A woman in her early 70s was recently referred to me for testing by a neurology practice. Their question was does she have a cognitive change referable to cerebral vascular disease. They also needed a baseline prior to a follow-up with a vascular surgeon to reassess the need for a possible carotid endarterectomy or stenting.
Given the circumstances, this referral was considered time sensitive.
The patient was covered under Medicare, which normally allows unfettered access to testing with a physician referral. However, the day preceding the testing appointment it was discovered that this particular Medicare plan required pre-authorization involving completion of a lengthy form reviewing history, symptomatology and a detailed list of proposed tests with time allotments and procedure codes for each test.
The appointment had to be cancelled pending completion of the form and an insurance company review.
There are powerful disincentives for psychologists to offer testing services on more than a limited/part-time basis. These include pre-authorization, low reimbursement and payment delays, the costs of a state-of-the-art armamentarium of testing equipment/supplies and revenue loss from late cancellation and no shows when several hours are put aside for each appointment.
The upshot is that most psychologists do not test. The relatively small group who do often do not take insurance. In many communities there are no providers of this service and waits of at least several months have become commonplace across the country.
This is an especially vexing state of affairs as testing is arguably the most empirically supported mental health intervention to facilitate accurate diagnosis and treatment planning. It has a solid track record for providing a comprehensive assessment of a patient’s neuropsychiatric difficulties and needs.
Unfortunately, our medical colleagues in pediatrics, neurology and psychiatry – the most frequent sources of referral for testing among the medical specialties – have done little to advocate for more reasonable insurance company practices despite extolling the virtues of this service and expressing regret that it is not more available.
The advent of the 2019 testing code revision (a truly impressive achievement) may help to improve this sorry state of affairs. But it could have unintended negative consequences – an increase in claims as well as the amount billed resulting in more restricted criteria for medical necessity and an uptick in mandatory pre-authorization.
Jerrold Pollak, Ph.D., ABPP, ABN, specializes in clinical and neuropsychology. He coordinates the program in medical and forensic neuropsychology at the Seacoast Mental Health Center in Portsmouth, N.H., and is affiliated with Exeter Hospital in Exeter, N.H. His email is: email@example.com.
April 13, 2021
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