Gap Exception Vs Single Case Agreement

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. 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. Here`s an example. Suppose you need an ear operation and you ask for a network exception to cover an otolaryngolog network that goes through the operation. However, there is a networked otaryngoologist in your geographic area. Once you`ve researched in-network options, return your results to insurance and explain your evidence in case these vendors are not OCD specialists and are therefore not suitable suppliers.

There may be other reasons why the providers on the list are not suitable for you: if they are dealing with the age group you need (fewer providers treating children and adolescents)? Are you within 10 miles of your home? Also make sure you make these points. If this is the case, you can also inform your insurance company that you have already tried network-specific and non-specialized therapists and that this has not been helpful. At the end of the day, insurance is interested in profitability. You will pay more money for ineffective therapy over a long period of time, because the patient will not improve. Make the case for them as you really try to save money by improving faster. Even if it is a significant prior investment, effective therapy pays off in the long run. One of the potential drawbacks of this strategy is that if the insurance company suspends a portion of the customer`s deductible, in which case you will have to charge it for it. It is not charged for the deductible is insurance fraud and is therefore unethical and illegal. Sometimes an insurance company may have a “payment policy with the highest in network rate,” in which case you will not be able to negotiate the rate. You still have the option to refuse the SCA if the sentence and conditions are not acceptable to you.

The information you need when applying for a waiver for network deficiencies include: What conditions do patients need to meet to reach an agreement on a case-by-case basis? To obtain a case-by-case agreement, you, as a health care provider, must commit to billing your patient with the insurance company.