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 $6,500 or $7,500, 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 $0 to $800 in a best-case scenario. If an HMO gives you 100% of the contracted rate, you are looking at $0 to $1,200.

For PPO, or out of network benefits, the same thing applies — $0 to $800 if they give you 65% of the contracted rate, or $0 to $1,400 if they give you 100%.

If your evaluation is for autism, insurers are generally required to cover the assessment, and ruling autism out is as medically necessary as ruling it in. If you fight a denial here, you are more likely than not to prevail, whether or not the evaluation ends in an autism diagnosis. This falls under mental health parity requirements and California’s autism coverage mandate.

Google, Apple, Oracle, and a number of other large employer and specialty plans have specific carve-outs for neuropsychological testing. We have seen these plans reimburse in full, particularly where the diagnosis is autism-related. Employees at these companies are frequently told the evaluation is not covered and accept it. It is worth reading the actual plan documents rather than taking the first answer you get on the phone.

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 and $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.

Which evaluation are you looking for?

These pages walk through the process, what the testing day involves, and what the report is built to accomplish.

• ADHD testing and evaluation — adults and children, San Jose and the greater Bay Area
• Autism diagnostic testing — adult and child assessment, including later-identified and high-masking presentations
• MCAT and standardized test accommodations — documentation built to meet what the testing agencies actually require
• Neuropsychological testing in San Jose — the full evaluation, start to finish

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Before you go

Everything above is general guidance. It applies wherever you live.

I practice in San Jose, California.

If you’re in the Bay Area

Call. 321-208-1554 or 321-298-8668

Tell us the question you’re trying to answer. You’ll be told what’s involved, how long it takes, what it costs, and what an evaluation can and cannot determine. Fees are listed on our evaluation fees page — diagnostic evaluations run $6,500 to $7,500, we don’t take insurance, and we provide a superbill so you can use everything on this page.

If it isn’t workable for you, say so. If an evaluation isn’t the right thing for your question at all, we’ll tell you that too, and we won’t charge you to find out.

Or send us your information and we will call you.

If you’re not in the Bay Area

You still need someone good, and most of this page was written so you could go get one. Here’s what to ask before you hire anybody:

• “Do you perform pre-authorizations?” If the answer is yes, the insurance company sets the pace of your evaluation. Ask how they keep that from rushing the diagnosis.
• “What happens if the report gets rejected?” By an insurer, a school, a testing board. Is the appeal included, or does the meter start over?
• “How will you rule out the alternatives?” An evaluation that only looks for what you already suspect is cheaper, and it’s worth less — to you, to your doctor, to a school, and to a court.
• “Have you done this exact thing before?” Not neuropsychology generally. Your specific question — MCAT accommodations, a custody matter, a capacity question, whatever brought you here.
• “What happens if you don’t find anything?” A good answer to this tells you almost everything. Finding out what isn’t going on is most of the value, and anyone who treats a clean result as a failed evaluation has the whole thing backwards.

Ask those five and you’ll learn more in ten minutes than any website can tell you. Including this one.