Single Case Agreement (SCA) with Insurance Companies
Making the case for single case agreement (SCA) with insurance companies
Most cosmetic surgeons have chosen not to be a part of any insurance panel. Patients pay directly for services (out-of-pocket). Your insurance company may direct you to the nearest plastic surgeon assuming anyone who performs liposuction can perform the liposuction for lipedema procedure. That is usually not the case.
The clinic needs to provide patients with a Superbill (a statement listing the dates, service codes and payments made) which they submit for reimbursement to their insurance company. Note: Many cosmetic/plastic surgery clinics may not have a practice management system and be unfamiliar with filing insurance. The patient will have to create and submit the claim.
A Single Case Agreements (SCAs) can be beneficial to all parties involved; it is a contract between an insurance company and an out-of-network provider for a specific patient, so that the patient can see that provider using their in-network benefits (i.e., the patient will only have to pay their routine in-network co-pays for treatments after meeting their in-network deductible [if any]). The fee for the service paid by the insurance company is negotiated by the insurance company and the provider as part of the SCA.
An SCA is not always required for the insurance carrier to pay the clinic; your carrier may decide to pay the clinic without one. However, without one the carrier is more likely to elect to pay the patient directly.
What are the conditions to be met to ask for a Single Case Agreement (SCA)?
An SCA has to basically address the unique needs of the patient and the cost benefits to the insurance company of the patient seeing you, rather than an in-network provider. The following are some of the conditions that must be met for an SCA to be granted. For a new potential patient:
- You have a specialized service (liposuction for lipedema) that is not available with any of the in-network providers.
- Geographical location – in-network providers (lipedema expert) are not available locally
- Treatment you provide that will keep the patient out of the hospital, or will reduce the cost of conservative treatment.
- If the patient is unable to find an adequately skilled in-network provider, then the patient makes the case for an SCA with the out-of-network provider before commencing treatment.
- For a current patient who has obtained a new insurance.
Continuity of Care (generally this won’t apply to Liposuction for Lipedema – Jeff)
When can one make the case for Continuity of Care?
If the patient has recently changed insurance providers, then the insurance company can agree to a limited number of treatments (around 10) and period (e.g., 60 days since insurance change), to allow the patient to continue treatment with the current out-of-network provider, while transitioning to an in-network provider. If there is evidence that the individual might be a danger to him/herself or others, or if it would adversely affect the patient psychologically/mentally (such as setbacks in the progress made in therapy), if required to transition to an in-network provider, than a case could be made for extended continued care with the current provider. Examples: a patient has an insecure attachment and finds it very hard to trust others. The therapeutic relationship that has already been established with the current provider may qualify as a factor for granting the SCA.
How does one negotiate the rates of payment and terms of the contract?
Insurance companies are legally obligated to provide patients with adequate treatment by properly trained professionals. Therefore, if the insurance plan does not cover any out-of-network services, and there are no in-network providers with the given specialty, then negotiate the surgeon’s customary full fee as the rate for new patients. This is because the patient is not simply choosing to see this particular surgeon, but is being forced to, with inadequate in-network providers. Some use a reimbursement advocate for the negotiation. Others negotiate on their own behalf. If your own efforts are not enough or you are uncomfortable with the negotiations you may consider hiring a healthcare attorney familiar with “breach of contract” suits in your state if you experience a lot of pushback.
In this case, the patient usually makes the case with the insurance company for an SCA with the Provider, before commencing treatment.
Sometimes an insurance company may have a policy of “pay at highest in-network rate”, in which case you will not be able to negotiate the rate. The surgeon has the option of declining the SCA if the rate and terms are not acceptable.
The SCA will also spell out the CPT™ and ICD-10-CM codes authorized, the start and end dates for treatment, and the number of treatments (typically two or more). Note again, that both the surgeon and the insurance company may be unfamiliar with the different codes used and that there is not 100% agreement or Medicare or AMA CPT™ Coding Assistant™ advice.