Ms. Vinodha Joly, LMFT is a psychotherapist with a private practice in Pleasanton, California. She specializes in working with adult survivors of childhood trauma, childhood emotional neglect and family violence. Before moving to a case-by-case agreement, it is designed to meet the patient`s essential treatment or therapy needs and the cost benefits to the insurance company without having to switch to another networked provider. In order to direct the negotiation process, the following criteria must generally be met. These include the following factors: It is important to note that insurance companies are required by law to provide clients with APPROPRIATE ABA treatment by a qualified physician. If no networked provider is available or if you, the off-grid practitioner, offer some kind of specialized treatment to a new client, you can negotiate with the insurance provider for the standard fees. In a scenario like this, a new customer may not select you specifically, but they won`t have another sufficient provider in the network. In such a scenario, the fee policy can be evaluated on a sliding scale. Although you cannot charge your insurer the full standard rate for recurrence, past sessions.

What conditions must patients meet for a case-by-case agreement? For a case-by-case agreement, as a health care provider, you should recommend billing your patient to the insurance company. The purpose of SAs is to meet the important needs of the patient; billing costs are more those of a networked provider. The following conditions make your patient`s case appropriate for an SCA: Sometimes called sca, the case-by-case agreement is essentially a contract between an insurance company and a provider outside the network to ensure that a customer does not have to switch providers. It is especially important for clients who need long-term prolonged treatment or therapy. Be prepared to negotiate your fees. This can be done on a sliding scale or the insurance provider can already have its own fee tables. This could be part of a „payment with the highest network rate“ protocol. Next, the therapist must accurately describe the benefits of continuing with the patient. Some insurance providers require that the agreement on a case-by-case basis be that of the rendering provider, which must be submitted on application form 1500. Case-by-case agreements must also use medical billing codes authorised by the ABA CPT.

It is important to describe them in the negotiation process with the insurer. This reduces the risk of a late complaint. In the case of a transition to a new network provider, the CPT code for the SCA may be specific to the number of remaining sessions. Insurers can only assign a specific code for this case or patients. For a long-term patient, the new insurance company may respond positively to the justification that you ensure continuity of care. If the patient can`t afford OON benefits to see you, and if there could be setbacks if they had to start over with a new therapist (network), make sure the insurance company is aware of this. Negotiations At Panacea, we negotiate to bring a maximum of refunds. We begin negotiations at 85-90% of billing fees by effectively communicating the patient`s condition and treatment requirements. Negotiations are fruitful if you remain persistent and the clinical literature supports the level of care.

To remain persistent, you must respond to any counter-offers and objections for insufficient payments. The insurance company will try to create barriers by expanding the approval process. You know you don`t have much time to negotiate. .