49 Transcript

Dr. Jeremy Sharp Transcripts Leave a Comment

[00:00:00] Hey, good morning, y’all. This is Dr. Jeremy Sharp, and this is The Testing Psychologist Podcast episode 49. Today, I’ll be talking with you all about medical necessity and how to increase the likelihood that you will get pre-authorization for those testing hours. Let’s do it.

Hey y’all, this is Dr. Jeremy Sharp. Welcome back to another episode of The Testing Psychologist Podcast. It’s great to be back doing some episodes. I had a run there where I recorded quite a few interviews and released them slowly over time. So it’s been a while since I was here in front of the microphone. It feels good to be back.

Today is a solo episode. I’m going to be talking with you all about medical necessity, pre-authorization, and how [00:01:00] to get those hours approved for testing.

Now, I should say here at the very beginning that none of these guidelines are meant to be set in stone. Nothing that I tell you is meant to be a guarantee that you’re going to get prior authorization or be approved for all of the hours that you’re asking for, particularly those of you like myself who tend to do pretty thorough evaluations. So just know that, but the things that I’m going to talk with you about are taken from my years of experience, research, and some trial and error in figuring out what works for getting pre-authorizations approved and getting the most hours that you possibly can for testing.

If you take insurance, this is definitely an episode you want to listen to. If you do not take insurance, then this might be one to skip, but if you have any plans of taking insurance or just want to know how this works in the insurance world, stick [00:02:00] around.

Let’s dive into it here.

First off, when we’re talking about this topic, it’s helpful to know a little bit of background about medical necessity, why this is even a thing in psychological testing, and why we have to request pre-auth.

The short story is that insurance companies across the board want to keep their costs as low as possible. Part of doing that is not authorizing or paying for services that are not “medically necessary.” This goes across the board for other healthcare professions and other fields as well: cardiology,

physical therapy, family practice, or anything where you’re doing a procedure or asking to do a procedure that falls outside routine care.

The basic deal is that insurance companies don’t want to pay for these services that [00:03:00] aren’t going to contribute significantly and specifically to a patient’s care. That’s where medical necessity guidelines come into play in general and why we have to ask for pre-authorization for some plans to do psychological testing.

Whereas some insurance plans consider psychological testing or neuropsychological testing to be part of that routine care and they don’t require pre-auth, I find that, for me, it’s about half and half in terms of the panels that we’re credentialed with. So the likelihood is that you’re going to run into a pre-auth request sooner or later in your practice and many insurance companies require it.

In our world, medical necessity means that the testing is going to contribute in a very specific way to the client’s care above and beyond what is already available in the mental health world. For us, that means[00:04:00] anything that could be accomplished through counseling, through a typical diagnostic interview, or through, in some cases, psychiatric care. Generally, we have to document that testing is going to add something above and beyond what is already available for the client in their mental health coverage.

Let me give some guidelines. These are coming from a document that I found from the Tufts Health Plan. It’s a health plan over on the East Coast but the document is one of the better ones that I have found that walks you through the coverage criteria for psychological testing, what medically necessary means, and the limitations for psychological testing. I think this will drive a lot of the discussion today. I will link to this in the show notes. Like [00:05:00] I said, this is not meant to be representative of all insurance plans by any means, but it is pretty comprehensive and runs through a lot of the scenarios when we might have to ask for pre-auth for psychological testing.

In terms of their guidelines, when they think about medical necessity, there are a few things that have to be met to demonstrate medical necessity and we have to provide the documentation to demonstrate medical necessity in the prior authorization or pre-authorization form. These criteria are all going to map onto information that you have to provide in the pre-auth form for your specific insurance company. Those forms can often be found by going to your insurance panel’s website and you can search within the site for psychological testing prior authorization, or neuropsychological testing prior authorization. You should be able to find that pretty easily.

[00:06:00] Getting to the criteria. Here are some things that we need to keep in mind when we’re considering medical necessity.

