Psychological Evaluation 101: Health Insurance and Psych Assessments

Thank you for checking out my series on psychological assessments! My goal in writing this series was to help people who don’t have years of graduate training understand what an assessment is and what information they might seek from an evaluation. As of right now, this is my final planned post in this series, though I am in the process of finding a guest blogger to speak on neuropsychological assessments. This is a common referral that I do not have the training to do, and I would prefer to have someone with more expertise speak to it.

Do you have more questions about psych assessments? Contact me, and I will do my best to add it to this series!

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Insurance is meant to shield us from healthcare costs, like an umbrella shields us from rain. Most Americans will tell you this isn’t how it usually shakes out.

If you’re in the United States, you will most likely have to deal with health insurance at some point. Health insurance is confusing and annoying, so I am going to do my best to explain how coverage works for psychological evaluations.

Short answer: it depends.

Long answer: psychological evaluations consist of a number of different billing codes, and depending on your policy, these codes might be covered as a co-pay or toward your deductible. Most providers will call your insurance company to check coverage before doing the evaluation, but it can save a step (and some time) for you to call them yourself. There is a phone number on your insurance card, which will connect you with someone who can check your coverage.

Now, if you call your insurance company and ask, “Does my policy cover a psychological assessment?” they might get confused. Often times, the person taking that call is not trained in what a psych assessment is and can consist of, so I encourage people to call about specific billing codes. The codes that I use most frequently are:

  1. 90791: this is the diagnostic interview or intake, where I get the client’s history and information about their symptoms. Typically this is covered at the same rate as other office visits.
  2. 96136: this is the first 30 minutes of testing in-person, so if your evaluator needs to administer tests to you, this covers that time.
  3. 96137: this is additional in-person testing units, with each unit being 30 minutes. This also covers the time it takes your evaluator to score the tests administered, so if you spend an hour doing in-person testing, it is possible the evaluator will bill three units to include time spent scoring the assessments.
  4. 96130: this is the first hour spent interpreting the results and writing up your report. You will not be present when the evaluator writes your report and interprets your results, but they are still compensated for the time that it takes to put this together.
  5. 96131: this is each additional one-hour unit needed to interpret and write results. Most evaluations take me two to three hours to interpret and write up, though more complicated assessments might take longer.
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When you call the insurance company, you can ask if these codes are covered and whether they require preauthorization. Preauthorization means that the provider (me) has to call and request permission to do the evaluation before moving forward. The purpose of preauthorization is for the provider to demonstrate that testing is “medically necessary,” which is insurance-speak for “you can’t make us pay for that.” (What does “medically necessary” mean? Will you die if you don’t get an evaluation? Will your quality of life improve if you do? It’s vague on purpose. But the problems with health insurance could be a whole other series.) Occasionally when I call to ask about preauthorization, they specifically want to know if I will be testing for a learning disorder, so it’s good to know the answer to that question before you call.

To request preauthorization, I have to complete the intake first in order to document why testing is appropriate, so typically that intake code does not require preauthorization.

Now, insurance companies also make a statement every time you call to ask about coverage: “Confirmation of coverage is not a guarantee of payment.” This, like the term “medically necessary,” basically means that insurance companies can do whatever they want – even if they tell you, “Yes, those billing codes are covered at 100% with your plan,” after testing is complete they can still refuse to pay.

As a human being with empathy, I hate this, but as a provider, I especially hate that I essentially have to then stick you with a bill for the cost of testing. The alternative is that I not only did the work for free, but the testing materials are quite expensive, so my practice loses quite a bit of money. I didn’t go into this field to become a billionaire, but if my employer can’t pay the electric bill, I can’t keep working. Not to mention, I also have needs like food and rent.

So, in addition to asking your insurance provider if these codes are covered, I suggest asking the provider who will be doing the testing for an estimate of what it could end up costing if insurance refuses to pay. (They might not have an exact number because the number of units is based on how long the evaluation takes, and sometimes things do take more time than expected, but they should be able to give you a rough estimate.) You can ask what kind of payment plan might be available if you are stuck with a large bill. At my practice, we are very flexible with payment plans and never charge interest as long as your account is current, so people with high deductibles can still be seen.

I hope this series has been helpful in giving people information about psychological assessments. Being referred for an evaluation can be intimidating, but this knowledge can make it easier to understand what to expect and de-mystify the process.

Published by Dr Marschall

Dr. Amy Marschall received her Psy.D. from the University of Hartford in September 2015. Her clinical interests are varied and include child and adolescent therapy, TF-CBT, rural psychology, telemental health, sexual and domestic violence, psychological assessment, and mental illness prevention. Dr. Marschall presently works in the Child and Adolescent Therapy Clinic at Sioux Falls Psychological Services in Sioux Falls, South Dakota, where she provides individual and family therapy and psychological assessment to children, adolescents, and college students. She also facilitates an art therapy group for adolescents and college students with anxiety and depression. Dr. Amy Marschall is certified in Trauma-Focused Cognitive Behavioral Therapy and Telemental Health.

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