PhD/PsyD Pediatric Neuropsychology integrated with Primary Care

[JP West]

Hi,

I'm a pediatric neuropsychologist looking at possibly integrating with a group pediatrics practice one day weekly. I might perform targeted (< 2 hours of testing) evaluations as well as consultation to the pediatricians around diagnosis and medication management (we have a severe shortage of child psychiatrists in my area).

Is there anyone out there on this forum doing something similar? How do you like it? How is billing and reimbursement handled. Anything I've found online pertaining to the financial side concerns integrated therapy which is not what I'd be doing.

Thanks for your ideas....

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[psych.meout]

What would be the utility and advantage of having a neuropsychologist on-staff part-time at generalist pediatric practice over them just referring out to a dedicated neuropsychologist private practice or to their associated medical network?

What kinds of testing would you be doing? What would the referral questions be?

Is this meant to be a pediatric neuropsych version of a health psychologist in integrated primary care?

 

[JP West]

What would be the utility and advantage of having a neuropsychologist on-staff part-time at generalist pediatric practice over them just referring out to a dedicated neuropsychologist private practice or to their associated medical network?

What kinds of testing would you be doing? What would the referral questions be?

Is this meant to be a pediatric neuropsych version of a health psychologist in integrated primary care?

Those are great questions, thanks.

There are only three peds neuropsychologists in my city and one doesn't accept any insurances. We don't even have any pediatric neuropsychology at the hospital. To the pediatricians, its an advantage to have access to this service quickly b/c wait lists are out of control. They can triage their neediest patients to see me quickly and receive immediate verbal feedback with a brief report that's turned around quickly. They can also use my diagnostic skills to help them decide which symptoms to target with medication since there's also an access problem to the very few child psychiatrists in the area.

On my side, it keeps me out of the "silo" of private practice. Further, there was a strong message sent at AACN conference last year that neuropsychologists should be looking at how they can integrate into systems with the changes coming up in healthcare (i.e. medical homes, reimbursement for keeping ppl healthy and costs down vs. billing by the service). If I can work successfully and profitably with this practice, I may be able to sell other practices in my area on the model, inserting employees in the future instead of myself.

 

[psych.meout]

Those are great questions, thanks.

There are only three peds neuropsychologists in my city and one doesn't accept any insurances. We don't even have any pediatric neuropsychology at the hospital. To the pediatricians, its an advantage to have access to this service quickly b/c wait lists are out of control. They can triage their neediest patients to see me quickly and receive immediate verbal feedback with a brief report that's turned around quickly. They can also use my diagnostic skills to help them decide which symptoms to target with medication since there's also an access problem to the very few child psychiatrists in the area.

Ok, but doesn't this sound like regular, ol' health psych? Where does the neuropsych come in? Why would they want you instead of a non-neuropsych-focused clinical psychologist with experience in health psych and peds?

When and why would testing be needed? How do you know that <2 hours per week of testing will be sufficient when you don't have a referral question and haven't established what testing would be needed?

Don't many insurers, especially HMOs, and Medicaid require pre-approval for neuropsych testing? Wouldn't that prohibit the "quick" turnaround?

On my side, it keeps me out of the "silo" of private practice. Further, there was a strong message sent at AACN conference last year that neuropsychologists should be looking at how they can integrate into systems with the changes coming up in healthcare (i.e. medical homes, reimbursement for keeping ppl healthy and costs down vs. billing by the service). If I can work successfully and profitably with this practice, I may be able to sell other practices in my area on the model, inserting employees in the future instead of myself.

From what you've described, especially the waitlists and lack of neuropsych at your hospital, it really seems like the problem is the lack of traditional peds neuropsych and psychiatry, not new, untested innovations.

 

[smalltownpsych]

I am a little confused by this too although I appreciate thinking outside the box. Isn't most integrated care aimed at brief interventions as opposed to brief neuro assessments? I guess concussions might be something you could be involved in especially if local school sports required some type of clearance after a head injury and this clinic dealt with that a lot. As far as billing goes, initial meeting with patient and parent could always be billed as a psychiatric diagnostic intake. After that, then if you decide to administer some testing, as psych.meout stated, pre-auth would be needed and then at that point I am sure you know all the appropriate codes for neuro testing. If you can figure out a way to bill for talking to the other docs, let me know.

