From Family Voices: Blue Cross and Neuropsychologists

This might be of interest to some of you.

From: massfamilyvoices@yahoogroups.com On Behalf Of Claudia B Rutherford PhD
Sent: Monday, February 09, 2009 11:48 AM
Subject: [MassFV] Fwd: Blue Cross Blue Shield issue

I don't know if any of you with BCBS insurance are aware of this yet,  but starting in May, BCBS is making some major changes to their policy for authorizing neuropsychological testing. Right now if you have BCBS HMO insurance, you can ask your pediatrician for a referral for testing for your child, and they can get one automatically by computer. It covers 16 hours total which is usually enough or more than enough to cover the testing, report writing, and so on. If you have a BCBS PPO plan, you don't have to go through the pediatrician at all and there is no cap on hours.

 As of May for the HMO plans and July for the PPO plans, BCBS is going to change their policy so that if you need neuropsychological testing, you will have to have the pediatrician and/or psychologist fill out a request form and get permission from BCBS to proceed. They are reducing the total number of hours allowed for children to 8-12 hours total. They will be using a set of criteria to decide whether or not to approve the testing that are proprietary, called InterQual. These criteria are not publicly available and are rumored to be very  restrictive. They are also saying that they will only authorize  testing for ADHD if they feel there is a good case for difficulty making the diagnosis, and they won't authorize testing primarily for educational or vocational purposes (like to help clarify a learning disability).

They are also saying that if you have an HMO plan, you cannot go to a BCBS PPO provider anymore to get testing, only an HMO provider. This is a problem because in many parts of the state, individual providers have not been able to get on BCBS's HMO panels, only the PPO. In the past if a psychologist was a PPO provider, they were allowed by BCBS to see HMO clients, but this will be changing. This means that in some parts of the state if you have a BCBS HMO plan and you want your child to have neuropsych testing, you will only be able to take them to a clinic or group practice to get it done, not an individual in private practice. In some parts of the state not only does this restrict who you can go see, but it will increase your waiting time to get your child tested.

BCBS has not been very responsive to concerns on the part of psychologists regarding these proposed changes. It may be that the only way to make a difference is to speak out as BCBS customers. If anyone is interested in finding out more, please feel free to contact me. If people don't make noise about this it will go through and there will be a deterioration in care for many children in the state. This also sets a bad precedent for other insurers in the state to follow.

Claudia Rutherford