Single Case Agreements for Specialty Concierge Physicians

As a specialist in a private concierge medical practice, you’ve chosen to terminate all insurance panel agreements. Patients will pay you directly for services (out-of-pocket). You provide patients with an invoice marked with dates of service, service codes, diagnosis codes and all payments paid by the patient. Patients agree that if they have insurance, they acknowledge responsibility to submit the supplied invoice and to be reimbursed by their health benefit plan for out-of-network benefits, if any. Generally, these plans have a high deductible to be met before any out-of-network benefits take effect. Comes now, a special case where you are willing to manage an exception to your policy. The problem is you aren’t sure how to go about negotiating and executing a Single Case Agreement (SCA), for a special procedure, a surgery, or an episode of care involving services over a distinct period of time for a covered condition. The SCA will benefit all parties involved. In this article, I’ve shared the essentials about SCAs so you can advocate on behalf of your patients when necessary, on your terms and conditions, and not have to capitulate to the very terms and conditions of standard managed care panel participant agreements that you previously decided to terminate.

Definition of 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. It enables the patient to receive care and treatments or surgery from a provider using their in-network benefit schedule. This means that the patient will only have to pay their routine in-network co-pays for office visits from you, or surgery or a set of sequential treatments bundled into an episode of care after meeting their in-network deductible.

The Fee Negotiation
The fee you charge has been agreed to by the insurance company in advance will be for this unique episode of care, for this patient and no other for a specific date of service or date range and then it’s over. I’ll cover more on fees below.

Continue reading inside the PDF and also find a helpful SCA Template Agreement to get you started. →