 

[erg923]

I would be worried about getting enough billable hours with this model to make it sustainable.

 

[psych.meout]

I would be worried about getting enough billable hours with this model to make it sustainable.

Yeah, which is why I asked what exactly OP would be doing in this integrated practice and how neuropsych would in with it.

 

[JP West]

Not everything I'd be doing would be neuropsychology. Some of the assessments would be more general psychology like doing a targeted ADHD eval or a thorough interview and rating Scales for a child with ASD to help guide medication management. Other patients might be children with seizure disorder who could use a half day with me since there's no neuropsychology at the medical center.

 

[Kadhir]

I know of someone doing this in adult primary care, but it's a grant-funded pilot program. I thought it was a great idea- clearly enough so to be fundable. Just don't know how you could sustain it otherwise.

 

[psych.meout]

Not everything I'd be doing would be neuropsychology. Some of the assessments would be more general psychology like doing a targeted ADHD eval or a thorough interview and rating Scales for a child with ASD to help guide medication management.

Ok, but what is the utility of having you there in the office? Why not refer out to outpatient psychology instead of taking the time energy, space, etc. to have you there in-office?

Why would they pick you over, say, a health psychologist who has more experience in integrated primary care?

Other patients might be children with seizure disorder who could use a half day with me since there's no neuropsychology at the medical center.

Wouldn't patients have to be seen by neurology before neuropsych for the first presentation(s) of their seizure disorders?

Once again, this really seems like you should focus more about getting neuropsych at the medical center itself (where they have the resources for it), where neuropsych typically is housed, rather than trying to shoehorn this novel approach in an outpatient primary care setting. Basically, you've identified actual problem areas, but aren't proposing actual solutions for them. Rather, you appear to be creating a solution searching for a problem to solve.

 

[ClinicalABA]

Hi,

I'm a pediatric neuropsychologist looking at possibly integrating with a group pediatrics practice one day weekly. I might perform targeted (< 2 hours of testing) evaluations as well as consultation to the pediatricians around diagnosis and medication management (we have a severe shortage of child psychiatrists in my area).

Is there anyone out there on this forum doing something similar? How do you like it? How is billing and reimbursement handled. Anything I've found online pertaining to the financial side concerns integrated therapy which is not what I'd be doing.

Thanks for your ideas....

I primarily do pediatric assessments, with many referral coming from Pediatrician's offices. I think that model is a good one in theory in that it may cut down on wait times to have a dedicated day. You'd still run up against then need for pre-auths for most services (we typically will schedule the testing at least 7 days after the intake, and that can cut it close). My guess is you'd soon get booked up pretty quickly though, depending on the size of the practice. For example, at my clinic we may evaluate 10+ kids per month from one local pediatrics office. While for the younger kiddos (under 4) typically referred for concerns re:ASD face to face testing and feedback time may be 2-3 hours, you need to factor in report writing (and they will need a report for school referals, EI services, ABA, etc. that has some pretty specific recommendations). I find that, at most, I can do 2 testings and a couple of intakes in one day, which means I'm catching up on writing later. I imagine you'd be busy enough to make it financially viable. What would be the financial arrangments (e.g., fee for service? Set fee/salary? You give a percentage of billed to cover office space, billing, scheduling, etc.? Who pays for testing materials?). If you can get a good percentage and they're covering everything, it might work out better than doing a day of private practice elsewhere. I like the idea of making it easier for families, as they already know where the peditricians' office is.

 

[deleted343839]

Most of the psychologists I know who practice in integrated settings are doing more than testing and evaluations. They are also providing intervention services. The thing that works well about integrated care is that the psychologist can be part of the longitudinal treatment team, not just a one-time consultant who happens to be within easy reach.

How accessible are solid, evidence-based psychological intervention services for children in your area? If the answer is "not very" then I'd be really wary of going into an arrangement like this with the goal of only doing testing and brief evaluations. Let's say, for example, that a pediatrician colleague consults you about a kid with symptoms of ADHD. You confirm the diagnosis and in your report recommend all kinds of guideline-appropriate management like behavior therapy with parent training and whatever else prior to starting meds. But the parents want to start treatment ASAP and the pediatrician writes for Adderall, and by the 1-month follow up visit there is still no behavior therapy because the good local therapist has a 2-month waiting list, or doesn't take insurance, or the only alternative is a counselor who doesn't offer behavior therapy.

