What is a Single Case Agreement for Rehab?

Understanding the SCA Process for Rehab Owners

Navigating the process with an insurance provider can be a frustrating process for any administrator or billing department employee at your substance abuse treatment facility. In certain instances, your staff may find it difficult to obtain approval from a certain insurance company that doesn’t consider your organization an in-network provider.

But what about employing a single case agreement for rehab services?

In most cases, those involved would assume that this is a situation that still requires the client to pay a significant amount out of pocket. And, unfortunately, the average person attending rehab isn’t able to foot the bill when the insurance company won’t provide coverage.

For a client who’s relying on your facility to provide continued care, this can be a punishing blow to their recovery efforts. This is where the answer to what is a single case agreement for rehab comes to the fore.

If you’ve never heard or dealt with a single case agreement – an arrangement your facility can make with insurance providers – you want to read this latest resource from our team at Ads Up Marketing all the way through.

Defining a Single Case Agreement

A Single Case Agreement – otherwise known as an SCA – is an arrangement between the insurance company and your facility (the out-of-network provider in this situation) stating that a client isn’t required to obtain a new insurance provider to accommodate their situation.

When clients require long periods of treatment – for example, a regimen that includes detox, inpatient rehab, partial hospitalization, outpatient treatment, and potentially applying to sober living facilities – these agreements can be lifesavers.

What Does the SCA Process Entail?

When you’re not considered an in-network provider, which in turn disqualifies your facility from receiving full payment for services rendered, a single case agreement can rectify the situation, leaving all parties involved satisfied. Typically, a negotiation takes place between the facility and the insurance company.

The end goal is to guarantee the insurance company pays a designated amount for treatment – typically the same amount they would pay an in-network provider, saving the client from expensive out-of-pocket costs.

What Type of Prerequisites Are Required by Insurance Providers?

When an insurance company provides in-network benefits to an out-of-network facility, naturally there are prerequisites attached to the situation that must be satisfied. Before offering coverage for in-network benefits, an insurance provider’s representative usually requires the following items.

Keep in mind not all insurance providers offer this arrangement, and requirements may vary.

1) Getting Coverage for Specialty Forms of Treatment

The specific therapeutic modality provided must be unique in the context of addiction treatment. This is to say, that your facility must have a treatment program that’s not available through the in-network providers the client can select from.

This can include a number of different program characteristics at your facility, including, but not limited to:

• Dual diagnosis treatment
• Holistic therapy
• Trauma-informed therapy
• Luxury rehab amenities
• Extended periods of inpatient treatment
• and more

2) Specific Location Requirements

If the client has specific needs based on location that aren’t satisfied by in-network providers, this provides potential grounds for a single-case agreement.

This can’t just be solely based on client preference – the location demand must play a prominent role in the outcome of client treatment.

3) Avoiding a Prohibitive Cost to Clients (and Insurers)

If the treatment you provide reduces the potential out-of-pocket expenses for the client or helps them avoid further complicating their situation, many insurance agencies are willing to negotiate a single-case agreement.

4) The Same Level of Care Isn’t Available Elsewhere

A case agreement may be the only potential solution if the client has searched but can’t find a qualified in-network provider that makes the same level of care available.

For example – if your facility provides detox, inpatient, intensive outpatient programs (and/or virtual IOP offerings), and partial hospitalization programs when primary options do not, the cost benefits outweigh enforcing in-network provider rules for the insurance company.

In this case, it would warrant a single-case agreement.

The Pressing Need for Continued Care

Aside from the situations mentioned above, dozens of examples could potentially qualify for a single case agreement. Essentially, in the case of substance abuse treatment especially – it all boils down to the need for continued care.

A client entering into rehab isn’t always afforded the luxury of time or shopping around. In many cases, these situations can arise in the middle of treatment, or when a client is transferring from one care level to another. Informing a client that their insurance agency isn’t offering coverage would be a potential death blow to the progress they’ve made.

These incidents can pop up if clients recently changed insurance providers, or if their provider was absorbed by a larger umbrella corporation. Regardless of the specifics, you must be aware of the negotiation process, in addition to steps you can take to ensure both sides agree.

What is a Single Case Agreement for Rehab? Looking Closely at the Negotiation Process

The law states that insurance agencies are legally obligated to make satisfactory treatment available to every client. If you’re seeking a single case agreement for a prospective client that requires immediate care, the insurance agency is likely to have flexibility.

The final agreed-upon rate might be impacted by the client’s preference for your facility. Even still, they are required to sign any binding paperwork that highlights the fact that they’re aware of what’s going on and could still potentially be responsible for marginal out-of-pocket expenses.

Usually, the fee is determined through a sliding scale that’s calculated by you, the facility owner. It’s worth noting that you’re not permitted to charge the insurance company your full rate for any back-logged time in treatment.

Adhering to In-Network Provider Rates and Reasonable Accommodations

In some cases, insurance agencies have policies that include paying the highest in network rate available. Agencies that employ these policies usually have no wiggle room for negotiation.

Regardless of the specifics of the agreement, there should be a mutually shared concern from you and the insurance agency – the wellbeing of the client. In 90% (or more) of cases, the insurance provider is willing to bend to accommodate their customer for the sake of preventing any future relapses and the need for further treatment sessions.

Suggestions for Obtaining the Preferred Outcome for Your Client

Use the following tips to obtain the most ideal outcome for your client:

• Timing is important. The request should be made during the initial authorization if possible.
• Be flexible regarding your fees. If you’re willing to drop your rates, the chances are higher that you’ll get the answer you’re looking for.
• Prepare your proof and documentation. Have everything ready to demonstrate to the insurance agency why the potential client has a pressing need for treatment at your facility.

Going Up Against an Insurance Agency? Obtain a Winning Outcome for Your Facility with Our Help

At Ads Up Marketing, our team has a significant amount of experience in dealing with provider and insurance agency relations. If you’re not well-versed in navigating the negotiation process and advocating for your client, we can help. Contact us today – the sooner you reach out, the higher your chances of both long-term client recovery and fair reimbursement for your services!