04/18/2021
Many people wonder why a lot of psychologists are not in-network for insurance, particularly for psychological testing (e.g., testing for issues such as ADHD, Learning Disabilities, Autism, etc...). I want to give a concrete example as to why many professionals have dropped off panels. If you read the following example, you will see an example of the types of hoops that professionals have to jump through to prove that psychological testing is medically necessary. Most companies assert that only an interview and some questionnaires are needed to diagnose, but there are other diagnoses that must be ruled out that interview alone will not detect (language disorders, Learning Disabilities, etc...). Insurance also will not cover educational testing. Its stance is that schools should provide that service.
So, to provide clients with the most thorough and careful diagnostic process without all the red tape and restrictions, psychologists such as myself are fee-for-service. That way, we can look in as much depth as necessary to make the RIGHT diagnosis with no shortcuts. Fees for such psychological testing are not cheap, but they are an investment in your child's future and can be LIFE-CHANGING.
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Example of testing restrictions (name of insurance company redacted):
[Company] considers neuropsychological (NPT) or psychological testing (PT) medically necessary when needed to enhance psychiatric or psychotherapeutic treatment outcomes after a detailed diagnostic evaluation if:
Testing is needed to aid in the differential diagnosis of behavioral or psychiatric conditions when the member's history and symptomatology are not readily attributable to a particular psychiatric diagnosis and the questions to be answered by testing could not be resolved by a psychiatric/diagnostic interview, observation in therapy, or an assessment for level of care at a mental health or substance abuse facility; or
Testing is needed to develop treatment recommendations after the member has been tried on various medications and/or psychotherapy, has not progressed in treatment, and continues to be symptomatic;
And all of the following criteria are met:
The number of hours or units requested for testing does not exceed the reasonable time necessary to address the clinical questions with the identified measures; and
The testing techniques are validated for the proposed diagnostic question or treatment plan; and
The testing techniques do not represent redundant measurements of the same cognitive, behavioral or emotional domain; and
The testing techniques are both validated for the age and population of the member; and they are the most updated version of the instrument; and
The instruments selected have the empirically substantiated reliability, validity, standardized administration and clinically relevant normative data to assess the diagnostic question or treatment planning goals.
NPT or PT is rarely considered medically necessary for uncomplicated cases of attention deficit disorder with/without hyperactivity (ADHD). However, referral to an outpatient mental health provider or outpatient chemical dependency rehabilitation may be considered medically necessary for the evaluation and comprehensive bio-psychosocial treatment for these disorders in collaboration with primary care physicians and other specialists. NPT may be considered medically necessary for neurologically complicated cases of ADHD, (e.g., post head trauma, seizures).
NPT or PT beyond standardized parent interviews and direct, structured behavioral observation is rarely considered medically necessary for the diagnosis of pervasive developmental disorders (see CPB 0648 - Autism Spectrum Disorders).
Reimbursement Notes
NPT or PT for educational reasons is not covered. This testing is usually provided by school systems under applicable state and federal rules. Most benefit plans exclude coverage of educational testing. Please check benefit plan descriptions. In addition, NPT or PT performed for educational reasons is not considered treatment of disease.
