Did any of you have a "pre-eval" appointment for insurance purposes

[kirstenhill]

Just wondering if anyone else had to do this and maybe what to expect. Our actual neuropsych eval appointments are scheduled for early next month, but our insurance requires a pre-eval evaluation, essentially, to determine if DS meets the "medical policy criteria" for covering the evaluation. That's later today. They told me it would last an hour and that DS needed to be present but gave no other hint as to what they will do to determine if he meets the coverage criteria for insurance.

 

it will be a real bummer if they don't prove he meets the criteria, because we went with a place that takes our insurance but is at the more expensive end of the spectrum of local cost options. If we could have known six months ago whether or not they would cover, i might have made different decisions on where to go. But they needed this appointment only 30 days out from the main appointments. Then if they say "no coverage" we have the difficult decision if we pay out of pocket for the $$$ eval, or we go with the less expensive place that didn't take our insurance and wait again. I'm just going to try and think positive today and hope it is in the best interest of the place we are having the eval done to look for reasons he would meet the criteria for coverage rather than the other way around.

[Lecka]

Yes, but they didn't term it that way.

 

I had to have a referral turned in from the PCM, we went to an appointment where she determined that she would submit the referral for him. 

 

The place we went also required a referral from the PCM, my impression is just so they wouldn't waste their time with kids who were not pre-screened as needing to go to their specialty clinic (it was an autism clinic thing). 

 

I think -- share information with your doctor.  If the doctor says "no" ---- ask what information/paperwork you can provide to get the referral or qualification. 

 

Good luck!  I bet it will go smoothly :)   I think it may just be a piece of paper they want you to have, and it is just something to make it a little harder to get an appointment, so some people don't take the trouble, who would if it were a simpler process.  I feel like that sometimes. 

 

Edit:  I needed the referral before scheduling the appointment (or anything) and I went in with an attitude like "this doctor is going to give me this referral!!!!!!"  And then, she was really nice about it and just started filling out the paperwork. 

 

She needed to ask me some questions as she filled it out, but she took my at my word for everything. 

 

 

Edited January 6, 2016 by Lecka

[kirstenhill]

Our insurance plan is set up not to require referrals for anything, so I wonder if for more expensive things like this, they take this extra step to make sure it isn't a complete waste of their money.

 

I think there must be something other than just paperwork involved, or they wouldn't need me to bring DS, right? The same person primarily doing the eval is doing this appointment too, so I am guessing they must do some kind of prelimary testing/evaluating with DS too. They were very clear that the insurance required DS to be present for the certification evaluation.

[Lecka]

Well, this is just me, but it sounds like they don't require referrals in general, but then sometimes, they still require referrals. 

 

My son had to be there, too, but the questions were really all for me (in our case -- but my son was an older 3 at the time).  I think the questions I answered on his behalf were very basic, but also the kinds of questions (very, very general) that an older child could have answered, and not be any big deal.

 

In our case -- it was pretty far from what I would call "preliminary testing/evaluating." 

 

She just decided we qualified for the referral.

 

I was really nervous before, too, b/c I really wanted the referral and thought it was needed, but I was worried she would, I guess, argue me out of it or something.  But that was not how it went -- she was more like, "so, you are seeking this referral?" And I said "yes."  And then she talked to me for a couple of minutes, and then said "let's start filling out the referral" and opened the program on her computer. 

 

That is how it went for us. 

 

I have had other referrals, and this was a different kind of one.... he had referrals for ENT and for speech therapy prior to this, and this one was the most involved requirement.... but even at that -- it was like a bureaucratic hurdle more than anything else. 

 

They were very, very clear my son had to be there, too.  For speech therapy, I could take school paperwork (from pre-school speech through the school district) and not have to take my son, and a nurse could do the referral form (like -- with me speaking to her at the front desk) and then the doctor just signing the paper. 

 

For this, it was "your son has to be present, you have to see the doctor" -- it was nothing that I could take care of at the reception desk. 

 

But still -- it did turn out to be pretty easy, the doctor was very nice and easily filled out the forms. 

 

But yeah, it seemed like a big deal to me, too, and I worried I would not get the referral. 

 

Edit:  In retrospect, I think it may have been pretty obvious to the doctor that he was showing signs of autism at this appointment.  But it was not obvious to me!  So I don't know how much that had to do with it.  She may have been looking for things that she didn't mention to me. 

