Yeah, yeah, don't need a full assessment to dx ADHD depending on who you talk to. But what is the feasibility of have an ADHD-only assessment practice? Too specialized? Also what is the reimbursement rate for ADHD evals from insurance?
Feasibility of ADHD only assessment center?
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insurance will not pay for neuropsych testing and will only pay for limited testing of psych instruments
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Ok. Well first of all, it's not "who you talk to." It is what is the specific question that needs to be answered in order to plan or deliver the standard of care treatment to the patient...the other possible diagnoses involved... the availability of collateral informants, and the age of patient. And what do you mean by a "full assessment?" Those are basics facts that will ethically and clinically dictate the nature and length of any assessment.
Second, of course a "full assessment" is needed. This may or may not include some psychological testing/tests.
The American Academy of pediatrics put this out recently. Please read and take note.
Commercial Insurance (as well as CMS) will typically not pay any (or very few) units of the psychological testing codes for this concern. Which is in-line with current AAP guidelines. Can you "game" it with some insurance/health plans? Probably. Should you? No. Should you build a practice around one diagnosis? No!
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The thing is, at least in my area, plenty of people pay for this testing but theur actual symptoms and timeline of impairment don't line up with an ADHD diagnosis. You can probably make a good amount of money doing it, and there are lazier clinicians that will refer primarily to these tests in adult patients. But they're no substitute for a thorough psychiatric evaluation, just one extra thing to consider
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Every ADHD assessment center I have ever seen also offers pseudo scientific "treatments" to go along with their diagnoses to make money.
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No. Probably not. ADHD is everywhere. But, coincidentally, the diagnosis is most prominent in younger Medicaid populations. Go figure? Take that for what it's worth.
Unless its waaaay complicated by other possible things.... usually its a 90791/90792, rating scales and we're done. Is that bad? Or maybe we just don't like misbehaved kids with crappy parents from disadvantaged backgrounds/circumstances?
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Around here they charge $350, cash. Seems like a scam tbph, basically just an assessment and TOVA test, but a lot of people pay because it's usually enough to get Adderall from a PCP
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Most competent, ethical clinicians don't really get into this in private clinics for a variety of reasons or adult assessment at least. Number one being that most people want this assessment for stimulants, and most of those people don't actually have ADHD. So, people tend not to be happy when you tell them they have anxiety, depression, ****ty life syndrome, etc, and not ADHD. Then you get a bunch of negative reviews online.
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20 years ago, you'd be full of honest patients. Nowadays, you'd basically be putting up a neon sign that reads, "legalized meth doled out here.". Which means you'd be full until word got out that you're not just handing out diagnoses. If you acted unethically, you'd find your office full of increasingly shady groups of drugged out people until you get shut down. If you acted ethically, that same group would spread the word that you don’t play ball and you’d lose the volume to the unethical people who also got the upper middle class.
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If you have a citation for this I would really like it for something I'm involved in. Feel welcome to post here or PM.
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See the above posts for more information, but if you're going to be performing the assessments well, I don't know how viable it is to fill an entire practice with just that. It can also of course depend on how populated your area is, and whether you're working with kids, adults, or both. If you broadened and were performing full psychoeducational evaluations (including high-stakes evaluations), it may be more likely. And if you also were offering evidence-based interventions, such as for ADHD and situational anxiety, I could see filling a practice with all of that.
Yes, I certainly see the ethical dilemma to this. It’s incredible how So many people want this diagnosis now.
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I'd also suspect that kids of more affluent adults are more likely to get private assessments or be going to higher SES school districts with more resources for ADHD/LD/developmental issues and not presenting as much in community type clinics.