One of those is that the patient has already undergone some type of mental health evaluation. That could have happened through their physician. It could have happened through a psychiatrist. It could be another therapist. It could have even been the diagnostic interview that you did with them as part of your evaluation. Basically, the patient should have gone through a prior interview or a diagnostic interview rather, and at the end of that diagnostic process, there should still be some questions that exist that cannot be answered through that diagnostic interview or history-taking process.

So that’s one piece is that you have these remaining questions even after you’ve done a diagnostic interview with the client. In many cases, this would [00:07:00] rule out the need for testing for anxiety, depression, and many mental health diagnoses particularly emotional or personality concerns. So there’s that piece that you should still have questions even after a pretty thorough diagnostic interview.

The second part of that that’s somewhat related is that the patient, hopefully, has gone through some amount of evidence-based treatment, therapy, counseling, or whatever it may be, medication if that’s an evidence-based treatment for what you’re testing for. So the patient should have gone through the evidence-based treatment and still has symptoms that are significantly impacting their life.

Basically, you need to be able to say that the patient has participated in evidence-based treatment and yet symptoms remain or they’re getting worse or you’re [00:08:00] seeing other symptoms that are not being addressed by that particular treatment. You need to be able to document those things.

Now, if you can document both of those pieces, and I should say, when you are documenting those things, you don’t have to be… the attempt at treatment does not have to be incredibly specific. The person does not have to have had 20 sessions of CBT exposure and response prevention, or a thorough course of treatment. As long as you can document that they have met with some other professional, even just their physician, and that a question remains outside or beyond that diagnostic interview with that medical or mental health professional, then that will go a long way toward demonstrating medical necessity.

Once you’ve documented those things, then we get into [00:09:00] asking for the assessments that you’re trying to do. 

Again, medical necessity is demonstrated when the tests or assessments that you have identified are “targeted to the identified referral question.” Okay? And then the second part of that is that once you answer that referral question, it’s going to lead to very specific recommendations and identifiable steps or changes in the treatment plan that will modify what’s currently being done for the better.

So, there’s a lot involved here. These two criteria map onto a big part of the prior authorization forms that we fill out. Two pieces. One piece is that you, first of all, have to have an identified referral question. I have found that [00:10:00] insurance companies like when you’re very specific. So instead of saying, the referral question is, does this client have any cognitive concerns that might be impacting functioning? That’s vague. That’s pretty vague in general. And it’s not mapped to a specific diagnosis by any means.

I have found that insurance companies respond a lot better when you list referral questions like, does this client have autism? Does this client have ADHD? Does this client have cognitive impairment secondary to birth trauma? And then put the birth trauma in parentheses, a hypoxic event, or whatever it may be. So getting as specific as possible with your referral questions and mapping those onto specific diagnoses I think will be very helpful.

Once you identify that referral question, then you have to identify the tests that go along with it. [00:11:00] Here’s another place where I think people get tripped up and get rejected. For better or for worse, we have to be realistic about the standard of administration and report writing time.

The insurance company is not going to reimburse for excessive time to administer, score, and write a test. Now, you might write a really thorough, amazing interpretation with these very specific recommendations and that is fantastic. I would say that our practice leans in that direction as well. But if you’re doing that and you’re billing insurance, there is a responsibility to try to do that in as efficient a way as possible.

For example, if you are going to administer WISC core subtests, you cannot ask for four hours to do that. The industry standard [00:12:00] is going to be closer to two hours if that. They would ballpark an hour to an hour and a half to administer and score, and then maybe a half hour to put those scores into the table and your report. So that is something to keep in mind. Just make your request very realistic in terms of the actual time for each specific test that you request. Most of these pre-auth forms will require that you spell out the test that you’re going to administer and how much time you request. So that’s one piece.

The other piece of that is that you are only requesting tests that map onto your referral questions. Again, I know there’s a lot of discussion around comprehensive evals and doing evals to rule things out versus more limited evals to just answer one specific referral question. In this case, it is going to help you to [00:13:00] tailor your prior authorization request to fit the specific referral question. Insurance companies are not fond of reimbursing for many tests to do exploratory testing to rule out other things that might be comorbid.

