Network exemption and single case agreement

I am requesting a network exemption from Aetna as there are no in-network surgeons for this surgery.

If the network exemption is granted, I understand the next step is for Aetna to negotiate a single case agreement with the surgeon.

If Aetna fails to negotiate the SCA, or refuses to pay the surgeons rate (They are expensive and not going to lower their rates), will I still be responsible for the remaining balance?

I understand there is no balance billing for in-network providers, but is this still correct if Aetna and the surgeon failed to agree on a rate?

I have already paid in full for the surgery, but I am hoping to get reimbursed by Aetna.
My plan is fully insured through my employer.

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If your surgery isn’t for a rare condition with very few surgeons who can do it, don’t expect an exception. If they don’t negotiate, you’ll have to pay the difference between the billed amount and the UCR reduction Aetna applies.

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I do think the exception will be covered for my condition, but I will have to wait and see. So if Aetna grants me an exception and covers the surgeon as in network, I might still have to pay more than my out of pocket max?

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Since you’ve already had the surgery, the surgeon is very unlikely to accept less than their normal fee. At best, Aetna might agree to pay their usual reimbursement, leaving you to cover the difference between that and the actual fee—this is called balance billing.

Even if you had requested an exemption before the surgery, the surgeon isn’t required to accept less, and the insurance company isn’t obligated to pay more or grant the exemption.

Usually, you request the exemption before surgery, and you need to provide a strong medical reason for it to be granted.

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Did you pre-pay for the surgery, or has it already happened?

Typically, you request a Network Gap Exception before the surgery. Sometimes, the insurance company will consider your suggested provider when trying to fill the gap, but if the provider won’t accept in-network reimbursement rates, the insurance would just find another provider who will.

If you’ve already pre-paid the surgeon, it’s unlikely they’ll agree to take less—but it’s possible. If the surgery is already done, insurance might not offer a Gap Exception at all, since that’s usually arranged before care is given.

If your surgeon won’t agree to the Network Gap Exception Single Case Agreement, then the insurance will treat your care as out-of-network, and you’ll face balance billing.

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I already paid for the surgery but haven’t had it yet. Is the patient involved in SCA agreements at all? I’m curious how that negotiation works. Is there a way to get Aetna to agree to a higher rate if I can show that this surgeon is cheaper than other out-of-network surgeons?

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What happens if the gap exception is approved, but the single case agreement isn’t negotiated?

I haven’t had the surgery yet, but the surgeon asked me to pay upfront.

The surgery is uncommon, and no in-network surgeons can do this procedure. I doubt Aetna will find any out-of-network surgeons willing to accept their reimbursement rates.

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Are you on a PPO or a HMO?

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