Edited January 6, 2016 by Lecka

[PeterPan]

This is for an ADHD or ASD eval?  We had a place (not our insurance, but a practice) that handle appointments like that.  They were observing the dc while talking with the parents.  I think the most calming thing is to just rest assured that you know it's happening (whatever it is) and that they'll probably see it.  And if they *don't* see it, come prepared to talk about the range of behaviors they might not be seeing.  But hopefully they'll see it.

 

I had this 1 1/2 hour talk with someone where I thought ds was being really good, sitting there playing quietly while I played, and at the end the person (a social skills worker) says to me "You know he's going to get an Aspergers label eventually, right?"  And I'm like NO, I just paid tons of money to be told (the idiotic assertion) that it's ADHD-inattentive!  So even behavior that we're used to will have indicators for people who are used to seeing this a lot.  

 

Well I hope it goes well.  Trust that it will, because I think it will!  :)

[Paige]

Sort of. We had to be denied treatment by a normal (cheaper) psychologist who told the insurance that a neuropsych was better suited to evaluate. Our insurance doesn't typically cover neuropsychologists so they referred us to a child psychologist for a full eval. I was expecting that to be it (and disappointed b/c I wanted a neuropsych) and it was sort of weird. When we showed up for the eval, expecting it to take hours, the psych spoke with me first for about 30min and then said she didn't want to bother meeting DD, that she wasn't qualified to evaluate her, and referred us out. With that, the insurance agreed to send her to the Dr I wanted in the first place. 

[kirstenhill]

This is for an ADHD or ASD eval? We had a place (not our insurance, but a practice) that handle appointments like that. They were observing the dc while talking with the parents. I think the most calming thing is to just rest assured that you know it's happening (whatever it is) and that they'll probably see it. And if they *don't* see it, come prepared to talk about the range of behaviors they might not be seeing. But hopefully they'll see it.

 

I had this 1 1/2 hour talk with someone where I thought ds was being really good, sitting there playing quietly while I played, and at the end the person (a social skills worker) says to me "You know he's going to get an Aspergers label eventually, right?" And I'm like NO, I just paid tons of money to be told (the idiotic assertion) that it's ADHD-inattentive! So even behavior that we're used to will have indicators for people who are used to seeing this a lot.

 

Well I hope it goes well. Trust that it will, because I think it will! :)

It's primarily ADHD, but the funny thing is at least from how I read the insurance criteria, they don't cover neuropsych for ADHD Only. The place doing the eval knows this (We have an insurance co. that is very common here, and the person I talked to on the phone said they were very familiar with handling these requirements). So I am definitely have in mind to share my other concerns - Sensory, behavior, some social issues, lack of flexibility in non-preferred activities, etc. Some of those things could be ADHD, but ??? I am not really seeing ASD based on what I know about ASD...but that is part of what the eval is for I guess...like you said, they may see something I don't.

[nature girl]

The place we went also required a referral from the PCM, my impression is just so they wouldn't waste their time with kids who were not pre-screened as needing to go to their specialty clinic (it was an autism clinic thing). 

 

 

She needed to ask me some questions as she filled it out, but she took my at my word for everything. 

 

This was the impression we got from our pre-appointment as well, I don't think it was pre-approval, it was just a matter of course that the neuro would see DD first. The appointment lasted about a half hour, she had us fill out paperwork while she talked to Anna, watched her play with Duplos, asked her to write her name, to catch a ball, stand on one foot (which she couldn't do) and hop (which she also couldn't do.) At the end she told us she was 99% sure just from observing Anna that she was ADHD, she hadn't even looked at our questionnaires yet. (She also mentioned her motor planning issues, which were pretty obvious.)

 

To capture things I knew she wouldn't be able to see at a short appointment, I wrote a 3-page essay about what we'd seen. It turned out not to really be necessary, but if you suspect there are other things going on (and want to make sure they're tested for and included in the referral) that would probably also be worth doing.

[PinkyandtheBrains.]

We had:

Referral from PCP

Pre evaluation appointment (received surveys and forms about my child to fill out)

Evaluation appointment

Post evaluation consultation to discuss results and what to do next.

Edited January 6, 2016 by PinkyandtheBrains.

