Unraveling The Complexities Of Billing Insurance For Master's Psychological Testing

Billing insurance for psychological testing can be a complex process, with variations among insurance panels and their specific requirements. It is important to understand the basics of insurance billing, including CPT codes and units, as well as the differences between psychological and neuropsychological testing. Most insurance plans cover psychological assessments, but prior authorization and meeting deductibles, co-pays, or co-insurance may be required. Medicaid, for example, covers the full cost of evaluation without any out-of-pocket expenses. The prior authorization process helps determine medical necessity, and each insurance company has its own criteria. If approved, the insurance company provides CPT codes and approved units to the psychologist, who can then schedule the evaluation. Patients can contact their insurance company to understand their expected costs.

Understanding CPT codes and units

CPT codes, or Current Procedural Terminology codes, are five-digit codes that psychologists and therapists use to bill insurance providers for specific psychological and neuropsychological tests. These codes are standardized across all healthcare professionals and are essential for accurate billing and reimbursement. CPT codes are updated annually to reflect changes in medical procedures and technology.

When billing for psychological testing, it is crucial to use the correct CPT codes to ensure proper reimbursement. The codes vary depending on the type of test, the administrator of the test (psychologist, neuropsychologist, or technician), and the duration of the test. Here are some common CPT codes for psychological testing:

• 96136 and 96137: Psychological or neuropsychological test administration and scoring by a psychologist or neuropsychologist for the first 30 minutes and each additional 30 minutes, respectively.
• 96138 and 96139: Psychological or neuropsychological test administration and scoring by a technician for the first 30 minutes and each additional 30 minutes, respectively.
• 96146: Automated psychological or neuropsychological testing with a single instrument via an electronic platform.
• 96105-96146: Range of codes for cognitive performance tests, developmental/behavioral testing, and psychological/neuropsychological testing.
• 96130 and 96131: Psychological test evaluation by a physician or qualified healthcare professional for the first hour and each additional hour, respectively.
• 96132 and 96133: Neuropsychological test evaluation by a physician or qualified healthcare professional for the first hour and each additional hour, respectively.

When billing for psychological testing, it is important to verify the patient's insurance coverage, obtain pre-authorization if needed, and create thorough documentation to support the claim. Understanding the correct CPT codes and following best practices will ensure timely and successful reimbursement from insurance companies.

Psychological vs. Neuropsychological testing

Psychological and neuropsychological testing are often used interchangeably, but they are different evaluation approaches. Both types of assessments help individuals understand the underlying causes of their struggles and provide a foundation for treatment and intervention. However, one is more detailed than the other.

Psychological Testing

Psychological testing is used to diagnose and identify psychiatric and developmental disorders, such as anxiety, depression, ADHD, and autism spectrum disorders. A clinical psychologist evaluates an individual's behaviours, medical and mental health history, answers to targeted questions, developmental milestones, and other factors to either diagnose an underlying condition or clarify a diagnosis.

Psychological testing is typically requested by medical doctors, treatment and rehabilitation programs, and educational or governmental institutions. It is an essential part of effective treatment planning. Standard psychological/diagnostic evaluations include clinical interviews, testing of cognitive and personality characteristics, a write-up of test results, and consultations with the therapist and consultants.

Neuropsychological Testing

Neuropsychological testing is a more specialized and detailed form of testing that covers many areas of cognitive and behavioural assessment. It evaluates the effects of genetics, development, and environment on brain functionality. Neuropsychological testing is used when there is evidence of neurological problems, such as ADHD, dyslexia, autism spectrum disorders, brain injuries, or other neurologic conditions.

Neuropsychologists have specific post-doctoral training and expertise in the applied science of brain-behaviour relationships. They use their knowledge to assess and evaluate patients with neurological, medical, neurodevelopmental, psychiatric, and cognitive conditions. Neuropsychological testing provides a comprehensive evaluation that examines the underlying neurocognitive processes and their relation to an individual's behaviours.

Billing Insurance for Psychological and Neuropsychological Testing

When billing insurance for psychological and neuropsychological testing, it is important to use the correct CPT codes (Current Procedural Terminology codes). CPT codes are five-digit codes that psychologists and therapists use to bill insurance providers for specific tests. There are specific codes for test administration, scoring, and evaluation, which vary depending on the type of clinician administering the test.

Prior authorization or pre-authorization from insurance companies is often required for these tests. This process determines if a service is "medically necessary", and each insurance company has its own criteria for this determination. Most insurance plans cover psychological assessments, but many require prior authorization, and some require meeting a deductible, paying a co-pay, and/or paying co-insurance for the evaluation.

It is advisable to contact the insurance company directly to understand the benefits and procedures for submitting claims related to evaluations, including any required authorizations.

Pre-authorisation requirements

Psychological testing often requires pre-authorisation from insurance companies. This typically involves submitting patient documentation and clinical assessments. It is important to understand the specific requirements for each payer, as pre-authorisations can take time and are only valid for a certain period. If the testing is not conducted within this period, the payer may not reimburse the claim.