I might be wrong -- there might be a surplus of excellent, readily accessible child psychologists in your area. But if my hunch is correct, you'll see situations like this played out over and over in the primary care setting. And if your only "intervention" service is consulting on meds -- dancing on the edge of your scope of practice, to be generous -- then you may end up being part of the problem.

 

[psych.meout]

Most of the psychologists I know who practice in integrated settings are doing more than testing and evaluations. They are also providing intervention services. The thing that works well about integrated care is that the psychologist can be part of the longitudinal treatment team, not just a one-time consultant who happens to be within easy reach.

How accessible are solid, evidence-based psychological intervention services for children in your area? If the answer is "not very" then I'd be really wary of going into an arrangement like this with the goal of only doing testing and brief evaluations. Let's say, for example, that a pediatrician colleague consults you about a kid with symptoms of ADHD. You confirm the diagnosis and in your report recommend all kinds of guideline-appropriate management like behavior therapy with parent training and whatever else prior to starting meds. But the parents want to start treatment ASAP and the pediatrician writes for Adderall, and by the 1-month follow up visit there is still no behavior therapy because the good local therapist has a 2-month waiting list, or doesn't take insurance, or the only alternative is a counselor who doesn't offer behavior therapy.

I might be wrong -- there might be a surplus of excellent, readily accessible child psychologists in your area. But if my hunch is correct, you'll see situations like this played out over and over in the primary care setting. And if your only "intervention" service is consulting on meds -- dancing on the edge of your scope of practice, to be generous -- then you may end up being part of the problem.

It seems like this idea of innovating neuropsych into primary is more about what OP would like to be doing (e.g. minimal testing and other commitment, but no therapy), rather than what the actual needs and deficiencies there are in the community and the realities of working in integrated primary care. Sure, the community may lack child psychiatrists, but that doesn't really make it within one's scope of practice to basically be a child psychiatrist (e.g. OP's multiple allusions to "medication management") without the training, experience, and licensing to do so.

Again, OP, why do this rather than fill the gaps in traditional neuropsych in your community? What is the benefit of doing this, why would providers agree to this arrangement, and, possibly most importantly, what are you getting out of this?

 

[JP West]

Most of the psychologists I know who practice in integrated settings are doing more than testing and evaluations. They are also providing intervention services. The thing that works well about integrated care is that the psychologist can be part of the longitudinal treatment team, not just a one-time consultant who happens to be within easy reach.

How accessible are solid, evidence-based psychological intervention services for children in your area? If the answer is "not very" then I'd be really wary of going into an arrangement like this with the goal of only doing testing and brief evaluations. Let's say, for example, that a pediatrician colleague consults you about a kid with symptoms of ADHD. You confirm the diagnosis and in your report recommend all kinds of guideline-appropriate management like behavior therapy with parent training and whatever else prior to starting meds. But the parents want to start treatment ASAP and the pediatrician writes for Adderall, and by the 1-month follow up visit there is still no behavior therapy because the good local therapist has a 2-month waiting list, or doesn't take insurance, or the only alternative is a counselor who doesn't offer behavior therapy.

I might be wrong -- there might be a surplus of excellent, readily accessible child psychologists in your area. But if my hunch is correct, you'll see situations like this played out over and over in the primary care setting. And if your only "intervention" service is consulting on meds -- dancing on the edge of your scope of practice, to be generous -- then you may end up being part of the problem.

Actually, there's an experienced social worker doing short-term behavioral therapy in this same office and he's very good. It was through a meeting with him that this idea hatched. He would be a gatekeeper of sorts in terms of who gets in to see me. In this model, the patient gets therapy and medication that's guided by my input. And btw I completely appreciate the concern about consulting on medication...I think the pediatricians want to know what disorder they're targeting with medication, which symptoms are causing the most distress, what might be amenable to therapy, etc. The more information they have, the better equipped they are to medicate in-house in our high need area.

 

[psych.meout]

Actually, there's an experienced social worker doing short-term behavioral therapy in this same office and he's very good. It was through a meeting with him that this idea hatched. He would be a gatekeeper of sorts in terms of who gets in to see me. In this model, the patient gets therapy and medication that's guided by my input. And btw I completely appreciate the concern about consulting on medication...I think the pediatricians want to know what disorder they're targeting with medication, which symptoms are causing the most distress, what might be amenable to therapy, etc. The more information they have, the better equipped they are to medicate in-house in our high need area.

