The Current State Of Psych Testing

[anotherconstruc]

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I am interested to hear from anyone who has been in the field for a while or who is being trained/supervised by those who have. What are your experiences with reimbursement, volume and levels of prea-uthorization associated with psychological testing. I've been doing testing for 23 years and have much I can and do say about the topic but would like to hear the experience or anecdotes of others. Please state what region you practice in.

 

[Rivi]

I am definitely curious about this.

 

[erg923]

I am in academia and only see patients (and supervise students) one day per week in a university CC for assessments and therapy, but one only has to be a member of the national neuropsych list-serve to know that reimbursement rates are lower now than they were in 1985 (adjusting for inflation of course), insurance companies deny claims and/or refuse to pay constantly, medicare pays like 25 cents on the dollar for testing, coding/billing and fighting denials or claims seems to be nightmare that requires so much knowledge and time I would have ZERO desire to do it myself (I'm sure it adds up to hours per week in work that you obviously cant bill anybody for). I prefer my not so ivory tower. 🙂

 

[erg923]

I also think that the demand is certainly there (as it always has been) but that there is little to protect it as "ours." I also happen to think that (based on what I saw in grad school and what I see now out in the community) the modal clinical psychologist is just not very good at it...or at least the report writing part.

Lastly, I believe part of the reason for the boom in forensic neuropsych (at least the amount of practitioners doing it) is due to the slow dwindling in payment for clinical neuropsych services. I suspect that this is due to the fact that insurance companies really don't see much cost benefit from the modal npsych evaluation.

 

[Therapist4Chnge]

I can't speak to trad. psych assessment, but I have seen neuropsych evals be in high demand in a range of different locales....but most of the $ is made outside of taking insurance and/or doing a larger % of forensic work. Being able to negotiate favorable rates is absolutely needed because many insurance companies are going to try and screw the provider if given half a chance: "Not medically necessary", "X is above the allowable units being reimbursed" (even with pre-approval), "We do not reimburse for [fill in random billing code]", etc.

 

[Rivi]

Do you guys with more experience have any advice to newer practitioners regarding the way things are going?

 

[anotherconstruc]

Other than a few years as a clinical director of a CMHA, I have always made my living doing testing. When I started practice fresh out of graduate school I was making an average of 150% more than I make now per assessment. Back then, there was no pre-authorization process. An agency, hospital or provider sent the referral and you did it. What is deemed "not medically necessary" often depends on the insurance company's finances. I've had employees of such companies confide this to me. For example, the largest Medicaid BHO in my state denied many requests last year for excessive units of testing. The reviewer stated they wanted disorder-specific measures. This year I've been told I'm the only one left in a major city they can refer to for in-depth testing and they routinely approve full batteries. After overhead, it only comes out to around $200.00

Private insurance pays little more than Medicaid or Medicare, sometimes even less. I know of one psychologist who charges $2,000.00 to $3,000.00 for an evaluation out of pocket but colleagues laugh when I mention him. He is far from the norm. I find many people want testing for their children but few are able or willing to pay cash. More will pay for psychoeducational testing as insurance never pays for this.

 

[Therapist4Chnge]

Private insurance pays little more than Medicaid or Medicare, sometimes even less. I know of one psychologist who charges $2,000.00 to $3,000.00 for an evaluation out of pocket but colleagues laugh when I mention him. He is far from the norm. I find many people want testing for their children but few are able or willing to pay cash. More will pay for psychoeducational testing as insurance never pays for this.

"What do you mean my insurance won't cover it?"
"It is medical insurance, and this assessment is for school."
"Can't you just say it is for....[fill in blank]?"
"They will reject it, and then you will have to pay the full fee."
"The co-pay, right?"
"No. The full fee, typically [fill in blank]."
"Why can't I use my insurance to pay you?"
...and so on.

 

[anotherconstruc]

"What do you mean my insurance won't cover it?"
"It is medical insurance, and this assessment is for school."
"Can't you just say it is for....[fill in blank]?"
"They will reject it, and then you will have to pay the full fee."
"The co-pay, right?"
"No. The full fee, typically [fill in blank]."
"Why can't I use my insurance to pay you?"
...and so on.

...and at least three out of four who are referred for a clinical dx expect you to tell them if there is a learning disability....

On a related note, the number of referrals that include a r/o of ASD has exploded. Psychologists who work for managed care companies as UR reviewers and try to adhere to best practices moan about how everyone is now making the diagnosis using only rating scales. Some will approve an ADOS-2, BASC-2, etc for very small reimbursement but forget testing for speech and cognitive aspects.

