Every so often, patients encounter a situation in which the provider they want (or need) to see is not covered by their in-network insurance—meaning that, in order to seek care from that practitioner, they will be subject to out-of-network fees as stipulated by their employer and health plan.

Typically, there’s no way around this—the patient will either have to accept the out-of-network fees or choose an in-network provider.

However, there is a type of workaround patients and providers can sometimes leverage. It’s called a single-case agreement. 

What is a single-case agreement?

A single-case agreement is a one-time arrangement between an out-of-network healthcare provider, such as a doctor or hospital, and an insurance company. It allows for customized payment terms and reimbursed rates for particular medical cases so the patient can receive care they might not otherwise have access to from a provider in their network.

Reasons why a single-case agreement would be approved

It’s understandable to wonder why payers (e.g., self-insured employers and health plans) might agree to a single-case agreement, as it means they will likely be required to pay more to cover the patient’s healthcare costs. Here are a few reasons one might be approved:

• Location: An out-of-network provider is more easily accessible to the patient’s home or place of work. This is typically more common in more rural and suburban areas where someone might have to drive an hour or more to see the nearest in-network provider.
• Cost: In some cases, care from an out-of-network provider can actually be less expensive for the patient than an in-network provider. For example, if the closest in-network provider is located in an area with a higher cost of living than a nearby out-of-network provider, the latter might charge less overall.
• Level of care: An out-of-network provider offers care options that an in-network provider doesn’t, such as a specific kind of physical therapy, a particular surgery, or certain medical equipment.
• Speciality services: An out-of-network provider offers a service that is unique to the patient’s needs (and there’s not an equal in-network option), such as a translator if the patient doesn’t speak the local language.

Why single case agreements insurance should not be a part of center of excellence programs

While we can certainly see the benefit of single-case agreements in some situations, we don’t believe they should be leveraged by centers of excellence benefits solutions.

Here are three reasons why:

1. There’s no quality evaluation

At Carrum Health, we put a lot of time and effort into vetting a center of excellence—assessing them on more than 50 different quality metrics—to make sure they can provide the high-quality care and optimal health outcomes we desire. The same can’t be said for single-case agreements.

When a center of excellence program rushes to make a single case agreement with a provider or facility, there’s no time to assess for quality, which could result in the patient receiving unnecessary, ineffective, and low-quality care.

2. Higher costs and surprise bills

Because single-case agreements adhere to a fee-for-service model as opposed to a bundled payments model, they can result in unexpected or higher bills.

With a bundled payment model, like we leverage at Carrum, everything is included under one upfront, transparent fee—from assessment, to labs and testing, to every single provider who treats the patient for that specific episode of care.

This is not the case with single-case agreements.

If the surgeon, for example, who the COE program makes the single-case agreement with decides to utilize an anesthesiologist or a medication that isn’t covered by the patient’s in-network health insurance, the patient and their employer will be left with the high out-of-network fees—and oftentimes, they don’t even know this is going to happen until after the fact, meaning there’s no way out of the bill.

3. There are usually no wraparound services

Part of the benefit of a best-in-class center of excellence program is that it includes wraparound services—for instance, second opinion programs and travel assistance—at no extra cost, providing the patient with a more holistic experience.

When a COE program makes a single-case agreement, these wraparound services typically aren’t included. If the patient wants them, they’ll have to seek them elsewhere, meaning this episode of care will likely be more confusing, stressful, and expensive.

Bottom line: single-case agreements won’t deliver the desired results

While single-case agreements can be helpful in allowing individuals to receive necessary care outside their insurance network, they are not well-suited for center of excellence benefits programs. Center of excellence programs, designed to uphold exceptional standards of care and deliver cost savings, require a broader and more consistent approach to provider-network relationships.

Single-case agreements, being case-specific arrangements, lack the scalability and systematic framework needed for comprehensive centers of excellence programs. The intricate nature of these programs demands ongoing collaboration, standardized practices, and a network of highly specialized providers, which single-case agreements cannot provide.

In the pursuit of excellence in healthcare, organizations must explore alternative strategies and contractual models that align with the broader goals and structured requirements of center of excellence programs. By doing so, we can better navigate the complexities of healthcare delivery, ensuring that exceptional care remains at the forefront of our collective efforts.

The information contained on this page is for informational purposes only. No material is intended to be a substitute for professional medical advice, diagnosis, or treatment.