Single Case Agreements: the release valve for network gaps

What a single case agreement actually is

A single case agreement (SCA) is a contract between a payer and an out-of-network provider that covers a single member for a specific service or episode of care, at a negotiated rate, for a defined period. Unlike your standard participating agreement, which binds a provider to treat every member in your plans under one fee schedule, an SCA applies to exactly one member and one course of treatment. When that episode ends, the agreement ends. The provider does not join your network, and no other member gains access through it.

The related term you will hear is letter of agreement (LOA). In practice the two are often used interchangeably, but there is a useful distinction. A letter of agreement is frequently the document that memorializes the arrangement, the written instrument that spells out the terms, while single case agreement describes the concept, a one-off deal for one case. Some organizations use LOA for a slightly broader or more standing arrangement and SCA for the strictly member-specific one. What matters is not the label but the substance: is this contract limited to one member and one episode, and does it end when that episode ends?

How SCAs differ from participating agreements

The difference is scope, and scope drives everything else. A participating agreement is a durable, network-wide contract. You credential the provider, load them into your directory, hold them to network adequacy and quality standards, and they see any member who walks in. The rate is set once and applies broadly. A single case agreement is the opposite: narrow, temporary, and transactional.

• Population: a participating agreement covers all members; an SCA covers one named member.
• Duration: a participating agreement is ongoing, typically with an evergreen renewal; an SCA is tied to a single episode or a fixed authorization window.
• Directory and access: participating providers appear in your directory and count toward network adequacy; an SCA provider does not join the network and generally does not count toward adequacy in the same way.
• Rate setting: participating rates come from a standard fee schedule negotiated at scale; SCA rates are negotiated one at a time, case by case.
• Credentialing: participating providers go through full credentialing; SCAs still require verification of licensure and credentials, but the process is often expedited for a time-sensitive case.

When to reach for one

The clean use case is a genuine network gap. A member needs a service that no in-network provider can deliver within a reasonable time or distance. Maybe it is a rare specialty, a specific tertiary facility, or a provider with a unique clinical capability. Maybe your build is new and a corner of the service area is not yet contracted. In those situations an SCA lets the member get in-network-level benefits from an out-of-network provider, which protects both the member and your compliance posture.

There is a second, softer use case: continuity of care. A member is mid-treatment with a provider who just left your network, or a new enrollee arrives already in an active course of care with an out-of-network clinician. Cutting the relationship mid-stream can be clinically harmful and, in Medicare Advantage and Medicaid managed care, may run afoul of continuity-of-care protections. An SCA bridges the member from the outgoing relationship to an in-network one without an abrupt handoff.

The trigger in both cases is the same question: can an in-network provider deliver comparable, timely, accessible care for this member? If the honest answer is no, an SCA is the right tool. If the answer is yes and someone is reaching for an SCA anyway, something else is going on, usually a directory that overstates access or a member steering problem.

Setting the rate on a one-off deal

SCA rates are negotiated individually, which means leverage matters. The negotiated rate typically lands somewhere between your in-network fee schedule and the provider's full billed charges. Where it lands depends on urgency, the provider's uniqueness, and how much documentation each side brings.

Providers with strong clinical justification and clear evidence that your network cannot serve the member have the upper hand, because you need the deal as much as they do. To keep rates disciplined, come to the table with your own data: benchmark the ask against Medicare rates, your existing contracted rates for similar services, and usual-and-customary charges in the market. Structure matters too. A flat case rate or defined per diem with a length-of-stay cap gives you cost certainty; an open percentage-of-charges arrangement does not. Always specify the authorized services, the CPT or DRG codes, the authorization window, and the billing terms in writing before care proceeds. An SCA negotiated after the care is delivered gives you almost no leverage and invites disputes.

The operational and compliance risks of leaning on them

Single case agreements are a release valve, not a network strategy, and treating them as the latter creates real exposure. The risks compound quietly.

• Cost leakage: SCA rates are almost always higher than your contracted rates. A handful is manageable; a pattern is margin erosion you will feel at reconciliation.
• Masked network deficiency: every SCA is evidence that your network could not serve a member. If you use SCAs to paper over a gap instead of fixing it, you may satisfy the individual member while remaining out of compliance with network adequacy standards that regulators actually measure.
• Data distortion: care delivered under one-off agreements can sit outside your normal utilization, quality, and encounter reporting workflows, distorting the picture you rely on to manage the population and, in risk arrangements, to reconcile.
• Administrative burden: each SCA is a bespoke negotiation, a credentialing check, an authorization, and a claims-configuration exercise. At volume, this consumes staff time that should be building durable contracts.
• Continuity and member-experience risk: if the SCA process is slow, the member waits for care, and a delayed authorization on a time-sensitive case is both a clinical and a regulatory problem.

How SCAs fit into a real network build

In a well-run build, single case agreements are the exception that proves the network is working, and the signal that tells you where it is not. We treat them as a diagnostic. Every SCA gets logged with the reason it was needed: which service, which county, which specialty, which member circumstance. Run that log for a quarter and it draws you a map of your true network gaps, more honest than any adequacy report, because it reflects care members actually tried to get.

That map feeds the permanent build. When the same specialty in the same county generates SCA after SCA, that is your next recruitment target. The goal is to convert recurring one-off spend into a participating agreement at a network rate, which lowers cost, improves access, and shrinks administrative load all at once. A network that never uses SCAs is probably either mature or overstating its coverage; a network that leans on them month after month for the same gaps has a build problem it is refusing to solve.

The discipline is simple to state and harder to hold: use SCAs to protect the member today, and use the pattern of SCAs to build the network that makes them unnecessary tomorrow. That is where we focus. We stand up the SCA process so members never fall through the gap, and we mine the resulting data to close the gaps for good, so the release valve stays a release valve and never becomes the plumbing.