The Basics of Single Case Agreements
A Single Case Agreement ("SCA") is a contractual agreement between an insurance provider and an out-of-network healthcare provider. The agreement allows the out-of-network provider to bill the insurance provider for services rendered to that patient, despite not being an enrolled provider with that insurance company . SCAs are typically entered when an insurance company does not have an in-network provider available to deliver the required form of treatment for an individual patient.
SCAs typically define the specific circumstances under which the out-of-network provider can provide treatment to the patient. Usually the length of the SCA is temporary, lasting only until an in-network provider has time to see the patient to provide the same service at a lower in-network cost.
When are Single Case Agreements Relevant?
There are a number of circumstances in which an SCA may be needed. The following is a non-exhaustive list of when an SCA may be appropriate:
• When a patient has a rare medical condition that requires treatment from a provider outside of their geographic area.
• When a critical service, including specialty care or treatments, is not available near where a patient live.
• When a provider is a subspecialist and the specialty care services are not offered in the patient’s area.
• Temporary network limitations may warrant a patient’s request for an SCA when a medical necessity determination is involved.
• Out-of-network care may be needed when a provider who is part of the plan does not have privileges to provide services in the inpatient setting.
• When a patient is being discharged from an inpatient facility where the particular specialty of care is required and no providers in the network offer that service.
• A request for primary specialty care may be needed by a member whose unique medical condition necessitates that they travel to another geographic area to obtain the specialized care.
• A patient may not be able to access a certain health care provider. An example would be when a patient is new to an area and must wait for an appointment with a family physician or when circumstances require a transfer of care.
A Guide to Negotiating a Single Case Agreement
Negotiating a Single Case Agreement requires a thoughtful approach from both providers and patients. For Providers, it is essential to include documentation of the clinical rationale for the request along with supporting clinical studies. A patient’s Provider can highlight that the Services cannot be provided by a network Provider and that In-Network Providers are not available to provide the Services within a reasonable period of time. Of course, documentation of "failures" in the Network are a key part of the analysis.
As noted earlier, the patient is required to notify the Insurer prior to obtaining the Services. Once a Single Case Agreement is entered into, the Provider is often required to defray penalties imposed on the patient when the patient fails to notify the Insurer prior to obtaining the Services. Therefore, Providers would be wise to either avoid negotiating an Agreement or to be very clear that the patient must comply with all of the terms and conditions of the Agreement.
The Pros and Cons of Single Case Agreements
The appeal process for a patient and/or the provider can be long and tedious. It is critical that the treating providers in understanding Single Case Agreements as an alternative to the lengthy appeal process.
Single Case Agreements are an alternative to the appeals process. This contract can be very beneficial for both the patient and for the provider. These agreements are between a particular patient (or a group of patients) and a particular health insurance plan. The provider, either individually or through an institution or association, constructs the agreement and submits it to the carrier. If the health insurance carrier agrees with the provider’s proposal, and provides authorization in writing, the provider delivers required care to the patient.
A Single Case Agreement should be considered for any patient who needs specific types of out-of-network care. For the provider, issues to consider include substantial patient needs for the service, the nature of the service, and whether the provider is the only practitioner or institution available to provide the service. Patients and providers should enter into a single case agreement when a patient presents with a substantial need for certain types of out-of-network services; there is at least a moderate degree of hardship for the patient to travel outside their geographic area for the services; and the service is not available from any in-network provider or facility in the northeastern Pennsylvania/ New Jersey region.
The carrier who receives a Single Case Agreement request has the option to post information regarding the agreement. This will enable other parties treating patients with similar conditions to facilitate care for those patient within their network, and the network will have the option of covering the out-of-network providers to treat their patients with this specific ailment, thus avoiding a referral to an in-network provider. So he benefits can be two-fold.
However, these agreements can be complex, so the patient and provider should discuss the merits of the case before attempting to negotiate this type of contract. If the agreement is overly complex or takes much more time than anticipated, it will defeat the main purpose of the agreement, which is to save time and complications for the provider and patient.
Legal Issues and Financial Impacts
The legalities surrounding SCAs can be complex and vary from state to state. It’s important that the SCA negotiation process includes careful attention to the key terms and conditions of the contract as well as a consideration of the relevant state insurance regulations. Further, all parties to the contract must comply with their obligations under the terms of an SCA or risk breach of contract and a possible arbitration or lawsuit.
When developing the terms of the SCA, a key consideration is California Health and Safety Code Section 1374.19. This section outlines the circumstances under which a health plan may require an enrollee to obtain approval for a referral to an out-of-network provider (Section 1374.19(b) – if the referred provider is not in the plan’s plan the referral can be made to a participating provider with similar training and experience) and the circumstances under which the health plan must permit a referral to an out-of-network provider or must provide coverage for the services of the out-of-network provider (if it is determined to be medically necessary to provide services by an out-of-network provider) (Section 1374.19(c). Section 1374.19 also sets forth the time limits within which a health plan must make an out-of-area referral decision (Section 1374.19(d)) and the time limits within which a health plan must pay claims for services rendered by an out-of-area provider after the plan’s decision to approve the referral (Section 1374.19(e)). Violation of Section 1374.19 by a health plan could subject the health plan to liability in a civil suit.
