If you are a practitioner looking for a case-by-case arrangement for a current client who needs ongoing care, the negotiated rate may be more flexible depending on the client`s preferences. In such a case, the negotiated price may be influenced by the customer`s consent. However, they must be properly informed and possibly sign official documents indicating that they are aware of the process and may be able to incur more expenses. A case-by-case agreement is designed to meet the patient`s essential treatment or therapy needs and the cost benefits to the insurance company without having to switch to another networked provider. In order to direct the negotiation process, the following criteria must generally be met. These include the following factors: Case-by-case behavioral health agreements can be entered into when a patient cannot receive the same or comparable service from a networked provider. If a patient needs a specialized service and a networked provider is not available within a reasonable time or in close proximity to the patient, an ACS may be considered to compensate for the lack of availability. These agreements may also be allowed if a patient has recently switched insurance providers and needs ongoing treatment with a particular provider who is outside the network with the new insurance company. Note that not all insurance companies provide a physical version of an SCA document, this detailed clinical information must be documented and maintained as part of medical necessity. In the event that a justification is required in advance for services or for post-case audits, you want all protection-related bases to be covered. As an ABA therapy provider, you may consider negotiating a case-by-case (CAS) agreement to provide services to a patient. These agreements exist between insurance companies and off-grid providers (OON) when the OON agency is recognized as a networked provider (DCI).
Although it is usually the patient who asks their insurer about ACS, based on the fact that there are no other ICD providers for ABA therapy in their area, your agency should always agree on the terms and rates of the services provided. Since insurers are not required by law to provide an ACS, it is important that you explain to them the benefits of offering this possibility. However, remember to remain honest and defensible when stating the reasons for the need for an ACS. Beautification means fraud. The requirement for an ACS generally falls into two categories: new client or current patient. When trying to get an ACS for a new patient, you need to consider the patient`s (family) need for your specialty and the benefit of being close to them. When helping a current patient apply for an ACS from a new insurer, justify the need for the agreement by focusing on continuity of care. Also, keep in mind that by the time an ACS is granted, you must have defined your patient`s financial responsibilities to your agency. You can choose not to provide services until the CAS has been authorized, or you can agree to a financial arrangement for meetings not covered by the agreement (just because a DSA is approved does not mean it will be backdated). Always ask for an SCA for OON plans for which you need permission. Consider the following strategies to get an agreement on a case-by-case basis: Some insurance providers require that the agreement on a case-by-case basis be included in the rendering providers that must be submitted on the 1500 application form. What else do I need to know about agreements on a case-by-case basis? If the patient has not had the chance to find a sufficiently qualified networked provider, they advocate for an ACS with the off-grid provider BEFORE starting treatment.
This is especially true if there is evidence in the past that the person poses a danger to themselves or others, or if they are at risk of suffering a significant setback to their mental health. Case-by-case arrangements are more common in patients who have identified trust issues and developed a professional relationship with their current ABA provider. Typically, insurance companies have a pool of contract providers in a geographic area. and the payer will not offer case-by-case arrangements if it believes that there are already enough providers available to meet the needs of its patients. Other payers, such as Medicaid or other government agencies, only offer networked benefits, so ACS are less likely to be an option. For smaller providers with fewer customers, it may be beneficial to selectively decide which payer networks you want to contract with. There are many therapeutic processes, such as ABA therapy, where continuity of care is crucial to achieving treatment goals. When a client moves to a new insurance provider, it is essential to maintain continuity of care or create a transition plan to a new networked provider.
In many of these scenarios, a case-by-case agreement often needs to be negotiated. It was not uncommon for case-by-case agreements to compensate services in a much more attractive way than that of network providers. Today, many payers offer SCA compensation at the highest rate in the network, but continue to allow patients to access their services on the network, reducing the patient`s financial responsibility. If you receive a TCA for a current patient to continue their care, the negotiated rate is based on the patient`s consent and agreement with you at the start of treatment. Fee increases are consistent with your informed consent fee policy. You can`t charge the patient a lower sliding rate out of pocket and then charge the insurance company your full normal rate if the SCA is backdated to cover sessions in the past. Case-by-case agreements must also use ABA CPT authorized medical billing codes. It is important to express them in the negotiation process with the insurer. This reduces the risk of a late claim.
In the case of a transition to a new network provider, the CPT code for the SCA may be specific to the number of remaining sessions. Insurers can only assign a specific code for this case or patients. Sometimes an insurance company may have a “pay at the highest rate in the network” policy, in which case you won`t be able to negotiate the rate. You always have the option to refuse the SCA if the price and conditions are not acceptable to you. It is also important to note that some insurance providers have standard protocols for negotiating an agreement on a case-by-case basis. Some have a “pay at the highest rate” as if you were a networked provider. This is based on their prices with no room for negotiation. One thing to keep in mind is that insurance companies are required by law to provide patients with appropriate treatment by properly trained professionals. So if the insurance plan does not cover off-grid services AND there are no networked providers with the particular specialty, as a trained provider, you can negotiate your usual full fee as a session price for new patients. Indeed, the patient does not simply choose to see you, but is forced to do so with an insufficient number of networked providers. In this case, the patient will usually speak to the insurance company for an ACS with you before starting treatment. In the case of a patient who needs to move from your care to a new networked provider, or a patient who prefers to remain in your care, you may need to help the patient make their request to the insurer.
It is a sad reality that not all insurance providers offer the same level of coverage and may have their own limited networks for patients. By familiarizing yourself with the agreement process on a case-by-case basis, there is a lot you can do to keep patients and ensure they receive the highest level of care. .