Medicare and Indigence Policy

Medicare Payments for Neuropsychological Evaluations

Medicare, Part B,  covers neuropsychological evaluations when they are deemed medically necessary according to the guidelines set forth by First Coast Service Options, the Medicare Administrative Contractor for Florida. These evaluations must be ordered by a physician to diagnose and treat specific medical conditions such as dementia or traumatic brain injury. The evaluation must include a comprehensive assessment, with clearly documented medical necessity, and follow Medicare's specific criteria to qualify for coverage.

Coverage Details

Medicare Part B typically covers 80% of the approved amount for neuropsychological evaluations once the deductible has been met. This means that Medicare beneficiaries are responsible for the remaining 20% as a copayment.

Supplemental (Medigap) Insurance

Many individuals opt for supplemental (Medigap) insurance to help cover the costs not paid by Medicare. Medigap policies can help pay for the 20% copayment, as well as any deductibles and additional charges not covered by Medicare Part B. The extent of the coverage provided by Medigap insurance varies depending on your specific plan.

Summary of Coverage

• Medicare Part B: Covers 80% of the approved amount for neuropsychological evaluations after the deductible is met.
• Medigap Insurance: Can help cover the remaining 20% copayment, deductibles, and other costs not covered by Medicare Part B, depending on the specific plan.

 If Medicare Part B rejects the claim for any reason, you will be responsible for the cost of the evaluation at standard rates. 

However, we are committed to working with you to provide the necessary documentation for medical necessity and can offer a hardship rate if applicable.

Importance of Understanding Your Coverage

It's important to review your Medicare and supplemental insurance policies to understand what is covered and to ensure that you are prepared for any out-of-pocket expenses. Consulting with your healthcare provider and insurance representative can help clarify your coverage and financial responsibilities for neuropsychological evaluations.

Advantage Plans (Medicare Part C) Not Accepted

Our clinic does not accept Medicare Advantage Plans (Medicare Part C). Here are the primary reasons why we do not accept these plans and why they may not be the most desirable option for neuropsychological evaluations:

1. Limited Provider Networks: Medicare Advantage Plans often have restricted provider networks, meaning you may not have access to the specialists you need. Our clinic prioritizes providing the best care without the limitations imposed by narrow networks.

2. Pre-Authorization Requirements: These plans frequently require pre-authorization for services, which can delay necessary evaluations and treatments. We believe in timely access to care without administrative hurdles.

3. Variable Coverage: Coverage under Medicare Advantage Plans can vary significantly from one plan to another. This variability can lead to unexpected out-of-pocket costs for services that might otherwise be covered under Original Medicare.

4. Higher Out-of-Pocket Costs: While Medicare Advantage Plans may have lower premiums, they often come with higher out-of-pocket costs for specialist visits and procedures. This can be particularly burdensome for patients requiring comprehensive neuropsychological evaluations.

5. Billing Difficulties: Dealing with billing and payments from Medicare Advantage Plans is often complex and time-consuming. These plans typically involve more paperwork and administrative work, and there are frequent delays in payment. Despite the extra effort, there are instances where we do not receive payment at all, making it unsustainable for our clinic to accept these plans.

Why Choose Original Medicare with Medigap?

We do not provide insurance advise, as this is outside the scope of our expertise and practice.  However, this is our personal  opinion of why patients  consider using Original Medicare (Part B) with a Medigap (supplemental) plan for the following reasons:

• Broader Access: Original Medicare allows you to see any provider that accepts Medicare, giving you more flexibility in choosing your healthcare providers.
• Predictable Costs: Medigap plans help cover the out-of-pocket costs that Medicare Part B does not cover, such as copayments, coinsurance, and deductibles, making healthcare costs more predictable.
• No Pre-Authorizations Needed: With Original Medicare and Medigap, there are no pre-authorization requirements, ensuring that you receive the care you need when you need it.

 How Medigap Plans Can Help

Again, this is not to be taken as insurance advise, this is our personal opinion, based on observation of payment trends fro neuropsychological evaluations: 

Medigap plans, also known as supplemental insurance, can significantly reduce your out-of-pocket expenses by covering costs that Medicare Part B does not. Typically, Medicare Part B covers 80% of the cost of medically necessary services, while Medigap plans can cover the remaining 20%. This combination ensures you have minimal unexpected expenses and access to comprehensive care.