Except a neuropsychologist, a social worker, and a pediatrician does not a child psychiatrist make. If these kids need to be medicated for psychiatric issues, they should be referred to an actual child psychiatrist (that's why that specialty exists), instead trying to approximate something similar with three separate providers.

As MamaPhD stated, this is at best on the periphery of your scope of practice. Ask yourself, whose needs are being met with this arrangement, the patients' or yours and the other providers in that office?

 

[JP West]

I primarily do pediatric assessments, with many referral coming from Pediatrician's offices. I think that model is a good one in theory in that it may cut down on wait times to have a dedicated day. You'd still run up against then need for pre-auths for most services (we typically will schedule the testing at least 7 days after the intake, and that can cut it close). My guess is you'd soon get booked up pretty quickly though, depending on the size of the practice. For example, at my clinic we may evaluate 10+ kids per month from one local pediatrics office. While for the younger kiddos (under 4) typically referred for concerns re:ASD face to face testing and feedback time may be 2-3 hours, you need to factor in report writing (and they will need a report for school referals, EI services, ABA, etc. that has some pretty specific recommendations). I find that, at most, I can do 2 testings and a couple of intakes in one day, which means I'm catching up on writing later. I imagine you'd be busy enough to make it financially viable. What would be the financial arrangments (e.g., fee for service? Set fee/salary? You give a percentage of billed to cover office space, billing, scheduling, etc.? Who pays for testing materials?). If you can get a good percentage and they're covering everything, it might work out better than doing a day of private practice elsewhere. I like the idea of making it easier for families, as they already know where the peditricians' office is.

I'm not sure about the billing. That goes back to my original post about whether or not its viable to work out of a pediatrician's office. And yes, its great for families to cut back on the anxiety of the unknown and see a provider who is endorsed by the pediatrician they've known for years in the office where they regularly visit.

Just out of curiosity, how many evaluations does each psychologist do per month at your clinic? I used to do 8 per month when I worked at someone else's large clinic and those were pretty long reports.

 

[WisNeuro]

I'm not sure about the billing. That goes back to my original post about whether or not its viable to work out of a pediatrician's office. And yes, its great for families to cut back on the anxiety of the unknown and see a provider who is endorsed by the pediatrician they've known for years in the office where they regularly visit.

Just out of curiosity, how many evaluations does each psychologist do per month at your clinic? I used to do 8 per month when I worked at someone else's large clinic and those were pretty long reports.

8 per month? What do you do with the other 2 and a half weeks of the month?

 

[JP West]

8 per month? What do you do with the other 2 and a half weeks of the month?

I wasn't full time

 

[deleted343839]

Actually, there's an experienced social worker doing short-term behavioral therapy in this same office and he's very good. It was through a meeting with him that this idea hatched. He would be a gatekeeper of sorts in terms of who gets in to see me. In this model, the patient gets therapy and medication that's guided by my input.

It's good to know that there is an integrated clinician in-house. But is your idea really going to work within the constraints of the practice? Is the real problem is (a) a surplus of kids with legitimate indications for formal psych evaluation or (b) deficient behavioral health skills in the current team?

I also still struggle with this question:

why do this rather than fill the gaps in traditional neuropsych in your community?

I'm not setting out to be a contrarian, but having practiced in integrated settings my entire career I have come to really value role clarity, and this sounds like a recipe for the opposite.

For what it's worth, I've seen a similar problem in medicine where subspecialists try to set up "visiting" clinics in primary care - I have yet to see this model work out well for the specialist.

 

[smalltownpsych]

I agree that having good assessments readily available in a primary care setting can be a good thing. We already do that to some extent here. However, treatment and ongoing concurrent communication and behavioral assessment is often more what is needed moreso than finding the correct diagnosis. For example, we don't really have a way to differentiate anxiety leading to attentional difficulties verses attentional difficulties leading to anxiety. The best assessments that I have done for ADHD (which is the common cold of pediatric assessment) are where I have had an ongoing treatment and evaluation of the patient in collaboration with the parent so that we can tease this type of stuff out. Sometimes the reduction in anxiety leads to improved performance and no medication is indicated other times we start a medication trial and either way I can monitor closely and bill for it with standard therapy codes with an interactive complexity add-on.

