, and confirmations of receipt.

Single-Case Agreement Approval Process

Approving single-case agreements involves a series of steps by the insurance company. It conducts an initial assessment and reviews the documentation. If that looks acceptable, it then negotiates rates with the provider and authorizes the agreement.

Here’s a closer look at the steps in the approval process:

The insurer conducts an initial assessment to determine whether in-network services are available and the medical necessity of the treatment. It also ensures that the out-of-network provider meets the company’s standards.
The insurance company then reviews the patient’s diagnosis and treatment plan documentation. Cases with recent in-patient hospitalizations or a history of serious behavioral issues (e.g., suicidal or homicidal behavior) may be more likely to receive approval due to the urgent nature of the care needed.
The insurer negotiates terms with the provider. This includes reimbursement rates, treatment duration, and any proposed modifications based on the insurance company’s policies and guidelines. Rates can vary even for patients with the same CPT codes. Dr. Jagadeesha highlights an example, “Patient A might negotiate an insurance payment of $22, while Patient B might secure $25, depending on the specifics of their cases.”
All parties sign the approved single-case agreement.

Tips for Successful Negotiation on Single-Case Agreements

The best tips for negotiating single-case agreements include providing thorough information and responding quickly. Also, be persistent with gentle nudges.

Negotiating a single-case agreement can be challenging due to potential delays and insurers’ hesitance to approve the requests. Follow these tips to secure favorable reimbursement rates, comprehensive coverage of services, and an appropriate duration for treatment:

Remain Persistent: Insurers may resist agreeing to terms that deviate from their standard policies or rates. Persistence allows providers to address concerns and push for more favorable terms. It also ensures that the terms of the single-case agreement comply with regulations and reduce the risk of disputes or complications.
Explain the Unique Situation: Provide clear evidence about why out-of-network care is necessary. For example, if a patient wishes to receive services close to home with an out-of-network provider, explain why this is important. Include detailed clinical documentation that supports unique situations for out-of-network care.

“A gentle nudge helps,” Bala says. “If the gentle nudge doesn’t work, the parent may have to use a harsher tone and threaten to go to another insurance carrier.”
Respond to Counteroffers: Negotiations can be challenging. Responding to counteroffers shows your engagement efforts and support for reaching an agreement with the patient’s care as a top priority. It also keeps the process moving forward to avoid gaps in the patient’s care.
Provide CPT Codes: Provide accurate CPT codes and modifiers, including the number of sessions needed and duration of treatment. This shows the insurance company exactly what the patient requires, leaving no room for questioning and reducing the risk of a delayed claim.
Research Other Providers: The insurance company will likely review other local providers offering similar services to understand their pricing structures and use this information during negotiations. Effectively position yourself in these negotiations by conducting your research beforehand. This proactive approach helps you set competitive rates and demonstrates your commitment to providing high-quality care.
Prepare Documentation: Processing times can be long. Plan by preparing documentation. If you agree to treat the patient during the single-case agreement processing time, have a clear financial agreement in place in case the agreement is denied.

Managing Single-Case Agreements

Healthcare providers must stay organized when managing single-case agreements. That means detailed tracking of the submission and approval process. Maintain clear records and follow up promptly with the insurance company.

Follow these tips to ensure a smooth process and optimal outcomes:

Use a spreadsheet or database to track them in one place.
Set reminders for expiration dates so you can prepare to extend the agreement if needed.

Single-case agreements typically cover the duration of the treatment, which is determined through negotiation with the insurance provider. The length of the agreement is based on the provider's expert assessment of the necessary treatment duration.
Document all communication and keep it organized in one location. This includes copies of forms, emails, and notes from phone conversations.
Conduct regular audits to ensure compliance and reimbursements align with the agreed-upon rates.
Inform patients about any financial responsibilities or steps they need to take.
Monitor the agreement to ensure the services provided match the descriptions outlined in the agreement and that cost estimates align with the agreed rates.

Single-Case Agreement Billing and Reimbursement

Providers submit a 1500 Claim Form for services covered under a single-case agreement. The provider bills at the rates negotiated in the single-case agreement. That can differ from their standard out-of-network rates, often reducing the cost.

Insurers require CPT billing codes for accurate payment. Submit claims as soon as possible to address any disputes quickly.

As Bala explains, “Coding (both CPT codes and modifiers) guidelines remain the same per that payers’ or state-specific guidelines. The single-case agreement is only in place of the prior authorization. We can input the SCA number in the claim form in box 19 as “SCA – Ref # xxxxxxxxxxxxxx.”

A current patient seeking a single-case agreement for continuity of care might be assessed using a sliding fee scale.

Denials may occur due to inaccurate or missing information. When appealing, be prepared to give the insurance company additional information and supporting documentation. Be aware that appeal processes vary by state and insurance providers, so following their specific requirements is important.

If denied, the provider must go to the parent and tell them their insurance is not approving a single-case agreement. Bala explains, “The responsibility then shifts to the parent. They have two options: The parent can call the payer and see if they will facilitate the single-case agreement, explaining why it’s vital. If the insurance company stands with the denial, the patient must pay cash for the services.”

Single-Case Agreements Best Practices for Medical Practices and Providers

Best practices for single-case agreements start clearly defining the patient’s necessary treatment. Providers must also understand and comply with their legal obligations. Follow the agreement’s terms closely.

Here’s a detailed list of practices for single-case agreements:

Use a spreadsheet or database to track them in one place.
Define Services Clearly: Specify the services your patient requires in the agreement to avoid misunderstandings.
Understand Legal Obligations: Single-case agreements are legally binding contracts. Both the provider and the insurance company must adhere to the terms, with insurance companies obligated to cover ABA treatment provided by qualified practitioners.
Ensure Compliance: Follow healthcare regulations and the terms of the agreement to minimize the risk of legal disputes over reimbursement rates or coverage.
Stay Within Legal Scope: Verify that you are operating within your legal scope of practice when negotiating single-case agreements for specialized services.

Although single-case agreements benefit patients who need services from out-of-network providers, they don’t uphold the same standards of care and cost savings as the Center of Excellence programs. Here are the reasons:

Lack of Cost Transparency: Single-case agreements follow a fee-for-service model, so some services or medications may not be covered, resulting in a higher patient bill. Fortunately, a law protects patients from paying more than their in-network coverage amount. The No Surprise Act is a law that bans out-of-network practices from balance billing commercially insured patients.
No Quality Evaluation: Single-case agreements are often needed quickly, with little time to evaluate the facility’s or provider’s quality. As a result, there is a risk of unnecessary, ineffective, or lower-quality care.
No Wrap-around Services: Wrap-around services such as case management, counseling, or housing assistance are typically not included with single-case agreements. This can be stressful and more expensive for the patients who would benefit from these services.

How to Streamline Your ABA Billing

Streamline your ABA billing and collections with Plutus Health’s expert assistance in managing single-case agreements. Our team proactively contacts the patient’s payer to verify acceptance of single-case agreements. If they’re accepted, we submit all necessary information and paperwork to ensure the client has accurately completed everything. We also address any denials and work diligently to resolve any that arise.

As Dr. Jagadeesha explains, “The billing process remains the same -- we use the same CPT codes and modifiers for single-case agreements. However, the claims payment varies based on the contract. Reimbursement for single-case agreements often exceeds in-network cases, and we leverage our expertise to reduce denials and secure additional funds for our clients.”

Choose Plutus Health to optimize your billing process, maximize reimbursement, and focus on patient care.