Out-of-Network Doctor? Save Big with Single Case Agreements

Out-of-Network Doctor? Save Big with Single Case Agreements

Sometimes life throws us curveballs. Whether it’s a new job, a change in insurance, or a move to another city, you may find yourself in a position where you can no longer see your trusted doctor or specialist. Switching doctors, especially when you’re in the middle of treatment, can be stressful.

But what if you didn’t have to?

A Single Case Agreement (SCA) could be the solution that keeps you with your preferred doctor without paying inflated out-of-network prices.

Let’s examine how SCAs work, under what circumstances they apply, and how patients AND doctors can potentially benefit from this kind of arrangement.

What Exactly Is a Single Case Agreement?

A Single Case Agreement is essentially a deal between your insurance company and a doctor who’s not part of your insurance network. It allows you to continue treatment with that doctor at a cost similar to in-network rates, even though they’re out-of-network.

When patients choose to see an in-network provider, they usually pay significantly less. This is because the insurer has already arranged discounted rates and agreed to cover a portion of the provider’s fees.

SCAs are often used when switching providers isn’t ideal—like when you’re in the middle of specialized or long-term treatment.

For instance, let’s say you’ve been seeing a therapist for behavioral therapy, and you’ve built a strong, trusting relationship. Suddenly, a change in your insurance means that the therapist is now out-of-network.

Continuing care with them without an SCA could mean paying steep out-of-pocket fees. But if your therapist and insurance company can negotiate an SCA, you’ll be able to continue your sessions at a more affordable cost.

Here’s another example: Imagine a family whose child with autism needs requires Applied Behavior Analysis (ABA) therapy. The family finds that none of the in-network providers in their area are available or experienced enough to offer the level of care their child needs. They find an out-of-network provider specializing in ABA, but the cost is too high.

With a Single Case Agreement, the provider and insurance company can agree on a more manageable rate, allowing the family to get the necessary treatment without facing financial hardship.

How Do You Get a Single Case Agreement?

The process of getting an SCA usually starts with your doctor, though you can take the lead, too. The most important thing is proving that in-network providers can’t easily provide the care you need. For example, maybe there are no in-network specialists nearby, or perhaps those providers don’t have the expertise required for your treatment.

Once you and your provider identify that an SCA might be necessary, the doctor (or sometimes you, as the patient) will contact the insurance company to negotiate the terms. This includes agreeing on the services that will be covered, how long the agreement will last, and what the payment will look like.

When both sides reach an agreement, it’s all set in writing, and you can continue seeing your doctor as planned—without the shock of an enormous bill.

In What Situations Is an SCA Warranted?

  • The outpatient provider or treatment program offers a specialized service that is unavailable through any in-network providers.
  • The in-network providers do not accommodate your specific age group, gender, or religious preferences.
  • There are no in-network providers in the patient’s geographical area.
  • A patient recently switched insurance plans or is transitioning to a lower level of care at the same facility, requiring continuity of care.
  • All in-network providers are fully booked and have no availability.
  • There is evidence that in-network providers are not suitable or could potentially cause harm (e.g., a transgender patient requires care from a provider with expertise in transgender issues).
  • Even if out-of-network benefits are available, the deductible, out-of-pocket maximum, or co-pays may be prohibitively expensive.
A Single Case Agreement benefits doctors, too.

What Should Doctors Know About Single Case Agreements?

If you’re a doctor considering negotiating an SCA with an insurance company, there are a few key things to remember. First, ensure you have thorough documentation showing why your services are essential for the patient. The more solid the case, the easier it is to get the insurance company on board.

It’s also a good idea to start the process as early as possible. SCAs can take time to finalize, and you don’t want a patient to experience a gap in care because of delays. Be transparent with your patients about any potential costs that might not be covered—nobody likes unexpected fees.

Why Single Case Agreements Are a Win for Doctors

1. Predictable Payments

One of the biggest challenges for doctors providing out-of-network care is getting paid on time (or at all!). SCAs offer a way to prevent this. With a clear agreement in place, doctors know exactly when and what they’re getting paid. It’s a straightforward arrangement that helps take the guesswork out of billing so providers can focus on patient care rather than chasing payments.

2. Keep Providing Specialized Care

Some patients require specialized treatments that aren’t easy to find within an insurance network. A Single Case Agreement allows providers to continue offering these services without forcing patients to move to another provider.

Take the example of a child with autism who needs ABA therapy—there may not be many options nearby, and the available ones might not offer the same level of care they are used to. SCAs let doctors continue that treatment, ensuring their patients get the best care possible while they’re compensated fairly for their expertise.

3. Build Stronger Patient Relationships

We all know how important trust is in a doctor-patient relationship, especially in fields like mental health or long-term care. If patients suddenly have to switch doctors because of insurance changes, it can feel like a step backward for both patients AND doctors.

Single Case Agreements help doctors keep those relationships intact. By negotiating an agreement, doctors can stay with their patients, and patients can avoid the stress and hassle of finding a new provider.

4. Less Paperwork, Fewer Hassles

Billing can be a headache for providers, particularly with out-of-network services. Claims often get delayed or denied, leading to a lot of back-and-forth between providers, the insurance company, and patients. SCAs simplify the process.

Since the payment terms are already negotiated, there’s less room for errors or misunderstandings, which means less paperwork for providers and fewer billing disputes.

5. More Flexibility for Doctors and Patients

One advantage of being an out-of-network Doctor is that they often have more flexibility in scheduling. They’re not juggling as many patients as their in-network counterparts, which can mean more personalized care and shorter appointment wait times. The downside is that out-of-network care is expensive for patients.

However, with a Single Case Agreement, providers can offer that flexibility without the financial burden, making their services more accessible.

Why Single Case Agreements Work for Everyone

Single Case Agreements are a win-win for both patients and providers. If you’re a patient, you get to stick with the doctor you trust without the added stress of high out-of-network costs. And if you’re a provider, you can continue delivering quality care while ensuring you get paid fairly and promptly.

SCAs also make it easier for patients to access specialized care that might not be available within their insurance network. They also help doctors keep their practices running smoothly, even when insurance changes throw a wrench in the system.

If you’re facing an insurance issue that’s threatening to disrupt your care or practice, remember that an SCA might be the key to keeping everything on track—without sacrificing the quality of care or financial stability.