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Depends on the diagnosis
To expand on some of what Erg and others have said, most insurances are going to require that you complete an authorization form where you request testing units (blocks of time) for specific testing services (group under billing codes (e.g., code 96137 is for neuropsychological testing, in 30 minute blocks). Almost all of these forms that I have seen ask specifically about ADHD, and require exceptions to authorize testing. For example, the inspirational named "Universal" Form contains the following language:
If the primary diagnosis is ADHD, indicate why the testing is not routine:
____ Previous treatment(s) have failed and testing is required to reformulated
treatment plan
____ A conclusive diagnosis was not determined by a standard examination
and/or
_____ Specific deficits related to or co-existing with ADHD need to be further
evaluated
By routine, they mean interview, rating scales stuff (those 90791 codes referenced earlier). If you check any of those items above, you are guaranteeing yourself a call from your friendly neighborhood insurance peer reviewer ( maybe even Erg!), and you better be prepared to justify things to someone whose job it is to know whats necessary and what is not.
Assessment only for ADHD? Probably not viable if you do it right (e.g. ethically). Add in comprehensive, evidence based treatment, including individual and group therapies, social skills training, and parent training, and you might have more luck. It would be crucial to develop strong relationships with local pediatricians. You have to remember that when working with school-aged kids, you really have only a small window of daily availability (3-6pm) for any regularly scheduled weekday appointments. There are also many cancelations.
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You don't think it's incredible. You're trying to open a clinic that only sees a diagnosis that affects about 6% of children, which persists into adulthood for about one third of those children. It's not about how common the diagnosis is, it's about the demand for the diagnosis.
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Psychologists: endless debate re: ADHD diagnosis, who should be providing it, how it should be assessed, and our capacity to reliably provide such as a whole.
Physicians: "Yeah...you've got it. Here's some pills."
Physicians: "Yeah...you've got it. Here's some pills."
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My favorite is when they're like, yeah, you need ADHD testing, but here's a temporary supply of pills until you can get tested.
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That sounds like a terrible idea for so many reasons. What you could probably do though is therapy to focus on behavioral / skills-based strategies to improve related difficulties / executive functioning. SO many people pay out of pocket for pseudo-treatments- I would hope that with the right advertising/promotion those folks would be willing to go for something backed up by research that insurance would also pay for. It's hard in my area to find therapists who do that well even though that's what I recommend very strongly to all of my clients who get an ADHD dx.
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Getting insurance to pay for things is the sticking point a lot of times. We don't really have mental health parity in this country.
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I used to be about the only guy in town who would do adult ADHD assessments. I had a detailed informed-consent emphasizing the nonspecific nature of most adult ADHD symptoms, and mentioning that a majority of adults who think they have ADHD usually do not. I then used a therapeutic assessment approach in terms of the assessment feedback. All this and a good dose of empathy (which is always a good idea, of course), meant I had very few complaints and the psychiatrists and neurologists who referred to me were happy, as were most of the patients.
I stopped filing insurance for patients and belonging to insurance panels in 1997, so getting approval from a mangled care company was not an issue.
Pediatric ADHD assessment is a different enterprise, as you know. I'm no expert there, but I would suggest the Testing Psychologist podcasts, which are excellent in general, and often cover ADHD topics, and the Testing Psychologist group on Facebook. A ton of very knowledgeable child & adolescent and school psychologists hang out there, plus a few adult psychologists like me, soaking up the wisdom.
I stopped filing insurance for patients and belonging to insurance panels in 1997, so getting approval from a mangled care company was not an issue.
Pediatric ADHD assessment is a different enterprise, as you know. I'm no expert there, but I would suggest the Testing Psychologist podcasts, which are excellent in general, and often cover ADHD topics, and the Testing Psychologist group on Facebook. A ton of very knowledgeable child & adolescent and school psychologists hang out there, plus a few adult psychologists like me, soaking up the wisdom.
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I used to be about the only guy in town who would do adult ADHD assessments. I had a detailed informed-consent emphasizing the nonspecific nature of most adult ADHD symptoms, and mentioning that a majority of adults who think they have ADHD usually do not. I then used a therapeutic assessment approach in terms of the assessment feedback. All this and a good dose of empathy (which is always a good idea, of course), meant I had very few complaints and the psychiatrists and neurologists who referred to me were happy, as were most of the patients.