 

[AcronymAllergy]

I'm probably going to open a can of worms here, but I wonder how much of this might have to do with non-psychiatrist physicians, and perhaps even other mental health workers, assigning these diagnoses to patients with little to no testing (and minimal evidence beyond a few self-reported symptoms) to back them up. ADHD is the first thing that springs to mind for me in this respect, but I could see it applying to just about any psych diagnosis.

Mind you, I'm not saying psych testing is necessary for most/all diagnoses, but at the least, in-depth clinical interviews should be the norm. Unfortunately, psychology has done a horrible job to this point of both advocating the value of what we do, and protecting it from encroachment from other disciplines. We really need to start pushing for the types of studies that show how we can add value via accurate diagnosis, effective treatment, etc., and we need to be unashamed to make legislators and insurance companies see and understand this information.

 

[Pragma]

I'm probably going to open a can of worms here, but I wonder how much of this might have to do with non-psychiatrist physicians, and perhaps even other mental health workers, assigning these diagnoses to patients with little to no testing (and minimal evidence beyond a few self-reported symptoms) to back them up. ADHD is the first thing that springs to mind for me in this respect, but I could see it applying to just about any psych diagnosis.

Mind you, I'm not saying psych testing is necessary for most/all diagnoses, but at the least, in-depth clinical interviews should be the norm. Unfortunately, psychology has done a horrible job to this point of both advocating the value of what we do, and protecting it from encroachment from other disciplines. We really need to start pushing for the types of studies that show how we can add value via accurate diagnosis, effective treatment, etc., and we need to be unashamed to make legislators and insurance companies see and understand this information.

AA I agree with your concerns here. The way many diagnoses occur these days lacks much specificity. But I am not exactly sure that a 90801 solves the problem either. I am skeptical of psychologists too...often they rely on the same rating scales and symptom counts (and really, many psychologists out there don't spend 90 minutes on an interview). I think the wide variability in training quality contributes to the situation, and makes it harder to argue our worth.

 

[AcronymAllergy]

AA I agree with your concerns here. The way many diagnoses occur these days lacks much specificity. But I am not exactly sure that a 90801 solves the problem either. I am skeptical of psychologists too...often they rely on the same rating scales and symptom counts (and really, many psychologists out there don't spend 90 minutes on an interview). I think the wide variability in training quality contributes to the situation, and makes it harder to argue our worth.

👍 Agreed

Which is why, in the end, it's of primary importance to establish some semblance of nationwide uniformity in admissions and training standards, licensing, boarding, etc. APA's current criteria are just too vague and minimal to meet these demands.

At the same time, that shouldn't stop us from increasing and improving our advocacy efforts, which have notoriously been fairly lackluster up to this point. We also need to get away from our apparent aversion to establishing stronger "standards of care" with respect to assessment, diagnosis, and treatment.

 

[paramour]

I'm probably going to open a can of worms here, but I wonder how much of this might have to do with non-psychiatrist physicians, and perhaps even other mental health workers, assigning these diagnoses to patients with little to no testing (and minimal evidence beyond a few self-reported symptoms) to back them up. ADHD is the first thing that springs to mind for me in this respect, but I could see it applying to just about any psych diagnosis.

Mind you, I'm not saying psych testing is necessary for most/all diagnoses, but at the least, in-depth clinical interviews should be the norm. Unfortunately, psychology has done a horrible job to this point of both advocating the value of what we do, and protecting it from encroachment from other disciplines. We really need to start pushing for the types of studies that show how we can add value via accurate diagnosis, effective treatment, etc., and we need to be unashamed to make legislators and insurance companies see and understand this information.

...and at least three out of four who are referred for a clinical dx expect you to tell them if there is a learning disability....

On a related note, the number of referrals that include a r/o of ASD has exploded. Psychologists who work for managed care companies as UR reviewers and try to adhere to best practices moan about how everyone is now making the diagnosis using only rating scales. Some will approve an ADOS-2, BASC-2, etc for very small reimbursement but forget testing for speech and cognitive aspects.

Agreed here. Most of my caseload (even though I was quite adamant when I started that I wanted minimal contact with these cases) are referrals and consults with therapists who are determined that every single one of their child/adolescent clients have autism/aspergers, "so can you do some testing to determine if they have a cognitive disability or a pervasive developmental disorder?"

Upon further probing, I've determined that most of them haven't the slightest what these diagnoses even mean. Per one therapist, "Testing is only required for insurance purposes" and "if you just do what we ask and confirm what we already know is correct, then we can really help this poor kid who needs it." These "poor kids" already have some fairly chronic mental illnesses that have absolutely nothing to do with autism spectrum disorders. Apparently we're going to disregard those for whatever reason. There's got to be something else going on to boot. The kids are (usually) enjoyable at least.