[Tiramisu]

We are still waiting for authorization for our recent testing. We did not have pre-eval meeting,  but the np spoke with me on the phone prior to the testing. She actually did not want too much info at first because she wanted to meet dd without any bias in her mind. She did tell me in that phone conversation that because dd had a history of concussion that might be a basis for getting insurance authorization for the testing. She told me that the primary care doctor had to be the one to request testing, and warned me that if ADHD was put as a reason for testing, it would be rejected.

 

Insurance is more likely to cover the testing if there's a medical reason, but not a specific learning issue. 

 

When we got np testing for my eldest, we had a pre-eval meeting. Insurance did not pay, but that was because the provider failed to apply for an authorization, even though we had a lot of documented email exchanges about how she was going to get the authorization. Even though that dd had a lot of medical stuff going on, our appeal for coverage post-eval was turned down.

Edited January 6, 2016 by Tiramisu

[PeterPan]

It's primarily ADHD, but the funny thing is at least from how I read the insurance criteria, they don't cover neuropsych for ADHD Only. The place doing the eval knows this (We have an insurance co. that is very common here, and the person I talked to on the phone said they were very familiar with handling these requirements). So I am definitely have in mind to share my other concerns - Sensory, behavior, some social issues, lack of flexibility in non-preferred activities, etc. Some of those things could be ADHD, but ??? I am not really seeing ASD based on what I know about ASD...but that is part of what the eval is for I guess...like you said, they may see something I don't.

Yes, I think that's pretty common, that if it's *only* ADHD, with no other questions about motor planning, learning disabilities, whatever, you don't have to go neuropsych.  That said, my dd (only ADHD) had her testing with a neuropsych and we learned a lot through the extra testing.  So I guess see what they cover.  And yes, if you have sensory issues, cognitive rigidity, behavioral challenges, meltdowns, etc., TALK about it!!!  Honestly, go through the DSM criteria and make a list of everything he does that fits the criteria.  Make VIDEO of him doing those things!!!  They CANNOT see everything in their office, so you need to TELL them about what's going on.  Don't be timid about it.  

 

I was reserved with our first psych for ds, thinking well he's the expert, I don't want to lead him.  Well the (I have no nice words here) told me the behavioral problems were MY fault (I kid you not!) and labeled him ADHD-inattentive, which was utterly laughable.  He has now had his ASD diagnosis reconfirmed and is at ASD level 2.  So don't mince words.  Take video, say what's going on.  ADHD is a diagnosis of exclusion, so they'll exclude every other cause and slap ADHD as an oh well, give you a label kind of thing.  IF it's ASD, you actually need to know.  

 

You probably know this, but TYPE UP everything you're seeing.  Write it all out and hand it to the guy.  I handed the next psych my paper, and the guy is like WHY did this not get diagnosed, this is classic aspergers?!?!  And I'm like I don't know, I couldn't understand some of the forms he gave us (which I couldn't), and he said everything was my fault.  

 

I'm sort of cynical about psychs at this point.  They're not omniscient.  TELL them everything, type it all out.  You're not going to be able to "make" someone get a diagnosis who isn't diagnosable, mercy.  All you'll do is save it taking multiple trips and psychs and years to get it figured out.  So yes, they can go ADHD with cognitive rigidity, yes.  A psych doesn't diagnose SPD.  It's not in the DSM, not their gig, totally an OT thing.  And really, the list for SPD *is* an ASD list.  Look at the OT questionares for SPD and see it.  To me, it's a construct of the public school to avoid giving ASD diagnoses.  But I'm cynical.

Edited January 6, 2016 by OhElizabeth

[kirstenhill]

Thanks for all the encouragement, everyone.  :-)

 

I'm really happy with how the appointment went.  I spent about an hour talking with the woman who will be doing the evaluation next month.  DS just sat in an adjacent room and played legos the whole time..she even said that the only reason he was there is that my insurance requires the child come to this initial appointment (all other pre-eval appointments with different insurance are parent only).  She just asked questions and I could download on her with all the stuff that DS does.  I really liked her and she seemed very supportive of homeschooling and supportive of us getting this testing done as a step toward getting answers and getting help for DS...so, I'm really happy about all of that.

 

She said that while she thought the eval will be helpful in understanding DS better,  it will take some good presentation on her part to get the insurance to cover it.  She said most other insurance co's would be fine, but mine in particular is hard to get things through in our situation.  She is going to emphasize his lack of flexibility and the social issues we've seen and hope that helps in getting it approved.  She said that more testing that usual has been getting approved lately from this insurance co, so, we will pray and hope for the best!