If you provide Medicare Part B information but are actually enrolled in a Medicare Advantage (Part C) plan, you will be responsible for the cost of the evaluation at standard rates. 

Choosing the right Medicare plan is crucial for your healthcare needs. We encourage patients to carefully consider their options and consult with a healthcare advisor to determine the best plan for their situation.

 We do not accept commercial insurance plans, including but not limited to:

•  Aetna
•  Blue Cross Blue Shield
•  Cigna
•  Humana
•  UnitedHealthcare
• Auto Insurance

Reasons for Not Accepting Commercial Insurances:

Coverage Issues: 

1. Many commercial insurance plans do not adequately cover neuropsychological assessments, leaving patients with significant out-of-pocket costs.
2. Billing Challenges: Commercial insurances often involve complex and time-consuming billing processes, leading to delays in payment and added administrative work.
3. Payment Issues: There are frequent instances where commercial insurances either underpay or do not pay for services rendered, making it financially unsustainable for our clinic to accept these plans.

By limiting our accepted insurance plans to Medicare Part B and select Medigap insurances, we can focus on providing high-quality care without the added challenges and uncertainties of dealing with commercial insurance providers. This ensures that our patients receive timely, comprehensive, and consistent care.

Commercial Insurance Assistance Policy

For patients with commercial insurance, we will assist by providing a fee ticket/superbill for the date of service, including proper CPT codes. Please note that we will not be able to provide further assistance such as creating CMS-1500/HCFA forms or filling out insurance claim forms, including pre-verifications or other forms required by your insurance provider. Payment for services is required upfront, and any additional paperwork or claim submissions must be managed directly by the patient or their representative.

Self-Pay Policy

1. Payment Required: Full payment for services is required at the time of service; a 50% deposit is required to book the appointment. We do not offer payment plans.
2. No Rescheduling or Refunds: As outlined in our refund policy, cancellations within 48 hours or no-shows are non-refundable. We do not reschedule appointments; a new pre-payment will be required to book another appointment.
3. Receipt and Documentation: We will provide a detailed receipt for all payments. It is the patient's responsibility to submit this receipt to their insurance company for any potential reimbursement.
4. Financial Hardship Consideration: If you are facing financial hardship, please discuss this with us before scheduling your appointment. We can offer a hardship rate in certain situations, but this must be arranged prior to the evaluation.
5. Insurance Reimbursements: If you are self-paying with the intention of seeking reimbursement from your insurance, you must manage all interactions with your insurer, including submitting claims and following up on reimbursements.
6. Documentation for Tax Purposes: We provide documentation and receipts for services rendered, which can be used for tax purposes or insurance reimbursement claims.

Neuropsychological evaluations are considered medically necessary when they provide critical information about the diagnosis, prognosis, and treatment of disorders affecting the central nervous system (CNS). These evaluations are essential when specific cognitive impairments are suspected or identified and cannot be adequately addressed through standard medical or behavioral health evaluations. To be covered by insurance, including CMS guidelines, the evaluation must meet specific medical necessity criteria. 

However, neuropsychological testing is typically not deemed medically necessary and is not covered when conducted primarily for educational purposes (e.g., learning disabilities, ADHD), vocational purposes (e.g., Fitness For Duty Evaluations), legal purposes (e.g., personal injury cases), or when it simply repeats previous testing without a significant change in functioning. 

Non-medically necessary evaluations are charged at the standard rate and do not qualify for fee reductions based on medical hardship (see the Clinical Hardship Discount Section).

Clinical Hardship Discounted Rate at Mind and Brain Care, LLC

At Mind and Brain Care, LLC, we understand that navigating the costs of healthcare can be challenging. To ensure that everyone has access to essential neuropsychological services, we offer a clinical hardship discounted rate for individuals who qualify. This program is designed to help patients who need medically necessary neuropsychological assessments but may face financial difficulties.

Eligibility Criteria:

1. Medically Necessary Evaluation: The neuropsychological assessment must be deemed medically necessary. This means the evaluation is essential for diagnosing and treating a medical condition. A referral from a physician is required to validate the necessity of the assessment.

2. Exclusion of Legal Questions: The purpose of the evaluation should not be to answer a legal question, even if a medical question is also addressed. Evaluations aimed at legal determinations, such as assessing capacity for estate planning or litigation purposes, follow a different, more rigorous process. These evaluations require longer interviews, additional collateral information, and must adhere to specific legal guidelines, which are beyond the scope of the clinical hardship program.

