Single Case Agreements and Other Tools for OON Patients
As the new year approaches, and with turmoil ahead with potential skyrocketing premiums, you
may see patients change insurance plans in the coming months. You may find patients who were previously in network are suddenly out of network (OON).
But a change of insurance doesn’t necessarily have to mean goodbye, leaving patients without their usual support during a time when they likely need it most. As a psychiatrist or mental health nurse practitioner, you may have a few tools at your disposal to continue care.
This article covers single case agreements (SCA), transitions of care (TOC), and in network exceptions (INE). Though there are some distinctions between them, the common thread is that they allow you – as an OON provider – to be treated in network to some degree.
By utilizing one of these tools, patients can benefit by receiving continuity of care with a provider they’re familiar with. Let’s look at how these work.
Making the Request
Typically, the patient makes the initial request with their insurance. TOCs are generally available from a new insurance company when a large employer switches from their previous one. We sometimes see TOCs granted when a mental health provider goes out of network, but not often.
SCAs and INEs can also make sense to pursue when an employer switches insurance companies. But generally, if the patient switches insurance on their own (on the ACA Marketplace), these options are unlikely to be allowed.
Clarifying Patient Responsibility
Just because a request is made, doesn’t mean it will be granted. Some, like an SCA, could take a few weeks to be finalized and are generally not backdated. Therefore, it’s important to have conversations with your patient about their financial responsibilities during any windows between coverage, or in the event the request is not fulfilled.
Making the Case
As the psychiatrist or mental health nurse practitioner, you may be asked to make a case, justifying why you should be given some kind of in network access. We recommend making sure the insurance company is aware of one or more of these points:
- Continuity of care – Make this point if the patient can’t afford the OON benefits to see you, and if there could be setbacks in progress if they had to start over with a new (in network) therapist.
- Expertise – Make this point if your specialty can be more effective, reduce the duration of treatment more than seeing someone with a more generalized practice.
- Hospitalization – Make this point if the treatment you provide can reasonably be argued to keep the patient out of the hospital or reduce the cost of medications. Insurance companies love saving money.
Claims Processing and Balance Billing
Before agreeing to terms, it’s important to understand how claims should process.
An SCA is actually a contract you and the insurance company sign. It makes you in network for a specific patient. SCAs process with in network benefits, at the rates you agreed to (see “Agreeing to the Terms” below), and you cannot balance bill (you take the insurance discount because you’re contracted).
INEs are generally delivered as an authorization, with a defined date range. You’re likely to receive an authorization number which goes on claim form. Claims should process using in network benefits. The reimbursement rates used are non-negotiable and variable OON amounts, and you are allowed to balance bill up to your billed rate.
TOCs should process like an INE and you can balance bill if you want. They are usually for a short amount of time (3 months is common) and are designed to give a patient more time to find an in network provider. After that, if the patient continues to see you, claims should start processing with OON benefits if they have any.
Agreeing to the Terms
Make sure you understand any terms or limitations as described above. With SCAs you can generally negotiate your rates. Try to settle on something as close to your regular billed rates as possible. For TOCs and INEs you won’t be able to negotiate.
Claim Processing Errors
Though claims should process as described above, sometimes they don’t. Generally, they don’t flat out deny but will instead process with OON benefits when they should use in network. Before agreeing to using one of these tools, make sure you’re committed to reviewing the EOBs for processing errors and have the capacity to call the insurance company to send claims back for reprocessing as needed.
If you don’t personally have the bandwidth, either don’t take on such cases or make sure your billing service understands how these work and have the workflow in place to identify and challenge processing errors.
If you want to see if MindEase is a good fit for your solo mental health private practice, click on the Request A Discovery Call button below.