The client has tried and cannot find a practitioner or supplier in his network that meets his needs in a way that allows him to feel comfortable. For treatment with ABA, this must be done before the start of treatment. Many therapists use unique case agreements (SCAs) to keep patients with a change of insurance. An SCA is an agreement between a therapist and an insurance company with which you are not connected (OON) that allows you to be effectively treated as a network for a particular patient. Patients benefit from continuity of care with the same therapist they know, and therapists benefit by maintaining relationships with patients and often reaching similar or similar rates. If the patient has not had the chance to find a sufficiently qualified network provider, then the patient pleads for an SCA with the out-of-network provider before the start of treatment. If the patient has recently switched insurance providers, the insurance company may accept a limited number of sessions (approximately 10) and a period (for example. B 60 days since the insurance change) to allow the patient to continue treatment with the current network provider while switching to a network provider. If there is evidence that the person could pose a danger to himself or others, or if it affects the patient psychologically or mentally (for example. B failures in the progress of therapy), if this proves necessary to switch to an in-network provider, a case could be advanced for an increase in adequacy with the current provider. Examples: a patient has an uncertain bond and finds it very difficult to trust others. The therapeutic relationship already established with the current supplier can be considered as a factor in granting the SCA.
Case-by-case agreements must also use medical billing codes authorized for the CPT abA. It is important to spell them in the negotiation process with the insurer. This reduces the risk of deferred demand. In the event of a transition to a new network provider, the CPT code for the SCA may be specific to the number of sessions remaining. Insurance providers can only assign a specific code in this case or for patients. A case-by-case agreement is intended to meet the patient`s basic treatment or therapy needs and the cost benefits to the insurance company, without having to switch network providers. As a general rule, the following criteria must be met to guide the negotiation process. It should be noted that insurance companies have a legal obligation to treat patients properly by well-trained professionals. Therefore, if the insurance plan does not cover off-network services, and there are no in-network providers with the specified specialty, then you, as a qualified provider, can negotiate your usual full fees as a meeting rate for new patients.
This is because the patient does not simply choose to see you, but is forced to deal with insufficient providers in the network. In this case, the patient usually makes the case with the assurance of an ACS with you before starting treatment. This is particularly true if, in the past, there is evidence that the individual poses a danger to himself or others, or if he is at risk of suffering a serious setback from his mental health. Case-by-case agreements are most common in patients who have created trust problems and developed a professional relationship with their current ABA provider.