Differences Between Medical and Legal Evaluations:

Medical Evaluations: Focus on diagnosing and understanding cognitive and psychological conditions. These assessments are typically shorter and involve standard clinical procedures to identify and manage medical issues.

Legal Evaluations: Designed to answer specific legal questions, such as capacity to make decisions, testamentary capacity,  competency in legal matters, any damage due to accidents, etc. These assessments require more extensive interviews, collateral interviews with family members,  comprehensive medical records review,  and/or attorney medicated reviews of legal guidelines. They also often involve additional documentation and follow a stringent protocol to ensure medico-legal standards are met.

Qualification Criteria for Clinical Hardship Discounted Rate:

To qualify for the clinical hardship waiver, patients must meet the following conditions:

No Litigation Involvement: The patient must not be involved (or be considering involvement) in any ongoing litigation or legal disputes.

• No Disability Claims: The patient must not be applying for or considering disability claims.
• No Capacity Questions: The evaluation should not involve assessing capacity for contracts, living arrangements, financial decisions, testamentary capacity/estate questions, or other legal decisions.
• No Auto Accident Injuries: The patient must not have been injured in an auto accident, as these cases often lead to attorney involvement, litigation, court appearances, or require additional work.

How to Apply:

If you believe you qualify for our clinical hardship discounted rate, please contact us to discuss your situation. Our team will guide you through the application process and help determine your eligibility. 

Ensuring that you have the necessary documentation and physician referral will expedite the qualification process.

Contact Us:

To learn more about the clinical hardship discounted rate and to see if you qualify, please call us at  239-768-6500. We are here to support you in accessing the care you need and improving your cognitive health and well-being.

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By providing this program, Mind and Brain Care, LLC reaffirms our commitment to making high-quality neuropsychological services accessible to all individuals, regardless of financial constraints. If you or a loved one needs a medically necessary neuropsychological evaluation, we encourage you to reach out and explore the options available to you.

At Mind and Brain Care, LLC, we are committed to providing high-quality neuropsychological assessments for injured employees under worker’s compensation claims. Our goal is to offer comprehensive care while ensuring a smooth and efficient process for both the claimant and the insurance adjuster. Here’s how we handle worker’s compensation cases:

Pre-Payment Policy:

To streamline the billing process and ensure timely services, we require pre-payment at standard rates before scheduling appointments. This policy helps us manage our resources effectively and ensures that we can provide prompt care without delays. We accept payment in advance and request that you provide proof of pre-payment, such as a copy of the check, to confirm the transaction.

Invoice and Documentation:

Upon receiving pre-payment or proof of pre-payment, we will schedule the appointment and provide an invoice detailing the costs and CPT codes for the neuropsychological assessment. This invoice will include all necessary documentation to facilitate your claim processing and financial record-keeping.

Post-Payment Policy:

Due to past difficulties with acquiring post payments and frequent requests for rate adjustments after services have been rendered, we unfortunately do not accept post payments. This policy helps us maintain consistency in our billing practices and ensures that services are paid for in advance, preventing any issues related to delayed payments or disputes.

CMS-1500/HCFA Forms:

If a CMS-1500 or HCFA form is required for a WC claim, we will be happy to provide it upon request (we do not provide HCFAs for commercial insurance such as BCBS etc). Our team is prepared to assist with all necessary paperwork to ensure compliance with worker’s compensation requirements.

Expedited Cases:

For urgent cases, such as pre-surgical clearances for spinal cord injuries, we can expedite the assessment process. We understand the critical nature of these situations and will prioritize scheduling to accommodate urgent needs.

Collaboration with Case Management:

We work closely with case management teams to address any questions or concerns regarding the case. Our goal is to provide thorough and timely information to support effective case management and ensure the best possible outcomes for injured employees.

Contact Us:

For more information or to arrange pre-payment and scheduling, please contact us directly at 239-768-6500 Our team is here to support you in providing the necessary neuropsychological assessments for your injured employees and to facilitate a smooth claims process.

At Mind and Brain Care, LLC, we are dedicated to delivering exceptional care while ensuring efficient administrative processes. We appreciate your understanding and cooperation in adhering to our pre-payment policy and look forward to working with you to support your workers’ compensation cases.