Reimbursement for neuropsychological testing still poses a problem

Neuropsychological testing has been used in a number of clinical areas to evaluate brain functioning and cognition. The Journal of Athletic Training cites neuropsychological testing as a proven method for assessing symptoms related to concussion.

Applied Neuropsychology: Adult credits neuropsychological testing for its effectiveness in diagnosing Alzheimer’s disease. But more commonly, this evaluation tool is used to examine the overall cognitive, physical, behavioral and executive functioning abilities, among others, in children.

In his practice, Greg Javornisky, Ph.D., pediatric neuropsychologist at the Connecticut Pediatric Neuropsychology Associates in Glastonbury, administers general intellect and achievement skills testing to pediatric patients from a developmental perspective.

“We look at things the schools do and go beyond reading and IQ,” he said. “We look at more extensive processing abilities and provide recommendations for learning. We also assess growth in cognitive skills and prescribe appropriate treatment for anxiety and mood disorders.”

His main focus is on executive proficiencies, such as organization, planning, inhibition and flexibility; attention; learning and memory; language; visual spatial skills; motor coordination; behavioral and emotional functioning; and social skills.

Javornisky added that he rarely considers neuropsychological testing for patients as young as two years old. “They are cognitively not far enough along to assess. It’s more of a developmental assessment for two to five year olds. They are more comprehensive after that age. We wait until age six,” he said, adding that, in the past, adult-specific tests were adapted for use in children.

“Now there is more direction toward testing children, which is much more appropriate.”

The field of neuropsychology is somewhat of a “gray area” when it comes to certification, according to Javornisky. When he began practicing in 1981, no structure, credentialing criteria or postdoctoral opportunities existed. He said, “It was just a matter of doing it. Now there are more expectations.”

Joseph Moldover, Psy.D., a developmental neuropsychologist in private practice in Wellesley, Mass., had a different experience. He completed a graduate program with a strong emphasis on neuropsychology and did a postdoctoral fellowship in an area that concentrated on testing and evaluations. “You can become board certified, but it’s not necessary,” he said.

Although certification is not required in Connecticut and Massachusetts, clinical neuropsychologist Kira Armstrong, Ph.D., ABPP-CN, private practitioner in Woburn, Mass., lobbies for two years of supervised postdoctoral training, at minimum.

“Having done this in a hospital setting, I was exposed to a wide range of conditions,” she said. “In an outpatient setting, you wouldn’t recognize a neurological condition unless you’ve already seen one.”

In recent years, the field of neuropsychological testing has trended toward technology, according to Moldover.

“Ten years ago, all tests were hands-on, using pen and paper. Now many tests have migrated to touch screens. A computer program scores, interprets and analyzes the test,” he said.

“Tests have also become increasingly discerning in terms of identifying functioning in fine grained ways. Now they capture more subtle aspects of a child’s functioning, which leads to more specifics around interventions.”

While the field is seeing new trends, some old practices remain the same. Reimbursement for neuropsychological testing continues to be a contentious issue.

“In Connecticut you aren’t likely to be reimbursed for a psychological evaluation of a child. It’s an educational concern the insurance companies say. They deny or give you a hard time about compensating,” said Javornisky, who noted that evaluating a child with a medical issue, such as seizure disorder or in follow up to chemotherapy may result in reimbursement.

“Generally though the amount of reimbursement doesn’t reach the amount we charge.”

Javornisky’s practice does not take insurance for this reason. He noted that half of his referrals come from the schools, which do tend to reimburse and half from families or self-referrals.

“Some families attempt to get reimbursed from insurance on their own,” he noted.

When Javornisky worked in a hospital setting, reimbursement was not an issue. “The insurance company is willing to pay for evaluations done in hospitals. The hospitals negotiate the rates with the insurance companies,” he said.

Moldover pointed out that the work neuropsychologists do falls within the realm of educational assessment. While schools will cover the costs of testing, their reimbursement falls short of the normal practitioner rate.

“When parents consider their child has special needs, the school is obliged to evaluate the child. If that’s not satisfactory to the parents, the school has to fund an independent evaluation. But state regulations regarding rates are very antiquated. There have been efforts to put forth a bill to adjust the rates to be more aligned with the current market. Frankly, it used to be that health insurance companies covered more, but it’s unlikely we’ll go back to that.”

When he first went into practice, Moldover was part of an insurance network, but does much less business with insurance now. “What we’ve seen is that insurance companies have become increasingly specific about defining what to pay for. They don’t pay for academic testing or consultation, ADHD diagnoses or learning disabilities,” he said.

“In the big picture, the trend in healthcare is away from covering monitoring diagnostic services.”

Armstrong said that the reimbursement issue is a barrier that “contributes to the multi-tiered system we have.” She said, “People with insurance or MassHealth can get assessments if they go through a hospital. They might have an eight to 12 month wait list in those settings though. And if you want to see a licensed psychologist, not a trainee, the wait could be longer.”

Regardless of trends and reimbursement issues, Armstrong pointed out that being a neuropsychologist involves much more than just conducting assessments and evaluations.

“It’s not the test that makes me a neuropsychologist. It’s how I interpret the tests and through what lens I do that,” she said. “It’s important for the clinician to understand that psychology influences performance. A patient’s personality comes into play.”

She cited one patient who was so anxious on the first day of testing that she seemed to present with a profound language disorder; in reality, her slow motion speech was the result of extreme anxiety. “I recognized that the first day scores tell you something interesting and meaningful.”