Clients are soon going to report New Year’s insurance changes, and you may suddenly be out of network. But, they might be entitled to “Continuity of Care” extensions of in-network coverage for a period of time. The reason for the network status change could be due to:
- Provider/Facility Contract Termination
- Policy network change (perhaps from a PPO to a HMO network)
- Previous policy no longer available (for instance, on the ACA Marketplace or Medicare Advantage)
- Employer group changes policies and the new network doesn’t include the treating clinician.
Sometimes Continuity of Care extensions of in-network benefits are mandated by the No Surprises Act, sometimes by state law, or even negotiated by your client’s employer. For our purposes, it’s not necessary to know who’s granting the extension – just whether the client has access to it.
What do I do if I’m suddenly out of network?
It’s a difficult situation and presents an ethical dilemma. You have a clinical and professional responsibility not to abandon your client. But the reality is that out of network might be unaffordable for them! Yet, you’re not a charity. You’re responsible for protecting your time and your income – and there’s no shame in recognizing this fact and acting on your own behalf.
When you discover that you’re no longer in-network, start by taking these 4 steps, in order:
- Alert your client that they might have “continuity of care in-network coverage” for at least the first 90 days of the year.
- To request access this extension of in-network benefits, the client will need to call their insurance company or login to their portal.
- If the client reports back to say that they have “continuity of care in-network coverage,” ask them for written documentation.
- Begin the Single-Case Agreement process.
Isn’t Continuity of Care the same as a Single-Case Agreement?
They’re related, but aren’t the same.
A single-case agreement is essentially mini-credentialing, joining the insurance panel for one specific client. Continuity of Care is one of the most common reasons a single-case agreement is given.
Single-case agreements are also granted for other reasons, such as a network gap due to clinical specialty, no one’s accepting new clients, cultural/linguistic needs, etc. Sometimes, single-case agreements are extended because a clinician is in the process of undergoing credentialing for full admission to the panel.
Payers who allow supervisory billing also have an obligation to extend in-network benefits for the same continuity of care reasons. When a provisionally-licensed clinician obtains full licensure, they can no longer legally bill under their previous supervisor. It’s the newly-licensed clinician is the one who has the relationship with the client – not the former supervisor. This, by the way, is the primary reason why supervisory billing is NOT the same as “incident-to.”
Not pairing a mandatory extension of in-network benefits with a single-case agreement is an invitation for claims to be denied.
“Continuity of Care” in-network extensions are usually doomed to fail without Single-Case Agreements!
Why?
Claims are adjudicated using artificial intelligence. With no human evaluating the claim, the system just sees a tax id/NPI combination that’s out-of-network. Even with a single-case agreement authorization number on the claim form, that out-of-network TIN/NPI combo often seems to control the outcome.
All other things being equal, single-case agreement claims are more likely to be denied than routine in-network claims. Out-of-network professionals tend to have a much harder time than their in-network peers: in order to get single-case agreement claims paid, repeated calls have to be made, and appeals/disputes filed, to try to reach a human with the authority to override the denials. That’s not easy! If you’re spinning your wheels in such a situation, you may have to resort to badass executive complaint methods. Which are available to you even out-of-network!
How a single-case agreement works
Once the insurance payer approves a single-case agreement (regardless of the reason), a shortened form of basic credentialing takes place. The insurance payer obtains the following information.
- Tax ID / W9
- License
- Malpractice insurance info
- Signature on a modified “contract” or “letter of agreement.” The document should include the reimbursement rates being offered, plus the usual obligations & contractual protections for clients that would be true of any in-network provider:
- Accepting assignment
- Filing claims
- No balance-billing
- “Timely” filing
When the above documents are received and loaded into the claims system, the care manager approving the single-case agreement issues an authorization letter for whatever period of time and/or number of visits will be covered at the “in-network” benefit level.
If you’re in the process of obtaining a single-case agreement, wait to file your claims until everything is in place.
Why Continuity of Care may not routinely offer single-case agreements
In the event of a network termination during a course of treatment, insurers are required to send automated letters to clients stating “[provider name] is out-of-network as of [date], here are your options for continuing your care” and listing the instructions to follow if the client wants to continue to obtain in-network level benefits for the transition period.
As with anything else insurance, clients are given impossible to understand instructions, and usually not in a timely manner. I recently received a Continuity of Care letter in my mailbox last month, dated August 2025, about a provider who left a family member’s network. Hmmm…you get Continuity of Care benefits for up to 90 days, but it takes 120 days to notify you!?! Right.
Typically, it’s the client who’s responsible for notifying the insurer that they want to utilize their Continuity of Care benefit. It’s very unusual for an insurance company to grant Continuity of Care benefits on the basis of a provider request. But when the client accesses their Continuity of Care benefits, it’s handled by Member Services. The client then typically receives a letter confirming that their care with the clinician in question will be paid at the in-network benefit level.
See the set-up here?! The Member Services department doesn’t always trigger the formal single-case agreement process, which is typically handled by Provider Services.
Then the client thinks they’re good, and that’s all there is to it.
Um…no. You, the clinician, aren’t being set up to succeed here. Quite the opposite.
If you think about what’s required to set up a single-case agreement, as described above, you’ll realize that single case agreements consume a lot of employee time the insurance companies have to pay for. (And they don’t like to pay for anything!)
What if the payer refuses to give a single-case agreement?
If you don’t have the time or energy to engage in a fight to obtain the single-case agreement, there are a few options.
- Collect either your full rate or your previous in-network reimbursement rate at the session and furnish a superbill. That’s now your right as an out-of-network clinician. (Sliding scales aren’t generally a good idea when using insurance.)
- Consider referring the client to one of the superbill-submitting services that help clients get reimbursed. It typically doesn’t cost you anything unless you choose to shoulder the cost as a courtesy for the client.
- You can submit a “non-assigned” claim, meaning you direct the insurance payer to pay the client. This is done by leaving box 13 or its electronic equivalent blank, by checking “no” in box 27, and by listing the full amount paid in box 29.
- One problem with “courtesy” billing (non-assigned claims) is that insurance payers may send you the money anyway. Why? Because it’s easier to claw back from you than from a client.
- Another typical problem is interference from companies such as Multiplan/Claritev, who try to reduce the rates you’re paid.
The problem with any of the above strategies, of course, is that they all require the client to pay the full billed charge at the time of the session – which not all clients can afford to do. Especially if there’s likely to be a longer-than-usual delay in obtaining in-network level reimbursement.
Regardless of the reason they’re granted, single-case agreements are great for clients – but they may be challenging for you. You may not have a choice if you left the network – continuity of care for your clients is a must. But if you’re now out-of-network for reasons you didn’t control, or if the single-case agreement was granted due to network inadequacy, you’ll want to learn all you can about what accepting a single-case agreement entails before taking it on. Or discuss other options with your client.