 

[ClinicalABA]

I'm not sure about the billing. That goes back to my original post about whether or not its viable to work out of a pediatrician's office. And yes, its great for families to cut back on the anxiety of the unknown and see a provider who is endorsed by the pediatrician they've known for years in the office where they regularly visit.

Just out of curiosity, how many evaluations does each psychologist do per month at your clinic? I used to do 8 per month when I worked at someone else's large clinic and those were pretty long reports.

I've been averaging 3-4 per week over the past few months. I'd like that to be more around 2-3 per month, but we have a backlog and and a long wait list.

 

[ClinicalABA]

8 per month? What do you do with the other 2 and a half weeks of the month?

I have a minimum billable hours per week (or a minimum monetary per year) contract. I could pretty much meet the weekly requirement with two testing cases and a few intakes per week. I typically bill out at 150% of my weekly minimum by scheduling additional assessments. I augment with school and home consultation (though some of that is billed under my masters level credential, so I try to do as much psych stuff as possible).

 

[PsyDr]

This sounds like a bad idea. You have a lower tier provider who gatekeeps your services, a lacunae in understanding of insurance, and 18 ways to get screwed.

1) a social worker does not have the training to determine who needs neuropsych testing. No where in their curriculum is a review of neuro even hinted.

2) what nonscreenjng neuropsych stuff takes 2hrs? What happens when insurance says they only cover one neuropsych set of codes per year and your screening just f'ed them out of seeing someone despite your testing indicating additional testing is necessary?

3) any idea on how educational testing is gonna be handled? Because insurance won't pay for that.

4) what is your malpractice liability for things like missing a tumor because your testing was 2hrs? What about epilepsy presenting as the common behavioral traits indicated by Geschwind? That Timmy is ******ed and you only looked at his mood? That it's not autism but really a fatal genetic disorder?

5) did you complete an mscp? Because that's the standard of care for medication.

6) what's your plan when a parent demands something for their child iep/504 hearing? Their custody case? Their child's jail placement?

7) is there any evidence that new providers create anxiety in 100% of parents or is this just something to indicate that the parents are anxious? Because in the latter you are reinforcing the maladaptive behavior.

8) why would a pediatrician group, who sees the potential for money based on their experience with you, give you a contract to hire more people. The reasonable thing to do would be to hire directly and cut you out of it.

 

[JP West]

All,

I listened to at least three speakers last year at the AACN conference in Chicago who touted the importance of working out new models of delivering neuropsychology services. These included tiered services (which includes doing brief NP evals when that's what's needed) and integrating with primary care. One of the speakers was Mark Barisa who literally wrote the book on the business of neuropsychology. If you have any helpful ideas, please keep them coming. I've seen a few good ones on here that have given me food for thought. I'm confident I can handle a parent concerned about their child's 504 hearing, but thanks.

 

[PsyDr]

All,

I listened to at least three speakers last year at the AACN conference in Chicago who touted the importance of working out new models of delivering neuropsychology services. These included tiered services (which includes doing brief NP evals when that's what's needed) and integrating with primary care. One of the speakers was Mark Barisa who literally wrote the book on the business of neuropsychology. If you have any helpful ideas, please keep them coming. I've seen a few good ones on here that have given me food for thought. I'm confident I can handle a parent concerned about their child's 504 hearing, but thanks.

I listened to a speaker at aacn say that pvts were stupid. A presentation at a conference does not a good idea make.

But this sounds like one of those "tell me that my idea is great" posts.

 

[erg923]

A presentation at a conference does not a good idea make.

Listen to Yoda, @JP West

 

[JP West]

No, if it's a bad idea by all means tell my why but you can leave out all the basic training items that I learned on post-doc about how not to get sued.

 

[deleted343839]

I listened to at least three speakers last year at the AACN conference in Chicago who touted the importance of working out new models of delivering neuropsychology services. These included tiered services (which includes doing brief NP evals when that's what's needed) and integrating with primary care.

Important for whom, though? Collaborative care and integrated primary care are here already. I suggest you chat up a few primary care psychologists and ask them what their priorities and challenges are. I don't think access to neuropsychologists is going to be high on the list.