In addition, the compliance implications for SB 1034 should not be overlooked. SB 1034, known as the "widely held" exception , permits a provider group contract that uses the term "health plan" or "health insurer" to refer to payors that do not fit the definition of "health plan" found in the Health and Safety Code. In determining whether a contract with an SCA falls outside the narrow scope of health plan or health insurer, it is important that the status of the referring provider and the relationship between the entities be considered in much the same way as would a plan/provider contract. The operative consideration is whether the contract demonstrates that the parties are conducting themselves as an insurer might do, as opposed to a provider that is developing a set of standards by which services are performed.
The enforceability of the SCA terms, and the impact the SCA will have on billing and reimbursement, is also influenced by Medicare and Medicaid laws. For Medicare Advantage plans, the referral and benefit authorization requirements outlined in the Medicare Managed Care Manual may apply. If the SCA involves a Medi-Cal managed care contract, a provider may be subject to the provisions of the Department of Health Care Services (DHCS) contractual provider regulations in Title 22 of the California Code of Regulations, Title 22, Section 51460. These regulations include, among other things, the requirement that a provider group or IPA under a Medi-Cal managed care contract must be permitted to send bills directly to DHCS (unless the provider has blanket-billed the intermediary for the past twelve months), the 14 day billing limit for providers under a Medi-Cal managed care contract, and the requirement that a provider must submit subsequent claims for reimbursement using the claim form developed for the service.
The various regulatory requirements that govern SCA contract relationships suggests that careful consideration be given to the terms and conditions of the SCA in order to reduce the possibility of unanticipated consequences that could result in contract dispute and arbitration proceedings.
Examining a Success Story: Single Case Agreements
As previously mentioned, SCAs allow providers to offer services to patients who may not be "in network," or that are outside a health plan’s service area. The cases below highlight some of the various ways SCAs have been effectively used to bridge the gap in coverage for unique patient needs.
Columbia/Geisinger
A health professional at Columbia University Medical Center contacted us regarding an out-of-state patient for whom she had been caring since 2014. The patient’s current insurance was not recognized by Columbia and her only other option was to return to her in-state provider with whom she had established a long-lasting relationship. We assisted in submitting a single case agreement request on behalf of the patient. We were happy to report that the patient will be able to complete necessary treatment at Columbia upon approval.
New York University/Reagan Institute
An interventional cardiologist at NYU Langone Medical Center reached out to us regarding a patient with thoracic outlet syndrome (TOS) who had been recommended for thoracoscopic first rib resection and subclavian artery venoplasty. However, the patient’s insurance plan would not cover the procedure because NYU Langone is not in the plan’s network. The patient’s care team is hopeful that this SCA will be approved, as the patient requires surgery in order to seek relief from debilitating neurological symptoms.
Insight and Advice for Patients Seeking Single Case Agreements
If you wish to pursue a single case agreement, state law requires that you do so within five business days (which do not include weekends or federal holidays) after the health care provider notified your insurer that it was refusing to provide coverage for a covered service. So the first step is to act quickly. The key to a speedy resolution is effective communication with your health insurance company and its designated Managed Care Organization (MCO). Be persistent and don’t be afraid to ask questions. MCOs are required by law to assist members in seeking out Single Case Agreements when it can be accomplished at little or no additional cost to the MCO or the insurers. Start by calling the customer service number on the back of your identification card and requesting an expedited Single Case Agreement. If calling does not produce results, place your request in writing. Be sure to keep a record of every call, including names, dates, times, and the telephone number where you can reach the person with whom you speak. The MCO will respond by confirming or denying the availability of an expedited review. The external independent review organization then has two business days to resolve your appeal. That means that everyone involved must act quickly to avoid any unnecessary delays in the approval process. Just as with internal appeals , the health care provider must follow all guidelines defined in a patient’s health benefits plan when submitting a Single Case Agreement request. As such, it is a good idea to ask your provider to submit the request on your behalf. Be sure to confirm with your provider that they have submitted your request and provide your insurer with a copy of all documentation related to your Single Case Agreement. The health care provider should include the following information along with the request (i.e., in the member’s medical file, as appropriate): 1. Previous treatment history; 2. Diagnosis; 3. Recommendations for further treatment, including supporting rationale and an explanation of why alternative or generic options are unsuitable; 4. Information regarding the use of non-covered items that would be medically necessitated if the covered item is denied; and 5. Any other information the health carrier may require. If the MCO denies the expedited Single Case Agreement, be sure to request an internal appeal. This will allow you to exhaust all available administrative remedies prior to filing a complaint with the appropriate state agency.
