What You Need to Know about Evaluations and Insurance
By Dr. Grettel Martinez
As a psychologist in an insurance-based practice, I deal with insurance companies daily. If you are one of many people with health insurance, you would likely want to use it. Insurance is a benefit that you have, whether paid for by your company or paid by you.
When it comes to insurance companies paying for services, you need to be well-informed before you decide to have a procedure done. Otherwise, it can be very costly. Some services are considered not-medically necessary, which means you will have to pay out of your pocket. The insurance company will not cover the procedure, regardless of how much you need to have this service done.
Psychological evaluations can be in this out-of-pocket category. Educational testing will always be in this out-of-pocket category. As I explain in another blog post, educational testing is part of a comprehensive assessment (called psychoeducational evaluation) to diagnose and treat learning disabilities.
Just as not all services are covered by your insurance, not all diagnoses are covered. Many mental health diagnoses are not covered because the insurance company does not deem services for these diagnoses medically necessary. For example, often therapy for attention-deficit/hyperactivity disorder (ADHD) and autism are not covered (and cases of ADHD and autism do need treatment!). Evaluations for autism and ADHD are not always covered, either.
When a patient calls our office for treatment, part of the initial procedure is a check of available benefits. There have been times in which an insurance representative has informed us that certain types of services are covered, and they turn out not to be. Unfortunately, there is no way of knowing until after the first claim is sent to the insurance company. It can take days for the insurance claim to be paid. The Explanation of Benefits (EOB), a statement from your insurance company that explains the services received, will detail the services paid and unpaid. If the services are unpaid (not covered), the EOB will give the reason why.
Every insurance policy is different; some are more comprehensive than others in what they offer and cover. One diagnosis that is never covered is learning disability (LD), such as dyslexia (reading disability). This is treated as a non-medically necessary diagnosis. In my years of professional experience, I have learned that insurance companies believe that it is the school board’s responsibility to diagnose and treat LDs.
If you are seeking a psychoeducational assessment, do not rely on your insurance company to pay for this service because they will not. This is an out-of-pocket expense that can be costly, yet extremely important. It helps to keep track of these expenses, as they are tax-deductible. Also, think of it as a long-term investment. If your child is struggling academically, and you and your child are physically and emotionally exhausted because everything you have tried hasn’t worked, then please consider making this investment. Your child will thank you years from now.
Our trained professionals at Healthy Minds Psychology can carefully tailor these comprehensive evaluations based on the presenting problems. Like a puzzle, the only way to find out the missing piece is by obtaining a psychoeducational evaluation. Please read more about our services under Specialty Services-Psychoeducational Evaluations.