 

[futureapppsy2]

...and at least three out of four who are referred for a clinical dx expect you to tell them if there is a learning disability....

On a related note, the number of referrals that include a r/o of ASD has exploded. Psychologists who work for managed care companies as UR reviewers and try to adhere to best practices moan about how everyone is now making the diagnosis using only rating scales. Some will approve an ADOS-2, BASC-2, etc for very small reimbursement but forget testing for speech and cognitive aspects.

ADOS isn't a rating scale... 😕

 

[anotherconstruc]

ADOS isn't a rating scale... 😕

Rating scales were discussed in the sentence before. My point was that some reviewers will approve an ADOS-2 because they are uncomfortable with restricting the tester to rating scales. Sorry for the confusion.

 

[futureapppsy2]

Rating scales were discussed in the sentence before. My point was that some reviewers will approve an ADOS-2 because they are uncomfortable with restricting the tester to rating scales. Sorry for the confusion.

Ah. The BASC-2 is a rating scale, though, so that threw me.

 

[anotherconstruc]

Ah. The BASC-2 is a rating scale, though, so that threw me.

Drug reps give med providers rating scales all day long. There's no telling how much "psych testing" these days consists of Conners, Gilliam, etc. I am not aware of med providers giving a BASC-2 yet. Let's not call this test a rating scale!! We can make the argument that it should be considered akin to an MMPI-2 or PAI because it contains validity scales and requires more understanding of psychometrics.

A good battery for ASD used by the Kennedy Center at Vanderbilt consists of a BASC-2, ADOS-2,Social Communication Scale, SIB-R, and Social Responsiveness Scale. You can also get approval from some companies to give an IQ test. Keep in mind, however, that with Medicaid and most other insurances you'll be doing all this, including a 90801, for around $400.00 If you own your own practice you have to pay 25 to 30% to overhead. If you contract you'll keep 60 to 70% of this. Over the years, it has been my experience that businesses that offer a higher % tend to be the ones who are unreliable in paying.

 

[cara susanna]

Isn't testing for educational purposes provided by the schools, though? Or is that not free, either?

 

[anotherconstruc]

Isn't testing for educational purposes provided by the schools, though? Or is that not free, either?

It is. A lot of parents complain that they can't get the schools to test then there are the increasing number of kids in private schools or home schooled.

 

[MBellows]

This isn't exactly in line with the rest of the postings here, but I figured that this would match up better than creating a new thread...

Our office still uses the MBTI, all of the research based classes that I've had specifically mention that the MBTI is hooie. Any thoughts?

 

[psychRA]

Isn't testing for educational purposes provided by the schools, though? Or is that not free, either?

In my experience with child and adolescent assessment, some school systems are really motivated to avoid assessing kids unless they absolutely have to (super pushy parents, really egregious behavior, etc.) because they don't want to have to pay for accommodations based on those test results. Districts are strapped for cash, so I get why they're looking to cut expenses, but it's very unfortunate.

As a result, parents who can't afford independent testing have a hard time getting services for their kids. And the parents who can afford private testing end up shelling out what seems (to them) like a lot of money - $1200-2000 in my area. I think that some parents get the idea that, because they're paying out of pocket, they're entitled to a diagnosis, so there's pressure on psychologists in that sense. In fact, I dealt with at least one parent who explicitly stated that she was paying our clinic to qualify her kid for services. Luckily, her child actually did meet criteria by about a mile, but I can only imagine that situations like that can get pretty annoying for people who do assessments.

 

[AcronymAllergy]

In my experience with child and adolescent assessment, some school systems are really motivated to avoid assessing kids unless they absolutely have to (super pushy parents, really egregious behavior, etc.) because they don't want to have to pay for accommodations based on those test results. Districts are strapped for cash, so I get why they're looking to cut expenses, but it's very unfortunate.

As a result, parents who can't afford independent testing have a hard time getting services for their kids. And the parents who can afford private testing end up shelling out what seems (to them) like a lot of money - $1200-2000 in my area. I think that some parents get the idea that, because they're paying out of pocket, they're entitled to a diagnosis, so there's pressure on psychologists in that sense. In fact, I dealt with at least one parent who explicitly stated that she was paying our clinic to qualify her kid for services. Luckily, her child actually did meet criteria by about a mile, but I can only imagine that situations like that can get pretty annoying for people who do assessments.

We ran into that at our university clinic as well, even with the college students (yes, some of them had their parents contact us and/or bring them in). And this with a significantly discounted price for evaluations. Often times, the "no diagnosis" feedback sessions were the most difficult/contentious.