Closed panels: single-case agreements, network adequacy and group contracts. A closed panel is not always final.

Summary

What can a practice do when an insurance panel is closed?

Three routes, each at the payer's discretion: an exception request that argues the network is short of providers like yours, a single-case agreement that covers one patient while the panel stays closed, or linking the provider to a group contract the practice already holds, where that payer's rules allow it. We tell you which route fits and file it.

A closed panel is a payer telling you it is not adding providers of your type where you practice. It says nothing about the quality of your file, and payers revisit the decision. Getting in after a closed notice can take months of exception requests and appeals, and panels reopen without warning.^A

Where panels close, and where they do not.

The closed notice almost always comes from a commercial plan, a Medicare Advantage plan or a Medicaid managed-care plan. Each of those runs its own network and decides how many providers it wants in it. Traditional Medicare enrolls a qualified provider through PECOS and does not run a panel that fills up. A practice can be enrolled with Medicare and turned away by a Medicare Advantage plan in the same county, because the two are separate applications with separate answers.

Closed notices also vary by specialty and by address. A plan can be full for primary care in one ZIP code and short of dermatology, podiatry or speech therapy two towns over. That is why we ask each payer the question for each provider and each location.

Network adequacy: the argument a payer has to answer.

Payers are held to network adequacy standards. States set their own in statute, and CMS sets standards for Medicare Advantage and Marketplace plans. The standards turn on how far and how long a member has to travel to reach an in-network provider of a given type, and on whether a specialty is scarce in the area.^A

An exception request works inside that frame. It shows the plan where its own network falls short for its own members: the specialty the provider brings, where the practice sits, what members nearby can reach in network today, and the services the practice offers that the network lacks. A patient can raise the same point with the plan as a member complaint.^A

We write the request as a case, in the payer's terms, and file it with the application. When the payer answers, the answer goes on the status record when it arrives, under the status word Panel closed until it changes.

Single-case agreements: one patient, not a way in.

A single-case agreement is a short contract between a plan and a provider outside its network, covering one patient, one provider and one specific medical need.^B It exists for the patient who cannot wait: care already under way, or a provider whose credentialing is still pending when the patient needs to be seen.

The plan grants one at its discretion, and usually only when its network cannot serve that patient or when continuity of care is at stake.^B The terms are negotiated case by case, usually tied to the specific service and patient. It does not put the provider on the panel.

For a dental practice or an aesthetics practice, a single-case agreement will rarely apply. Where one does, we request it with the clinical reason in writing, and the claims under it get built to the terms of that agreement.

Group contracts: changing who is asking.

A payer weighs a practice by what it brings to the network. One contract that covers every provider in a practice carries more volume than a string of individual contracts, and more weight when the terms are set.^C

That is why the practice's own application matters as much as each provider's. A group contract is its own file, and a provider joining a practice that already holds one is tied to it through a practitioner application. Whether a closed notice reaches a provider joining an existing group is each payer's rule, and we ask it before we file. We price the two files separately: $450 for an organization application and $350 for each practitioner application.

What we do the week a payer says closed.

We file the exception request with the practice's case in writing, keep every other application moving, and record the response and tell you what it means. If a patient needs care before the plan answers, we ask for a single-case agreement where the facts support one. When we run the practice's billing, those claims go out built to the terms that apply on the date of service.