If you receive a CSA for an ongoing patient for further treatment, the negotiated price will be based on the patient`s informed agreement and agreement when they begin treatment with you. Rate increases are consistent with your pricing policy in informed consent. You cannot charge the patient a lower horizontal rate out of your pocket and then charge the insurance company your full normal rate if the CAS has been dated in the past to cover the meetings. It should be noted that insurance companies have a legal obligation to properly treat patients by well-trained professionals. Therefore, if the insurance plan does not cover off-network services, and there are no in-network providers with the specified specialty, then you, as a qualified provider, can negotiate your usual full fees as a meeting rate for new patients. This is because the patient does not simply choose to see you, but is forced to deal with insufficient providers in the network. In this case, the patient usually makes the case with the assurance of an ACS with you before starting treatment. 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. The SCA will also provide approved CPT codes, start and end dates and number of meetings. You can request an extension of the SCA if there are only a few sessions left (2 to 3). The client has tried and cannot find a practitioner or supplier in his network that meets his needs in a way that allows him to feel comfortable.
For treatment with ABA, this must be done before the start of treatment. Case-by-case agreements must also use medical billing codes authorized for the CPT abA. It is important to spell them in the negotiation process with the insurer. This reduces the risk of deferred demand. In the event of a transition to a new network provider, the CPT code for the SCA may be specific to the number of sessions remaining. Insurance providers can only assign a specific code in this case or for patients. 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.