Insurance

SINGLE CASE AGREEMENTS

MAKING THE CASE FOR SINGLE CASE AGREEMENT (SCA) WITH INSURANCE COMPANIES​

    There have been a few exceptions, in which I did contract with insurance companies for Single Case Agreements (SCAs), which were beneficial to all parties involved. Here's what you need to know about SCAs to advocate on behalf of your case.

FAQS

What is a Single Case Agreement (SCA)?

    A Single Case Agreement (SCA) is a contract between an insurance company and an out-of-network provider for a specific patient, so that the patient can see that provider using their in-network benefits (i.e., the patient will only have to pay their routine in-network co-pays for sessions after meeting their in-network deductible (if any)). The fee per session that will be paid by the insurance company is negotiated by the insurance company and the provider as part of the SCA.

What are the conditions to be met to ask for a Single Case Agreement (SCA)?

    An SCA has to basically address the unique needs of the patient and the cost benefits to the insurance company of the patient seeing you, rather than an in-network provider. The following are some of the conditions that must be met for an SCA to be granted:

• For a new potential patient: I have a clinical specialities (i.e. Biofeedback, Behavioral Medicine, Chronic Pain, etc.)  that is not available with any of the in-network providers (other specialities can include cultural competency)
• Geographical location - in-network providers are not available locally. Treatment I provide will keep the patient out of the hospital, or will reduce the cost of medications

If a patient has had no luck finding an adequately skilled in-network provider, then the patient makes the case for an SCA with the out-of-network provider BEFORE commencing treatment. 

• For a current patient who has obtained a new insurance:

Continuity of Care

When can one make the case for Continuity of Care?

    If the patient has recently changed insurance providers, then the insurance company can agree to a limited number of sessions (around 10) and period (e.g., 60 days since insurance change), to allow the patient to continue treatment with the current out-of-network provider, while transitioning to an in-network provider. If there is evidence that the individual might be a danger to him/herself or others, or if it would adversely affect the patient psychologically/mentally (such as setbacks in the progress made in therapy), if required to transition to an in-network provider, than a case could be made for extended continued care with the current provider. Examples: a patient has an insecure attachment and finds it very hard to trust others. The therapeutic relationship that has already been established with the current provider may qualify as a factor for granting the SCA.

How does one negotiate the rates of payment and terms of the contract?

    One thing to keep in mind is that insurance companies are legally obligated to provide patients with adequate treatment by properly trained professionals. Therefore, if the insurance plan does not cover any out-of-network services, AND there are no in-network providers with the given speciality, then a trained provider will be able to negotiate the customary full fee as the session rate for new patients. This is because the patient is not simply choosing to see Dr. Dihmes, but is being forced to, with inadequate in-network providers. In this case, the patient usually makes the case with the insurance company for an SCA with you, before commencing treatment. 

If you are obtaining an SCA for a CURRENT CLIENT for continuation of care, then the rate negotiated will be based on the patient's informed consent and agreement when beginning therapy with you. Fee increases will be consistent to your fee policy in the informed consent. 

   The SCA will also spell out the CPT codes authorized, the start and end dates for treatment, and the number of sessions. One can request for a renewal of the SCA when there are only a few authorized (2 to 3) sessions left.

COURTESY BILLING

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If a client provides all necessary information information, I will submit a 1500CMS claim form on their behalf. This is a cost to me, but one I am happy to take on to express my gratitude for clients choosing and trusting my services. 

The insurance company will receive the information about your session (the duration, the location, the fee, and sometimes diagnosis.) Depending on your coverage, and deductible, a reimbursement (full, partial or none) will be mailed to your home address.

I will work with your insurance to  provide additional forms or information, as long as it requires less than 30 minutes. Once, the paperwork exceeds this time, I need to charge for my time. 

TALKING TO YOUR INSURANCE COMPANY ABOUT SINGLE CASE AGREEMENTS

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1. Contact your physician, pain doctor, or psychiatrist and request that s/he write a letter stating that you (first and last name) are under their care. They should also note your diagnoses and and how long s/he has worked with you, as well as list your current medications. Have the provider state that the patient requires “specialized psychotherapy and/ or biofeedback” (i.e., a licensed psychologist certified in biofeedback with experience in pain management). Note that many practitioners claim to offer biofeedback treatment without providing comprehensive treatment (consisting of EMG, cardio-respiratory, temperature, or GSR; individual psychotherapy; chronic pain management; CBT) or having attended full training or being formally certified. With assistance from our team, you will need to make the case to the insurance company that they do not have anyone “in-network” who can provide the scope of comprehensive treatment that Dr. Dihmes does (e.g., intensive psychotherapy, certification by the BCIA Board).

2. Call your insurance carrier’s Behavioral Health department. Contact information may be on the back side of your insurance card. Ask for the contact information for the individual who authorizes single case agreements.

3. Fax the provider's letter and any supporting documentation to the contact person at your insurance company. You may also want to include discharge summaries, if there have been any hospitalizations, and any medication lists from the past, surgeries, treatments, prior suicide attempts, ideation or self harm behavior — any documentation that supports the request that comprehensive treatment and/ or biofeedback is required.

4. Follow up within 2–3 days by calling your insurance company and asking to speak with the individual in behavioral health who oversees authorization of single case agreements.

5. If the insurance company denies your request, ask (firmly) that you need a letter for your files stating that the insurance company “is refusing the recommendation of your physician or psychiatrist.” You may also remind the person with whom you’re speaking that “pain management services is one of the core measures of the Joint Commission.” The Joint Commission (jointcommission.org) regulates care practices, so this may be an additional strong motivator for them to agree to your request. An additional resource describing the cost-savings benefit to the insurance company can be found at https://www.ncbi.nlm.nih.gov/pubmed/3122851 and https://draxe.com/biofeedback-therapy/ 

https://www.aapb.org/i4a/pages/index.cfm?pageID=3440

https://www.mayoclinic.org/tests-procedures/biofeedback/about/pac-20384664