I'm all for integrated care but this doesn't pass the smell test. If you really want to work in primary care, come roll up your sleeves and get your hands dirty. If you want to remain a specialist, be an amazing specialist and stay in that orbit.

If you have any helpful ideas, please keep them coming.

There are many ways to build a collaborative practice without co-locating. You can work out an expedited referral process with the practice that will keep the docs and parents happy and keep your referrals coming. You can visit the practice periodically, bring lunch, and give a talk on something useful to them. You can get in the habit of communicating effectively with referring docs and "closing the loop." You can open an office closer to the practice if they are consistently sending business your way. In short, there are a lot of ways to play well together without jumping into a co-located arrangement.

 

[JP West]

Important for whom, though? Collaborative care and integrated primary care are here already. I suggest you chat up a few primary care psychologists and ask them what their priorities and challenges are. I don't think access to neuropsychologists is going to be high on the list.

I'm all for integrated care but this doesn't pass the smell test. If you really want to work in primary care, come roll up your sleeves and get your hands dirty. If you want to remain a specialist, be an amazing specialist and stay in that orbit.



There are many ways to build a collaborative practice without co-locating. You can work out an expedited referral process with the practice that will keep the docs and parents happy and keep your referrals coming. You can visit the practice periodically, bring lunch, and give a talk on something useful to them. You can get in the habit of communicating effectively with referring docs and "closing the loop." You can open an office closer to the practice if they are consistently sending business your way. In short, there are a lot of ways to play well together without jumping into a co-located arrangement.

Very helpful, thanks.

As for your question about who it could be important for, the answer is for neuropsychologists. Barisa's talk was about NP's getting cut out of the loop with future models of healthcare reimbursement structure that could be on the horizon. Then again, he works in a traditional model

 

[erg923]

All,

I listened to at least three speakers last year at the AACN conference in Chicago who touted the importance of working out new models of delivering neuropsychology services. These included tiered services (which includes doing brief NP evals when that's what's needed) and integrating with primary care.

I am not a neuropsychologist, but there is an amount and length of testing that is wasteful and probably not beneficial to anyone involved. I actually see this a lot. However, there is also an amount and length of testing that would border on negligent, if not just simply clinically inadequate/inaappopriate. What neuropsych testing evaluations are you gonna do in just 2 hours with a pediatric population that is really going to substantial benefit a treatment plan or inform diagnosis? Would these really require a pediatric neuropsychologist to do them, if so?

 

[deleted343839]

As for your question about who it could be important for, the answer is for neuropsychologists. Barisa's talk was about NP's getting cut out of the loop with future models of healthcare reimbursement structure that could be on the horizon.

OK, so he's reading tea leaves. And positing that somehow reimbursement issues are going to disappear if you water down your services and provide them in primary care. Like if you mix underutilization and overutilization, it all evens out? And I presume he has no data to support these ideas? Sorry -- I think this is naive advice, at best.

You'd do better to network with successful neuropsychologists who have steady referral streams and strong collaborative relationships with referring docs.

Then again, he works in a traditional model

Of course he does. Why bear the risk when you can ask others to do it?

 

[JP West]

In two hours of testing I could complete an IQ and an ADOS (also requires a thorough diagnostic interview with parents for a separate hour plus rating scales) and diagnose ASD. Would more hours be helpful? Absolutely. But if the alternative is waiting for 5 months longer to get the evaluation and then another 4 weeks before the clinician writes up the long eval and gets around to sending it to the pediatrician and then doesn't have time for a phone call...I don't have to be a neuropsychologist to do this but I know very few non-neuropsychologists in my area who are competent in this diagnosis. I could get a developmental eval done for a three year old with a genetic disorder and learn whether they are ID or at-risk for it. Two hours might also work for a tune-up, for someone who had a full eval two years ago but is having social and behavioral struggles. Maybe I check in on some of their skills but I don't do IQ this time (or I just do a two-subtest screener). It's true that you don't have to be a pediatric neuropsychologist to tackle every concern.

