Providing a higher level of care means that a provider must be reimbursed at a higher rate than medical care. Providers, especially long-term care providers, should negotiate reimbursement for many levels of care. In their letters of authorization, payers indicate the degree of care they authorize in order to make the calculations of expected payments simple and simple. Scenario 3: The institution and the payer enter into an agreement to pay a percentage of the fees charged. LOA/SCA States are reimbursed at 40% of the fees charged. Scenario 2: The provider and the payer enter into an agreement stipulating that the payer must pay a rate of USD 1,500.00 provided that authorization is requested. The LOA/SCA does not indicate the level of care subject to treatment authorized by regimen. Hospitals often execute letters of agreement (LOA) and single case agreements (SCAs) with an insurance payer when the provider is not considered a network provider with the patient`s insurance plan. LOA and ACS are usually performed at the time of admission when the patient has a non-contractual insurance plan. However, they can also be done before admission, if the patient is ready for transfer, or at any time during the stay. While LOA/SCA does not guarantee payment, it helps the provider know what to expect and streamlines the claims management process. The LOA / SCA, signed reciprocally, provides a legal document that constitutes the intention of both parties and provides the necessary supporting documents to appeal in case of erroneous payment. In the absence of a clearly defined level of care, most paying agencies only allow medical-surgical care.
A patient may require medical surgical care upon admission, but may require telemetry or intensive care during the stay. Scenario 1: The patient has traditional Medicare as primary and a commercial plan as secondary. Medicare Part A is sold out before registration. The provider is not in the network with the secondary. The hospital runs a LOA/SCA with the supplement to pay $1500.00 per day. The LOA does not mention Medicare Part B co-insurance reimbursement. The supplement is paid daily at $1500.00 per day, but does not pay Medicare Part B. . . .