Advantages of Single Case Agreements for Healthcare Centers

Healthcare is becoming more complicated, and providers struggle to provide high-quality care while balancing their finances. One tool that providers use to reach patients, even if they are outside of their network, is the single case agreement. This is a contract between a healthcare provider and an insurance payer for services rendered to a particular patient who isn’t in the provider’s usual network. This is often used on a case-by-case basis, but SCAs are highly beneficial, not only to the patient who now accesses their healthcare service at an affordable price, but also to the provider who can enjoy profitability. Let’s take a closer look at how single case agreements can help. 

Higher Revenue from Out-of-Network Patients 

The most immediate way single case agreements improve provider profitability is by unlocking a new stream of revenue, this time from out-of-network patients. SCAs are common in behavioral health, substance abuse treatment, oncology, neurology and other specialties where there are unique cases. These treatments are not usually covered by standard insurance, so that the provider can sign an agreement with the insurance company specifically for that patient.

Providers would have to turn patients away without the SCA if they don’t accept their insurance plans. An approved SCA allows the provider to bill for services they would otherwise lose, the patient gets the care they need, and the practice earns more income.

This is especially valuable for providers with limited treatment options in specialized fields or geographic areas. It can attract patients from outside their immediate coverage area. Providers can even negotiate higher reimbursement rates than the standard in-network contracts with the insurance company.

Custom Negotiation and Favorable Terms 

Unlike the standard network contracts, SCAs offer an opportunity for custom negotiation. Providers can leverage their unique valuable proposition such as clinical outcomes, special certifications or high patient satisfaction scores, to get better rates and terms.

For instance, a behavioral health provider that has resulted in trauma recovery can negotiate a more favorable SCA for a patient that needs specialized PTSD treatment

Providers who understand their cost structures and operational margins can use SCAs to optimize reimbursement terms, like the authorization process or payment turnaround time.  This can even be applied systematically instead of for a single patient.

Higher Operational Efficiency 

SCAs promote operational efficiency by giving providers full control over case scope and clinical planning. Since the agreement is focused on one patient, episode, or care, the provider can define the exact services and when they will be delivered. This will reduce billing disputes and ensure that administrative teams are aligned with care delivery.

Also, SCAs reduce the risks of unpaid claims from uninsured patients or those with limited out-of-network benefits. Providers can fully understand the coverage of their services, rates, and required documentation, making revenue capture more predictable. 

Building Long-Term Referral Networks 

Although SCAs are designed for individual cases, their value can offer way more than just for a single patient. Providers with a reputation for delivering high-quality care under SCAs might become out-of-network partners for some insurers. This allows the healthcare provider to connect with more payers and even get referrals.

The agreements can strengthen relationships with referring physicians, hospitals or social service agencies. If a provider accepts and treats a case under a SCA successfully, the referring parties might return to them in the future, improving patient volume and profitability. If the SCAs are used repeatedly with the same insurer, they might just give it a permanent in-network status.

Supporting Value-Based Care 

The healthcare industry is more focused on value-based care, so single-case agreements allow providers to demonstrate their ability and deliver measurable outcomes. Since SCAs focus on specific treatments or time-limited interventions, they are great for outcomes-based tracking. If the provider has good results, like clinical improvements or patient readmission, they can negotiate higher rates or better agreements next time.

Moreover, this outcome focuses on single-case modern payer priorities, like better patient satisfaction and healthcare quality metrics. When providers meet or exceed these benchmarks, SCAs are proof of the value they offer patients. 

Risk Mitigations and Financial Stability 

When looking at it from the perspective of risk management, SCAs offer contractual protection. All the services and rates are defined from the start and agreed upon by the two parties, so there’s nothing about claim denials or non-paying. This is especially important for providers that work with high-cost interventions like outpatient programs, ABA therapy or specialty surgeries. In volatile or seasonal healthcare sectors, like mental health services during crises, SCAs provide a buffer against revenue fluctuations. With these agreements, providers maintain a more stable cash flow. 

Using SCAs for Better Care 

Single-case agreements are more than just administrative tools for handling out-of-network patients. They can improve healthcare providers by helping them unlock new revenue streams and build long-term relationships with diverse insurance companies. They also allow for better negotiation, efficiency, and risk management within the value center.