For example, if you identify your referral question as, does this client have ADHD, then it would not make any sense to list on your test request form an ADOS or an SRS questionnaire, for example. That’s probably going to get rejected. Now, if you list, does this client have autism as an additional referral question, then that would completely make sense.

But again, these insurance companies are very specific about what they are going to approve. They employ licensed psychologists to review these requests and those psychologists know what they’re looking for and know the standard [00:14:00] time for each test and which tests are going to be appropriate for which referral questions.

So if you want to do a comprehensive battery, make sure that you list all of those specific referral questions in your pre-auth request. If you list all those referral questions, you also need to make sure to list all of the specific symptoms that are leading you to devise that referral question. So, that’s another piece.

The second element of that is that when you answer those referral questions, that’s going to somehow lead to specific recommendations or some direct impact on the treatment. So you also need to be able to demonstrate this.

For example, a lot of the pre-auth forms will ask what will be the outcome or value of psychological testing. That’s where you need to be able to say, psychological testing will be used to guide treatment choice. And in that sense, you can put in parentheses [00:15:00] cognitive behavioral therapy versus group therapy versus social skills training versus any number of other options that might be considered. You can also say that it might be used to guide medication choice, and you can specify that the testing information will be used to guide, certainly, if you have a medical question, head injury, serious illness, or something like that, you can put that in there as well, that it will guide where to seek medical treatment or course of treatment for those medical concerns.

Again, you want to map those referral questions directly to the tests you administer, and then map those testing results directly to treatment recommendations, treatment of choice, and how that might change what’s already been happening with the client.

So that covers a lot of the [00:16:00] pre-auth form and what you’re going to have to be required to list on the pre-auth form. While you’re going through this process, there are a few things to keep in mind. Cases where it’s almost impossible to get testing approved. The biggest one that we know about is probably learning disorders. No insurance company that I know of is going to reimburse testing for learning disorders as a primary diagnosis.

Now, in our billing podcast with Jeremy Zugg, he detailed that you can administer academic measures in the context of a different primary diagnosis. So if you administer some academic measures that you can in good faith, say, are contributing to your assessment of ADHD, for example, then that’s a different story, but no [00:17:00] insurance company is going to reimburse for educational testing as the primary diagnosis. Other exclusions under there include vocational testing, legal or forensic testing, substance use evaluations, adoption evaluations, and things like that.

Many insurance plans will also exclude testing for what they call uncomplicated ADHD. When I say uncomplicated ADHD, that means, if there are no suspected comorbidities, if the data is pretty straightforward from questionnaires that may have been administered by the physician.

So if you are requesting psychological testing for ADHD, to be on the safe side, I would suggest that you make sure that you have some documentation that it is complicated ADHD by which I mean there is a suspected cognitive issue going on, there is a suspected emotional disorder going on, there is [00:18:00] a suspected autism spectrum disorder also comorbid. So again, making sure that as much as you can get the symptoms and the documentation to suggest that this is above and beyond what can just be determined by a typical interview.

Other exclusions are if you’re administering any tests that don’t require a licensed psychologist to administer or interpret the tests, testing that is requested only to guide medication or dosage of medication. I think there is a difference between choosing a type of medication. That is legitimate. But if you’re only doing testing to figure out how much medication should be administered or what the dose should be, that doesn’t typically count.

Let’s see. If there’s been a recent evaluation say within the [00:19:00] last six months to a year, and there has not been any significant change in the person’s functioning, then a lot of insurance companies are going to say, why are you doing testing again? We’ve already had this full evaluation.

Let’s see. The other situations are when, we touched on this, but if the amount of time requested includes way too much time for the presenting concern.

The other piece is when, this is a big one that comes up, is when testing is considered experimental or investigational for the diagnosis. So this circles back to that need to have a specific referral question so that you’re not just “seeing what’s out there”. That for an insurance company is a big red flag to say that we’re probably not going to approve this because, in theory, you could do as much testing as you [00:20:00] wanted to explore all these different diagnoses. So as best you can, try to nail it down and identify a very specific referral question that you are trying to answer or several referral questions. That’s totally fine.