 

[erg923]

In two hours of testing I could complete an IQ and an ADOS (also requires a thorough diagnostic interview with parents for a separate hour plus rating scales) and diagnose ASD. Would more hours be helpful? Absolutely. But if the alternative is waiting for 5 months longer to get the evaluation and then another 4 weeks before the clinician writes up the long eval and gets around to sending it to the pediatrician and then doesn't have time for a phone call...I don't have to be a neuropsychologist to do this but I know very few non-neuropsychologists in my area who are competent in this diagnosis. I could get a developmental eval done for a three year old with a genetic disorder and learn whether they are ID or at-risk for it. Two hours might also work for a tune-up, for someone who had a full eval two years ago but is having social and behavioral struggles. Maybe I check in on some of their skills but I don't do IQ this time (or I just do a two-subtest screener). It's true that you don't have to be a pediatric neuropsychologist to tackle every concern.

The face-to face admin time for those two alone is 2 hours. So, you really mean 4-5 hours by the time you score and integrate and write. Regardless, your presence in the office does not produce the brevity or expediency to which are striving. You (your approach and work ethics and efficiency) are responsible for that. And you can do that no matter where you are located. So again, wheres the benefit?

I really feel like you are gonna run into alot of problems with insurance, preauths, etc. doing what you describe. Interqual is pretty strict regarding its criteria for reassessment of a known condition, for example.

 

[deleted343839]

In two hours of testing I could complete an IQ and an ADOS (also requires a thorough diagnostic interview with parents for a separate hour plus rating scales) and diagnose ASD. Would more hours be helpful? Absolutely. But if the alternative is waiting for 5 months longer to get the evaluation and then another 4 weeks before the clinician writes up the long eval and gets around to sending it to the pediatrician and then doesn't have time for a phone call...I don't have to be a neuropsychologist to do this but I know very few non-neuropsychologists in my area who are competent in this diagnosis.

I missed the part where you needed to be physically in a primary care office to have short wait times and work efficiently. Either your assessment is sufficient to answer the referral question, or it's not.

It's true that you don't have to be a pediatric neuropsychologist to tackle every concern.

Bingo. And if it were your job to decide whom to pay for health services and how much, what would you say about that?

 

[JP West]

These are great points, thanks

 

[PsyDr]

No, if it's a bad idea by all means tell my why but you can leave out all the basic training items that I learned on post-doc about how not to get sued.

Talk crap all you want, but I'm not the one taking my business advice from a dude who is an employee and likely makes the median.

 

[Therapist4Chnge]

All,

I listened to at least three speakers last year at the AACN conference in Chicago who touted the importance of working out new models of delivering neuropsychology services. These included tiered services (which includes doing brief NP evals when that's what's needed) and integrating with primary care. One of the speakers was Mark Barisa who literally wrote the book on the business of neuropsychology. If you have any helpful ideas, please keep them coming. I've seen a few good ones on here that have given me food for thought. I'm confident I can handle a parent concerned about their child's 504 hearing, but thanks.

Mark is great. I definitely recommend his talks and book.

 

[smalltownpsych]

When I used to roll out new treatment strategies or delivery structure to my clinical team. They could spend the rest of our lives picking it apart. I learned that it was a good idea to get some of their feedback in case there was a major pitfall that I hadn't seen, but ultimately we would never really know what works and what doesn't until we begin to implement it. Kind of the same reason we run an experiment. In my mind, the biggest danger would be to get caught up in the recommending medication without adequate credentialing or expertise. I do see several advantages to having in-house neuropsychological assessment and although it is true that for most referral questions, most psychologists could answer, one could argue that a specialist might pick up things that I could miss. I am a so a little confused by the social worker being the gatekeeper. In my mind they would just be another referral source. I would think that the bulk of the referrals would come straight from the pediatricians.

 

[JP West]

When I used to roll out new treatment strategies or delivery structure to my clinical team. They could spend the rest of our lives picking it apart. I learned that it was a good idea to get some of their feedback in case there was a major pitfall that I hadn't seen, but ultimately we would never really know what works and what doesn't until we begin to implement it. Kind of the same reason we run an experiment. In my mind, the biggest danger would be to get caught up in the recommending medication without adequate credentialing or expertise. I do see several advantages to having in-house neuropsychological assessment and although it is true that for most referral questions, most psychologists could answer, one could argue that a specialist might pick up things that I could miss. I am a so a little confused by the social worker being the gatekeeper. In my mind they would just be another referral source. I would think that the bulk of the referrals would come straight from the pediatricians.

