Can my insurance company do this? This doesn't seem fair!

[bisous]

So, more wrinkles in my quest to get neuropsych testing for my DS1. Its a long story but the basic idea is that I checked with member services for Kaiser who informed me that "psychological testing" costs $20 "per visit". However, the department of behavioral services informs me that neuropsych evaluation is only available for patients with suspected autism. That seems odd to me! It IS covered but only for certain patients? How is that allowed? I asked and there is no fine print anywhere so this just doesn't seem like it should be allowed. Is it acceptable for a service that you provide to have hidden exclusions (ie we will cover SOME neuropsych testing but not for YOU)?

Also, the psychiatrist I talked to told me that neuropsych testing is not what I really want--that neuropsych testing is only for someone who has some kind of brain injury which is totally not what my research has been telling me. Am I way off here??

Thank you,

[Snow mom]

I'm not 100% on your question but I think it's pretty common to require a referral for specialized services. If you don't fall into the category of needing that service according to your PCP or insurance then your insurance won't cover it. Typically there is a pre-approval process so you know whether the service will be covered for you or not before you show up. Wiser BBB mamas might have advice on advocating for a referral/pre approval of the service you feel you need.

[egoldber]

The short answer is this is not uncommon. In very few cases is a full evaluation actually covered. Often only parts of it are, if any is covered at all. They get away with this because the testing if typically for mental health or for education information, which is not a medical issue. It's also why speech therapy is often not covered for children with a language delay. Technically that is not a health issue or a medical diagnosis, it's a developmental delay.


Also, the psychiatrist I talked to told me that neuropsych testing is not what I really want--that neuropsych testing is only for someone who has some kind of brain injury which is totally not what my research has been telling me. Am I way off here??

I think that what you actually want for your DS is probably more accurately called "psychoeducational testing". People often say "neuropsych testing" when they really mean psychoeducational testing. It's confusing, because many times the tests actually performed will overlap. But the psychiatrist is right in that technically neuropsychological testing more properly refers to testing for medical/organic issues of the brain and how it functions. This can be secondary to a trauma or a stroke. The testing for autism will often include more medical pieces.

Psychoeducational testing is a broad term and can include many different types of tests depending on what the specific concerns are.

[ahisma]

A pre-auth for a specialist visit is not uncommon. A referral is standard practice. My insurance doesn't actually require a referral or a pre-auth, but the specialists in my area won't see you if you don't have a PCP referral.

When you say that you spoke to the department of behavioral services - do you mean at Kaiser? If so, I think what you've run into is a protocol. If they deny your pre-service request (which I think it what you're explaining here), you can request a copy of that denial in writing and can request a copy of the protocols that the decision is based on. That should give you a better understanding. The denial is appealable.

[BunnyBee]

There's been a big lobbying push from autism advocates to get states to require insurance coverage by law for testing and services for children with autism. California is one of those states. I doubt Kaiser would cover it for children with autism if not legally required. Autism is recognized as more than an educational issue, hence its special status for coverage. You need testing for educational issues that are not required by law to be covered by medical insurance.

I suspect there's a terminology hang up between how the Kaiser psychiatrist defines neuropsych testing and how you define it.

[ett]

I suspect there's a terminology hang up between how the Kaiser psychiatrist defines neuropsych testing and how you define it.

:yeahthat: I would ask what medical code the neurospsych testing would be billed under and then give the code to the insurance company to determine whether it's covered or not.

[ckso]

I don't think it's uncommon for insurance to have specific exclusions or requirement. For example my ins says they'll cover for acupuncture but only for nausea if your pregnant. And the local hospital is on the list of contracted hospitals but will not cover births.


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