In a debate that has been brewing for the past few years, it seems that insurance companies have had the deciding word.
Three years ago, Russel A. Barkley, Ph.D., a clinical professor of psychiatry at Medical University of South Carolina, wrote about a lack of validity for the use of neuropsychological testing for the diagnosis of ADD and ADHD (“Impairment in occupational functioning and adult ADHD: the predictive utility of executive function (EF) ratings versus EF tests,” Clinical Neuropsychology, May 2010). He concluded that testing did not identify the disorder as reliably as self-reported scales.
“The controversy started in the literary journals with publications of mine that replicated and expanded earlier studies, but focused specifically on ADHD, and got the same results,” says Barkley.
Studies have shown, he says, that neuropsychological testing is not useful in diagnosing in part because it can often have false negative results.
“I was arguing that the use of these tests is no longer defensible and even borders on malpractice,” he adds.
The reaction to his article was immediate and fierce.
“The listservs across the country lit up over it,” he says. The issue, he adds was that for many, this discussion was about finances and was “not science-based. It was more emotionally charged.”
His comments began to work their way into legal cases and he found insurance companies asking for his opinion. In part because of his view, he says, private insurance companies have begun to change the way they cover neuropsychological assessments.
“It was no longer just an academic discussion,” he says. “It was now going into practice.”
Locally, the debate has begun to affect the way psychologists treat clients.
“It used to be far fewer insurance companies required prior authorization, which is really a cost management tool, for neuropsychological testing,” says Mitchell Clionsky, Ph.D., ABPP(CN), a neuropsychologist with a clinical practice in Springfield, Mass., “The insurance companies started insisting you know the answer [about the diagnosis] before you ask the question and they decided that ADD was not a diagnosis that required neuropsychological testing.”
In many cases, testing is covered as a medical benefit in a case where neurological impairment (head trauma, seizures, etc.) can also be proven.
While Clionsky agrees that testing should not be used as the primary tool to diagnose ADD/ADHD, because of the possibility of false negatives, the in-depth look at executive functioning should not be undervalued.
“I am in agreement that neuropsychological testing is not necessary to do a diagnosis,” says Clionsky. But, he adds, the testing can help tease out which executive functions are impaired and whether medication is helping. “To understand how the patient does with learning and memory, these things are not answered with a check list.”
Clionsky, who attended graduate school with Barkley, had a discussion with him recently about the debate. He felt that Barkley’s position on testing had been taken too far by insurers. The problem is that insurers do not want to pay for any claim that has ADD as the diagnosis, even if it is not used to actually make the diagnosis, but to support or to help with treatment.
“The statement that it is not needed for diagnosis (made by Barkley) was used by insurance companies to say that there is no place for it in ADHD at all. We do it more to see what else is impacted. It is important as a tool to rule out other issues, to make sure we are not missing something.”
With testing harder to get covered, practitioners often find they cannot provide services they feel would be helpful.
“It puts us in a difficult situation on how to provide adequate services of a growing part of our population,” Clionsky adds. “Why would we not bring to bear the important information that neuropsychological testing offers?”
By Catherine Robertson Souter