There are some very important things to keep in mind regarding dealing with insurance companies when trying to get them to pay for the professional healthcare services by the neuropsychologists at the Brain Clinic.
One important idea is “Medical Necessity.” This means that the service is necessary according to medical judgment. For example, a learning disability evaluation may be viewed by the insurance company as not medically necessary, because they will consider this as an “educational issue.” Many insurance policies explicitly exclude learning disability evaluations because they are viewed as something that should be handled by the school systems. Our view is that any cognitive problem is a medical necessity and deserves to be evaluated. If a person is having trouble in school or there is a problem in learning, reading, memory and/or reasoning, it would be very important to get a prescription from a medical doctor (MD) which says that the doctor wants a “Neuropsychological Evaluation, CPT code 96118.” The CPT code is a procedure code which tells what the service is. The medical doctor can write this on his prescription pad, and a copy of this should be sent to us and to our billing service.
The Brain Clinic needs a diagnostic code, which usually can be “Cognitive Disorder, Not Otherwise Specified,” or “Cognitive Disorder, NOS,” and the ICD-9 number is 294.9. and ICD-10 number is R41 (current coding). With both the CPT code and the diagnostic code, the service can be requested. The patient (or parent) needs to state what the problems are; but sometimes this should be done by the professional. If the professional needs to state the problems, then there needs to be a meeting with the psychologist and the patient to be evaluated (or the parent). This meeting needs to be paid for, and it should be figured out in advance if this is going to be paid for by the insurance company or by the patient.
Sometimes the insurance company will not tell the professional how many hours are granted and at what rate. Of course, it is foolish for someone to agree to do something before knowing the terms, but this is common with insurance companies. Several times we have called up and have been told that for CPT 96118, we would be paid $350. Is that $350 per hour, or the entire payment? How many hours are granted? The person at the insurance company may say they do not know the answer; therefore, ask to speak to a supervisor. We believe by law the insurance company must tell the policy holder (you), so this needs to be found out so that we know the terms under which we are asked to work. This is important, since a neuropsychological evaluation usually consists of about 8 hours of testing and 7 hours to score the tests and write a report, or approximately 15 hours of professional time. Few neuropsychologists would accept $350 for 15 hours of professional time.
Because you are requesting a neuropsychological evaluation, there is a presumed neurological disorder. This means the evaluation would be considered under the Medical Benefit, and not the Mental Health Benefit. For fees covered under the Mental Health benefit, the insurance company usually pays 50 percent. For Medical benefits, the insurance company will often pay 80 percent.
Another thing to know about your own situation is the deductible and co-pay. For cases under the Medical Benefit, the co-pay may be something like 20 percent. Since a Neuropsychological Evaluation usually costs between $2500-$3500, then the co-pay would be $500 or more. This $500 will be applied towards your co-pay. The report is delivered to the patient/guardian when the bill is paid in full. Therefore, it is to your advantage to get the payment situation to work out. For the last 15 years or so the Brain Clinic has not taken insurance assignment (except for No Fault, Workers Compensation and Medicare) because of problems with getting paid. This is true for most neuropsychologists with more than 15 years experience (and you want someone with this level of experience). However, we have been trying to find a way to get insurance companies to pay for these evaluations, since we think they have an obligation to support these services (considered here as neuropsychological evaluations). So a key idea is to get approval ahead of time. This is sometimes called “pre-certification.” Essentially this means that the client or the billing service gets approval for the service (Neuropsychological Evaluation) in advance. Of course, this should be in writing from the insurance company. With this document in hand, there is solid evidence that they already agreed to pay.
There is another thing to keep in mind when dealing with insurance companies. When asking for a neuropsychological evaluation, one should never use the terms learning disability, dyslexia or attention deficit/hyperactivity disorder when talking about this. These diagnoses are either considered to be “educational,” as noted above, or not in need of testing, which is sometimes stated for ADHD. We believe that these are excuses for not paying for testing and are unfair. The important thing to keep in mind is that you are asking for an evaluation to have a professional precisely figure out what is going on, not to document what you already know. Otherwise there is no need for testing.
It in unlikely that insurance companies will have neuropsychologists on their panels. Even if they do, it is likely that the evaluation will not be a very thorough one. You can always ask for a neuropsychologist on the insurance company panel, but remember it is to the insurance company’s advantage that impairments are not found, just as it is to a school system’s advantage to not find impairments in the children they test. If problems are found, they are obliged to support treatment.
What this comes down to is that you will probably have to fight for your rights. But if you do fight properly, you will likely get paid for the evaluation. However, you also need to understand that the professional wants to be assured of getting paid. For these reasons, it is understandable why almost no neuropsychologists will take assignment for their evaluations. It is not the professional’s responsibility to make sure the bill is paid; it is the person who has the agreement with the insurance company— and that is you. As the professional, we have no legal rights in the contract you have with the insurance company, so they can deny payment, and we have no recourse. It is up to you make this system work, and you may have to work hard to do so. Also, having insurance companies reimburse and pay for their share may take much longer than paying for it up front.
If you want to try and get the insurance company to pay the Brain Clinic for the evaluation directly, you will need to sign an agreement that assigns the benefits directly to us. You must also be willing to wait until they decide to approve paying for the evaluation. A form is available to begin this process on the Brain Clinic’s website www.thebrainclinic.com. This process might take some time. We have waited for up to two years to get approval to do a neuropsychological evaluation.
Another aspect of dealing with insurance companies is the issue of confidentiality of your records. Although we keep all our records very confidential (as prescribed by professional ethics), insurance companies do NOT have to keep their records confidential. This may caution you from getting the insurance company involved. After all, if you are asking them to pay some of the bill, they have a right to our file. Another possibility is that a learning disability evaluation can be deducted as an educational expense.
You should be willing to file a complaint with the state insurance commissioner if it comes down to this, in order to get reimbursed. You are also required to sign a contract that says you are responsible for the fee in case the insurance company does not pay the bill. Therefore, you will have an incentive to make sure that all payments are made by the proper parties.
Visit fees page for information about insurance and pricing.