I stopped filing insurance for patients and belonging to insurance panels in 1997, so getting approval from a mangled care company was not an issue.
Pediatric ADHD assessment is a different enterprise, as you know. I'm no expert there, but I would suggest the Testing Psychologist podcasts, which are excellent in general, and often cover ADHD topics, and the Testing Psychologist group on Facebook. A ton of very knowledgeable child & adolescent and school psychologists hang out there, plus a few adult psychologists like me, soaking up the wisdom.
As someone who routinely does adult ADHD testing, can I ask what your assessment procedure was?
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I'm a little confused as to how you would build an entire practice around just one diagnosis... if the clients coming in already know their diagnosis, why would they need you? If they only suspect ADHD, then in reality you're going to end up doing a lot of different types of evals, because a lot of people who think they have it actually don't. Am I missing something? I guess you could just do a whole report that says: We checked for ADHD and you don't have it. That seems weird. In my side-hustle private practice, I do a variety of evals, a lot of which are for suspected ADHD - but I would never refer to these as "ADHD evaluations." They're psychodiagnostic evaluations - based on the interview and early testing results, it could - and often does - go in another direction entirely. FWIW I don't take insurance, and have found if you are open and transparent about the hypothesis testing assessment process with clients, they don't complain.
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When I meet with parents to plan an assessment, the referral question is never "do they have ADHD." It's usually along the lines of "hey, my kiddo is struggling with these behaviors and xyz symptoms and I need help." When I am formulating possibilities for the "why" it's important to examine all the conditions that may be related to xyz symptoms as there is overlap between many of the neurodevelopmental conditions (e.g., inattention in adhd, autism, ID, etc) and mood disorders (e.g., inattention in anxiety/depression).
The goals of assessment are the same as the goals of psychology: to describe, to explain, and influence outcomes.
Of course the final diagnosis has a bearing on that stuff, but it's also just a part of the evaluation.
Goals of the my evaluations ALWAYS include the following:
If people stop thinking the only goal of assessment is the diagnostic impression section assessment can turn from something analytical to something therapeutic.
The goals of assessment are the same as the goals of psychology: to describe, to explain, and influence outcomes.
Of course the final diagnosis has a bearing on that stuff, but it's also just a part of the evaluation.
Goals of the my evaluations ALWAYS include the following:
- improving diagnostic clarity
- identifying strengths and weaknesses,
- providing recommendations to inform treatment/interventions.
If people stop thinking the only goal of assessment is the diagnostic impression section assessment can turn from something analytical to something therapeutic.
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This was in latter half of the 1990s until 2007, so I would adjust based on research if I were doing adult ADHD assessments now. I'm also pulling this quickly from memory. With those provisos ....
- Asking the evaluee to do everything reasonably possible to obtain school records even if from 25+ years ago (parents were often the best source);
- collateral interviews (spouse/partner, sibling, etc.);
- semi-structured clinical interview for other mental disorders (SADS & portions of the SCID), and one for ADHD (I think it was one Barkley had developed);
- Wender-Utah, and Barkley ADHD self-report questionnaires (recollection of childhood & current), and a questionnaire Brown had developed for the evaluee and collaterals (I think it's more sophisticated now);
- neuropsych screening battery (I consulted with a neuropsychologist on that);
- insist on and review medical & psychological records;
- MMPI-2 and if significant exaggeration/feigning was a possibility, SIRS.
- Word Memory Test & TOMM (tons of research on dissimulation with adult ADHD in the last 15 years, so I'm sure I would modify if doing today).
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It's really more about marketing IMHO. If someone like you has an established, successful assessment practice, then you probably don't need to do any niche marketing because you already have steady referral sources (because you do excellent work, I would bet). But for someone in the earlier stages of building an independent practice, marketing is important.