That is my rundown of medical necessity. Quick and dirty. I know there’s a lot more to it, nuances that we could get into, but this has been a really popular question in the Facebook group and I wanted to put something together to try and elucidate this process a little bit.

Quick rundown again when you’re trying to seek prior authorization for testing:

One, you want to make sure that you can document in some form or fashion that this individual has already participated in a diagnostic interview or even better for our purposes that they have participated in treatment that has thus far been unhelpful or ineffective. You want to be able to demonstrate that [00:21:00] symptoms remain despite treatment and you want to be able to demonstrate that the symptoms present are more complex than can be sussed out via a clinical interview. All you have to do for that is to say this person has participated in such and such treatment or interview and symptoms remain confusing or unresolved.

The other piece is that when you want to request the tests, you have to make sure that the tests you request match your referral question. So you have to have a very specific referral question. Typically, in my experience, it’s been diagnosis-based that is the most likely to get reimbursed. So does this client have ADHD? Does this client have autism? And then you want to request both the tests and the number of hours for those tests that are reasonable to answer those referral questions. Don’t exaggerate or inflate.

The third part of that is that you want to then document how [00:22:00] answering those referral questions will guide treatment. So talk about how the testing results will help choose a treatment approach or a medication or a medical intervention or something like that.

Otherwise, we talked about exclusions. I will let you go back and read for yourself all of those exclusions but just know that educational testing as a primary diagnosis is not typically covered and any other situation that you would call exploratory where you don’t have a specific referral question is unlikely to be covered

As we sign off, I should say that a lot of this has happened through trial and error for me. I have found that there are some insurance companies who require pre-auth for psych testing, so 96101, but not for 96118, which is neuropsychological testing. I have found that some are the opposite. I have found that [00:23:00] some require pre-authorization if you exceed a certain number of hours, but they will grant you a certain number of hours without prior authorization. I found that some insurance companies will only reimburse eight hours in a day, but if you stay under that limit, you can bill up to 16 or 20 hours for an evaluation. So some of this may take some trial and error on your part to figure out what the insurance companies dictate that you are actually in network with.

Above and beyond all of this, there’s the discussion about the balance billing statement, and that can help quite a bit. If you get permission from your insurance companies that you can balance bill, then you can take that and go back to the client and explain that balance billing process and what that means, and why you do that and get their signature on a balance billing consent form, then that can help circumvent some of these [00:24:00] problems with only getting a few hours of testing approved.

We’ve done some other podcasts about balance billing forms and it’s been discussed at length in the Facebook group. But if you have questions about that, reach out to me directly, I’m happy to talk with you. You can also search in the Facebook group for balance billing and prior authorization or pre-authorization. There’s a lot of good info in there.

Thanks as always for listening. I hope that everybody is doing well. We are headed into the springtime here in Colorado, which is awesome. I’ve talked about being a summer-spring person on the podcast before. I grew up in the South. It’s really hard to sit through winter in Colorado. This is about the time of the year when I start to get pretty antsy and thankfully we’re having a nice run of 50 to 60 even 70-degree days here lately and it is [00:25:00] just gorgeous. We’re starting to get a little rain. The grass is starting to turn green, which is fantastic.

I hope that y’all are all doing well and maybe enjoying some of that spring weather as well, and I hope you will stay tuned to the podcast.

As always, if you have not subscribed or rated the podcast, I would love it if you did either of those. Subscribing is fantastic. Rating is like a thousand bonus karma points. So if you haven’t done those, I would appreciate it. And if you have not joined us in the Facebook group, we’d love to have you there as well. That’s The Testing Psychologist Community. We just keep growing. I think we’re up to about 800 members now and we just talk testing. So jump in there. If you have an interest, we’d love to have you.

In the meantime, take care. I will see you next week. Bye bye.[00:26:00]

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