Playing the Insurance Game: When Is Testing Covered?

Insurance and Testing - Diagram around word "Insurance" pointing to each "Yes" and "No"


Posted in: Grade School, Parenting Concerns, Teenagers

Topics: Learning + Attention Issues

John’s mom was perplexed. John’s teacher had suggested he be evaluated because he was having trouble learning to read and paying attention in class. John’s mom, Lisa, didn’t want to get the testing completed through the school system because Lisa’s friend recommended a psychologist, Dr. Lewis, who she said was “the best!” Lisa had felt hopeful Dr. Lewis would be the perfect professional to help her understand John’s difficulties in school. Even better, Dr. Lewis was a covered provider under Lisa’s insurance plan. However, when Lisa submitted a request for approval for testing, the request was denied. What happened?

In John’s case, the referral form was submitted asking for testing to assess reading issues. The insurance company indicated that learning issues weren’t covered. With John’s pediatrician’s help, the claim was resubmitted with a focus on John’s problems with attention, memory and focusing. John’s family received partial coverage, but Lisa was still confused as to why this was not covered in full.

More and more, insurance companies are cutting back on what they will pay for evaluations. Many companies aren’t paying anything at all. Yes, they’ll say they cover neuropsychological evaluations, but when you look at the fine print, the plan only covers medical issues such as brain tumors, traumatic brain injuries, and multiple sclerosis. I’ve seen insurance companies deny testing for a child with a brain tumor – because the insurance company deemed the brain tumor “terminal,” thus indicating there was little point in getting additional information. This is beyond cruel.

What Can Help Your Case?

A lack of coverage for learning and attention issues is perplexing, especially because there is strong evidence that every kind of learning and emotional disability is at least in part biologically based. So, what can help your case?

1. Framing the issue in context of medical diagnoses. It usually helps if the referring doctor can make a case that the testing should be considered “medical” in nature. For example, rather than saying Mindy is having “school problems,” her pediatrician should say, “Mindy is presenting with variable attention, trouble with memory, and difficulty with impulse control – I am requesting neuropsychological testing to rule out an organic/medical cause for these concerns and to arrive at an appropriate diagnosis.”

As soon as most insurance companies hear “school problems” or “learning issues,” they immediately relegate the testing to the school system, assuming this is something the school district can evaluate. Because of this, you will likely not receive authorization for the private evaluation. Thus, it’s important to talk about these concerns with the referring doctor to arrive at an honest way of explaining the need for testing that is not just school-related.  This will increase the chances that the service will be covered by insurance.

2. Ruling out possible psychiatric diagnoses. Likewise, if you are concerned about your child’s emotional well-being, I suggest that the referring clinician use formal psychiatric diagnoses as “rule-outs” when making the referral for psychological testing. When 10-year-old Sam was acting moody, nervous, irritable, and tired, his parents became concerned. So, when his pediatrician called in the request for testing authorization, she said, “I am requesting a full psychological evaluation to rule out major depression and generalized anxiety disorder.” This was much more helpful than saying something like, “Sam seems sad and worried, so I would like psychological testing done.”

3. Appealing an unsuccessful request. Even when you and your referring doctor take these steps to improve the chances that the evaluation cost will be covered by your insurance company, there is no guarantee. You should know that you always have the right to appeal the authorization denial from your insurance company. The company should explain to you the proper course of action for appealing. Sometimes the insurance company needs additional information from a therapist, a neurologist, or another professional to support the need for testing. They may want to review any testing that might have been done by the school to determine if any more testing is necessary. You don’t have to provide this information, but you should know that it is unlikely that they will change their decision to deny coverage without it.

4. Following up after direct payments. If you have to pay directly for any evaluation because the practice won’t accept your insurance, make sure that you get a receipt from the evaluator with appropriate DSM-V and ICD-10 diagnostic codes, service codes, and tax identification number to submit to your insurance company. You may be able to get reimbursed for all or at least some of the cost of the evaluation. If nothing else, you can submit the receipt to a flexible spending account or claim at the end of the year as a medical expense on your taxes (if appropriate).

Important Things to Know

So, what are the important things to keep in mind?

  • Neuropsychological testing often consists of both educational and neuropsychological testing. Even if your insurance company covers the cost of neuropsychological testing, educational testing is rarely covered.
  • Most insurance companies will only cover neuropsychological testing if it is medically necessary to make a diagnosis.
  • It is important for the referring clinician to highlight any relevant medical issues in the referral form. These can include issues such as a head injury, premature birth, stroke, epilepsy, congenital abnormalities, head trauma, memory problems, and any relevant medical diagnosis.
  • Having a medical doctor make a referral for a neuropsychological assessment can help with the insurance company’s willingness to pay for these services.
  • Some insurers will not cover neuropsychological assessments if the child has already undergone a similar assessment in the past 12 (or 24) months.
  • It is important for you to call the number on the back of your subscriber identification card to inquire about coverage for neuropsychological assessments. Keep these things in mind:
    • Ask if your child is covered for codes 96101 (“psychological testing”) or 96118 (“neuropsychological testing”). When you call, be sure to specify the reason for the testing.
    • If you are told that the testing is covered, ask if you will need “preauthorization” or “pre-certification” (i.e., advanced approval). It is also important to find out whether the evaluator is “in-network” or “out-of-network” and whether your insurance company provides approval in those cases.

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Ellen Braaten, PhD

Ellen Braaten, PhD

Ellen Braaten, PhD, is executive director of the Learning and Emotional Assessment Program (LEAP) at  Massachusetts General Hospital (MGH), an associate professor of psychology at Harvard Medical School, and former co-director for the MGH Clay Cente...

To read full bio click here.