For example, Blue Cross Blue Shield (BCBS) insurance generally requires prior authorisation for psychological testing services. BCBS will cover some types of psychological tests if they can be medically justified and clinically necessary to diagnose and treat a medical condition or injury. The provider must document why the testing is medically necessary for BCBS to provide coverage.

It is also important to note that the Mental Health Parity and Addiction Equity Act of 2008 prohibits private insurers from discriminating against mental health services. Insurers must cover mental health care to the same degree as physical health care.

To ensure a smooth claim process, verify your patient's insurance coverage and double-check their demographic information and plan ID number before conducting the testing. If there are any coverage issues, address them with the patient before the appointment.

Appealing a denied request

If your insurance company denies your request for coverage of psychological testing, you have the right to appeal the decision. Here are some steps to help you with the process:

Step 1: Understand the Reason for Denial

Know why your claim was denied by carefully reviewing the denial letter from your insurance provider. Common reasons for denial include missing or incomplete information, the service not being covered by your plan, the service being deemed not medically necessary, or reaching the maximum coverage limit.

Step 2: Contact Your Insurance Provider

Call your insurance company to get more details about the denial and explore your appeal options. Each insurance company has its own specific appeals process, so make sure you understand and follow all the required steps. Ask about the necessary forms and the deadline for submitting your appeal.

Step 3: Involve Your Doctor

Discuss the denial with your doctor's office. There may have been an error in the claim form or the use of an incorrect code. Ask your doctor to resubmit the claim with the necessary corrections. Additionally, request a letter from your doctor explaining the medical necessity of the service and gather any supporting documentation, such as health records.

Step 4: Collect the Required Paperwork

Gather all the relevant paperwork, including the claim denial letter, original bills and documents related to the service, notes and dates from phone calls with your insurance company or doctor's office, supporting information from your doctor, and your policy documents.

Step 5: Submit an Internal Appeal

Compose an appeal letter addressing the specific facts, details, and evidence supporting your claim. Maintain a respectful and concise tone in your letter. You can use the sample internal appeal letter provided by the National Association of Insurance Commissioners as a guide.

Step 6: Await the Decision

Your insurance provider is required to respond to your appeal within a certain timeframe. For a service you haven't received, they must decide within 30 days; for a service you've already received, the deadline is 60 days; and for urgent care appeals, they have 72 hours to respond.

Step 7: Proceed with an External Review, if Necessary

If your internal appeal is rejected, you can request an external review by an independent third party. This step involves someone outside your insurance company conducting a full review and providing a final answer. Information about your external review options and contact details should be available in your Explanation of Benefits (EOB).

Getting reimbursed

Verify Insurance Coverage

Before conducting psychological testing, it is crucial to verify the patient's insurance coverage. Establish a workflow that confirms insurance details, including demographic information and plan ID numbers. By doing so, you can identify any coverage issues in advance and work with the patient to resolve them before the appointment.

Obtain Pre-Authorization

Some psychological and neuropsychological tests require pre-authorization or prior authorization from insurance companies. Familiarize yourself with the specific requirements of each payer, as they may include submitting patient documentation and clinical assessments. Keep in mind that pre-authorizations have validity periods, so don't delay the submission process. Conduct the testing within the authorized period to ensure reimbursement.

Create Thorough Documentation

Maintain detailed documentation throughout the assessment, testing, and evaluation process. Providing comprehensive information to the insurance company justifying the testing will increase the likelihood of full reimbursement for your claim.

Understand Payer-Specific Filing Rules

Different payers have different filing rules, so it's essential to know the specific procedures for each. For instance, some payers require evaluation and testing codes to be billed on the same claim, even if they are performed on separate days. Staying compliant with these rules will help avoid claim rejections.

Stay Informed About Payer Changes

Payers frequently make changes to their claim submission rules and requirements. Staying up-to-date with these adjustments will help ensure better reimbursement rates and fewer denials and rejections.

Submit Claims Timely

Payers typically have time limits for submitting claims after a test is completed, known as timely filing requirements. Most payers fall within the 90-, 180-, or 365-day timeframe for claim submissions. Submit your claims within the specified period to avoid potential reimbursement issues.

Provide Appropriate Diagnostic Codes

When seeking reimbursement, ensure that you provide the correct diagnostic codes, service codes, and tax identification information to the insurance company. This includes CPT (Current Procedural Terminology) codes specific to the tests conducted. These codes vary depending on the type of test, the provider conducting the test (psychologist, neuropsychologist, or technician), and whether it involves test administration, scoring, or evaluation.

Understand Reimbursement Scenarios

Reimbursement scenarios can vary. In some cases, the insurance company may apply the amount paid towards the patient's deductible. Alternatively, if the patient has already met their deductible, the insurance company may reimburse a percentage of the cost. It's important to understand the patient's insurance coverage and how reimbursement will be handled.

Frequently asked questions