Yes, point well taken on having a social worker as the gate keeper. This idea hatched between he and I only last week so it's not something I've thought through extensively. These conversations are definitely helpful. And I agree with your point about NP's picking up stuff others miss. I have been the clinician to pick up on a seizure disorder or a genetic disorder etc. many, many a time when its been missed by primary care, school psychology, and general psychology. I'm sure many NPs have this experience, particularly those practicing outside of medical centers or in areas where specialty care is over-extended.

 

[ClinicalABA]

In two hours of testing I could complete an IQ and an ADOS (also requires a thorough diagnostic interview with parents for a separate hour plus rating scales) and diagnose ASD.

Could work for younger kiddos. For the little guys (younger than 3) you can get through a Bayley (both cog and language) plus an ADOS Toddler Mod or Mod 1 in a few hours. You could even have parents complete some rating scales (e.g. Vineland and SRS) while you're doing the cog/language. As erg points out, however, you'd basically be able to do one of these assessments plus a one hour intake session in an 8 hour day, factoring in report writing. there wouldn't be time for much else. would this be enough benefit to the pediatricians to justify the cost of the space/materials? Could that same space generate more revenue split into two medical exam rooms? Would it be worth it to you to limit your referral sources on that day to one practice? Would be a "dumping" ground for the cases that need more case management/social work?

 

[erg923]

877Could work for younger kiddos. For the little guys (younger than 3) you can get through a Bayley (both cog and language) plus an ADOS Toddler Mod or Mod 1 in a few hours. You could even have parents complete some rating scales (e.g. Vineland and SRS) while you're doing the cog/language. As erg points out, however, you'd basically be able to do one of these assessments plus a one hour intake session in an 8 hour day, factoring in report writing. there wouldn't be time for much else.

The issue for me is that this is just the traditional consultant model of neuropsychology, you just happen to be right next door to them. I don't see the real advantage for them (the pediatrician).

The rationale and advantage of a primary care psychology/mental health service is that you are working with them in an assessment (not necessarily testing) and brief treatment/intervention model where you are triaging stuff out that cannot be handled "in house." You are not gonna treat much of what is being diagnosed here, no? They will be referred out. Wouldn't we rather consultant out to a large (or small) PP that does both the assessment and the treatment?

So lets say you're getting auth for 5 billable hours for one of these assessments (and that may be generous depending on the clinical question/issue and the payer). What does 98118 pay per unit, on average, when we factor-in a mix of payer sources? Is there really enough business from one pediatrician practice to do this 4-5 days a week indefinitely? Who handles appeals and preauths? You? Is the practice going to pay the overhead and cost of testing materials for this? If they don't, the model seems even less financially stable/workable. I don't see how this is feasible unless the person takes on a more tradition treatment role. Which would then beg the question of why they would seek or prefer a neuropsychologist for this role?

 

[ClinicalABA]

The issue for me is that this is just the traditional consultant model of neuropsychology, you just happen to be right next door to them. I don't see the real advantage for them (the pediatrician).

The rationale and advantage of a primary care psychology/mental health service is that you are working with them in an assessment (not necessarily testing) and brief treatment/intervention model where you are triaging stuff out that cannot be handled "in house." You are not gonna treat much of what is being diagnosed here, no? They will be referred out. Wouldn't we rather consultant out to a large (or small) PP that does both the assessment and the treatment?

So lets say you're getting auth for 5 billable hours for one of these assessments and that may be gereous depedninfg on the clinical question/issue and the payer). What does 98118 pay per unit, on average, when we factor a mix of payer sources? Is there really enough business from one pediatrician practice to do this 4-5 days a week indefinitely? Who handles appeals and preauths? You? Is the practice going to pay the overhead and cost of testing materials for this? If they dont, the model seems even less financially stable/workable. I don't see how these is feasible unless the person takes on a more tradition treatment provider role. Which would beg the question of why they would seek or prefer a neuropsychologist for this role?

Yeah- I agree. I can see where there'd be a perception of making it easier/quicker for the patient (in the same way that my personal physician's group is now located in the same building with a lab and X-ray), but psych doesn't quite work the same way. There may be more direct consultation, and it could potentially help with marketing the pediatrician practice. The physicians probably see a lot of "stuff" that they need to refer to psych, and seems intuitive that having one down the hall would make things easier, though it may not really.

Though I can't back it up with any research, I also think that a combined psych PP that does assessment and treatment is a better option, with more informed treatment and assessment being the end result. That's what my practice is and it works very well (though we only do autism).