How to calculate potential cost of neuro-psych or ed-psych evaluation and whether it's worth changing insurance

[Transplant_1]

Hello all, I currently have health insurance but it covers only in network care (BCBS Federal Employee Program Basic). But it appears most providers providing neuropsych and edpsych testing are out of network.

I'm considering getting insurance that provides some coverage for out of network care (BCBS FEP Standard), but it has a higher premium, and a deductible. For 2024, Standard would be more by about $3,560 more than Basic (deductible plus the difference in premium. There are a few other differences, but I think the rest are very minor. This is all public info on the OPM website.) I'm trying to calculate whether it's worth the trade off.

Under Standard plan, I will pay 35% of the Plan allowance (and whatever amount the provider charges above the allowance) and BCBS will pay 65%. I' have to "use up" a large enough Plan allowance so that 65% of it would at least equal $3,560, to be worth the trade off. So, I'd have to use up at least $5,500 worth of medical care Plan allowance out-of-network to be worth the gtrade off the $3,560 in increased premium and deductible.

So, I called the insurance company and asked "what is the plan allowance for neuropsych or edpsych testing" but they said it all depends on the code, but they won't tell me what the code is.

I google a bit to see if I could figure out the code, but there appears to be several, for different types of activities. This is one source I found (https://www.apaservices.org/practice/reimbursement/health-codes/testing/neuropsychological-testing.pdf).

Also, how much to providers out of network tend to charge above the plan allowance?

I would be utterly indebted to anyone that could help me think this through.

Thank you.

[Anonymous]

These are the codes I was given by cnmc as possible codes to run by my insurer:

Description of CPT codes most commonly used:
96116 and 96121: Neurobehavioral Status Examination (1st hour/ each additional hour)
90791 Psychological Diagnostic Interview (each encounter)
96130 and 96131: Psychological evaluation services, incl. record review, interpretation and report writing time (1st hour/ ea. add’l hr)
96132 and 96133: Neuropsychological evaluation services, incl. record review, interpretation and report writing time (1st hour/ ea. add’l hr)
96136 and 96137: Psychological or Neuropsychological test administration and scoring (2 or more tests) by psychologist (1st 30min/ ea. add’l 30 min)
96138 and 96139: Test administration and scoring (2 or more tests) by technician (1st 30 min/ ea. add’l 30 min)
90846 Feedback on results and treatment recommendations (family psychotherapy) without patient present (50 min).
90847 Feedback on results and treatment recommendations (family psychotherapy) with patient present (50 min).
96154 Feedback on results and recommendations to the family with patient (ea. 15 min)
96155 Feedback on results and recommendations to the family without the patient (ea. 15 min)
Academic Achievement Testing: assessment of reading, writing, and/or math skills; academic test administration, scoring, interpretation and reporting with school recommendations (based on time and number of measures required).
Social-Emotional Learning Education Plan: Detailed recommendations for school plan to support social and emotional learning based on the neuropsychological/ psychological evaluation findings (based on time required).
School Meeting attendance and/ or IEP development, for educational purposes (per hour).

[Anonymous]

I don’t know the answer to this (sorry), but just wanted to say that I think that if you’re at a public school, the neuropsych can be paid by the school 100% if you request an IEE.

[Anonymous]

If your child is in a public school, request an IEE from your district and have them pay for it.

[Anonymous]

It's not a given that a school district will pay for an IEE

[Anonymous]

One thing to consider is that a neuropsych (if you pay out of pocket) is $3500-$4000.

I'd also check to see if there might be exceptions through your current insurance for out of network providers where there are no reasonable in-network options available. I think we managed to get a neuropsych eval from Children's National approved for coverage that way because we were able to show that there were no other in-network options within a 50 mile radius.

[Transplant_1]

Thank you all for your thoughtful replies. My sense is that there are in network providers available, but that the wait lists are very long. I think Children's National is in-network. Thank you all again.

[Anonymous]

FEP will not pay for the educational part of the assessment. They will also only cover 8 hours of services. That is enough for an ADHD evaluation and some providers will separate out the ADHD from the rest of the Psycho-educational evaluation so that you can get reimbursement for that.

[Anonymous]

dredwinoliver.com is $3000 and has helped with families obtaing placement at LSW, Jemicy and other schools.

[Transplant_1]

OP here. Thank you all very much. I wind up calling a practice to start exploring, and they helped me think things through. I wish I'd know I could've just called. They told me the codes, and "how" to ask what questions to my insurance company.

1) What percentage do they cover out-of-network for the following procedure codes? (The practice also told me on average the number of "units" they would use for each code.)

90791
96130 / 96131
96136 / 96137
96138 / 96139

2) What is their "usual and customary" rate for the above procedure codes?

3) Do they have any limits on the number of units that can be charged?

4) How much of the out-of-network deductible has been met?

This was all very helpful to me.

I suggest if you are facing the same issue, get a good recommendation on a practice. And call and ask how much and what kind of questions you should ask your insurance to help you plan and figure out how much it will cost you.

My best to all, and good luck. It's not easy.

[Anonymous]

Anonymous wrote:It's not a given that a school district will pay for an IEE

And even if they do, it's for a psycho-ed, not a full neuropsych.