How To Get Insurance To Pay For Neuropsychological Testing

“Will insurance pay for my neuropsychological evaluation?” This is the most common and important question neuropsychologists get. When one looks at the costs of a neuropsychological evaluation, they often stop there, assuming it is way too expensive! Why can’t insurance help?

The truth:

Most of the time you can get some reimbursement, but there are lot of conditions attached.

Getting insurance companies to pay for neuropsychological evaluations (or anything outside of their provider network) is very difficult. If you are going out of network, getting reimbursed is going to be somewhat of a battle! Fighting this battle often means multiple phone calls to the insurance company and having multiple individuals within that company give you different answers at different times.

Sometimes it is not that bad, and the insurance support is accurate and helpful. Other times, it’s a complete struggle. Read on for more details regarding the ins-and-outs of getting reimbursed by insurance for neuropsychological evaluations.

Most common reasons insurance companies won’t cover a neuropsychological evaluation

• Having an HMO: Individuals that have an HMO must stay within their HMO to receive any kind of reimbursement. If your HMO does not have a neuropsychologist provider for you to see, we have seen clients fight their HMO insurance company and get compensation for our services.
• Pre-authorization: A pre-authorization is when an insurance company wants a neuropsychologist to see a patient “for free.” The neuropsychologist then tells the insurance company why they need certain testing so that it is medically justified. However, insurance companies often want this done at a pace that does not allow enough time for a proper diagnosis.
  We do not perform pre-authorizations because a pre-authorization requires a psychologist to work under the insurance company’s rules. If your insurance requires a pre-authorization, getting reimbursement out of network is going to be much more cumbersome. They can say that the testing was not necessary because it was not “pre-authorized.” Often, moving at the speed required by the insurance company can lead to a misdiagnosis.
  Many of us neuropsychologists feel pre-authorization evaluations are unethical and unjustified, as bureaucrats and accountants are making medical decisions as opposed to trained and experienced doctors. Often, the pace dictated by insurance companies is entirely too fast to draw an accurate diagnosis and can lead to a hurried misdiagnosis.
• Medicaid, Medicare, TRICARE: Individuals with these insurances will not be able to get reimbursement in most cases.
  -Medicaid does not have any neuropsychologists on their panel and billing is cumbersome with a lot of room for error.
  -Medicare may work, but they prefer in-network providers. Sometimes, if Medicare refuses to pay, supplemental insurance can pay so that you recoup some of the costs.
  -Most of the time, TRICARE requires a pre-authorization, but it is possible with a super bill to recoup funds.
• Academic testing? Legal Case? Court Order? Family Law? Injured? Work problems? Need SSDI? These all are “not medically necessary” and unless you have these coverages in your insurance policy, your insurance views these procedures like cosmetic surgery, i.e. “not needed” or “not medically necessary.”

Why Most Neuropsychologists Do Not Accept Insurance

Many neuropsychologists do not accept insurance payments because they must spend several hours on the phone with the insurance company to be paid. Often, these neuropsychologists don’t have the time or resources to deal with insurance companies in this manner.

Reimbursements are typically low, and often very difficult to get. If you get a neuropsychological evaluation and find out that’s nothing’s wrong, often the insurance company will refuse to pay you because they will say that the evaluation was not “medically necessary.”

How Much Will You Get?

If the evaluation is $5000 or $6000, is that how much the insurance company pays?

The insurance company has a contracted rate. This is the rate that they pay individuals on their insurance panel for neuropsychological/and psychological testing. These rates are low and very difficult to understand, often requiring several phone calls from the doctor to receive reimbursement.

If an HMO gives you 65% of the contracted rate, you are looking at somewhere between $500 and $800 maximum reimbursement in a best-case scenario. If an HMO gives you 100% of the contracted rate, you are looking at anywhere between $500 and $1200 in reimbursement.

For PPO, or out of network benefits, the same thing applies, you may receive anywhere between $500 and $800 maximum reimbursement if they give you 65% of the contracted rate, or if they give you 100%, you might be somewhere between the $500-$1400 in reimbursement.

If you have autism, or your evaluation is for autism, insurance companies must pay, period! If you fight them, you are likely to get the higher reimbursement rate whether you end up with an autism diagnosis or not, because it is medically necessary to rule out autism or to rule it in. This is per the Autism Parity Act.

Google, Amazon, Netflix, Apple, [insert awesome corporation here] and many specialty insurances have specific carve outs for individuals to have neuropsychological testing. In many cases, individuals can always get reimbursement, and we have even seen cases where the entire bill has been paid, especially if the diagnosis is autism-related.

Best strategy for Reimbursement

The best strategy, is when you select your plan for the year, add neuropsychological testing, especially neuropsychological testing out of network to your plan. That way, you can select the provider that you want, and receive a higher rate of reimbursement. The following year you can discontinue and/or remove neuropsychological testing from your plan.

Your best course of action if you need a neuropsychological evaluation right now is to call your insurance company and see what the contracted rate is. See whether they cover out of network, and if they do, you can assume you will get somewhere between $0-$1,400 back.

Getting $0? Fight and get your reimbursement, especially if they have no providers or you or your child has autism spectrum disorder!

Why Neuropsychological Testing?

Neuropsychologists and neuropsychological testing are the gold standard to finding out what is and what is not wrong with someone! Spending fifteen minutes to an hour with a doctor getting an interview, or filling out a couple of checklists is helpful, but it can sometimes miss the larger picture.

Furthermore, neuropsychological testing is found to be admissible in court. Your diagnosis gives you legitimate evidence for use with schools, employers, other doctors, insurance companies, disability services and other individuals.