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2/25/04
Robert J. Barth, Ph.D.
Southeastern Neuroscience, P.C.
2337 McCallie Avenue
Plaza One, Suite #300
Chattanooga, Tennessee 37404
Re: Neuropsychology in Tennessee
Dear Dr. Barth,
I hope this letter finds you and yours well.
Let me begin by again thanking you for your willingness to serve as a member of the Legislative/Professional Affairs Subcommittee, with special focus on the issues and concerns of neuropsychology in Tennessee. I know you are busy and TPA is fortunate to have someone of your caliber willing to help us carve out constructive outcomes on these matters. Know how much I appreciate your efforts.
I am writing to provide you feedback on discussions undertaken by the TPA Board of Directors at their January 23-24, 2004 meeting as well as some future directions I am recommending to the Board for us to pursue. I distributed the package of information you sent to me to all Board members and it was reviewed in fine detail at their most recent meeting. Here is a summary of the discussions of the Board that weekend:
1) Legislative Efforts in 2004
The cutoff date for legislative efforts in 2004 has passed so even if the association wanted to introduce some sort of legislation related to neuropsychology, nothing can be done legislatively this year. With our RxP efforts in high gear, much of our legislative energy is necessarily directed to passing our prescriptive authority law (which will of course have many positive “rebound” effects for neuropsychology in our state).
2) Position of the Board of Examiners in Psychology
The TPA Board reviewed the letter sent to you by the BOE on 8/16/00. The Chair (Robert Pusakulich, Ph.D., ABPP) at that time incidentally is a Board-Certified Neuropsychologist very interested in championing neuropsychology issues in our state. Despite his personal views, the Board is telling all of us that they will strictly interpret the letter of the law in Tennessee as it relates to the unlicensed practice of psychology in our state. TCA 63-11-206 (a) states “Any person (bold print is my emphasis) who engages in the practice of psychology, and does not then possess in full force and virtue a valid license to practice as a psychological examiner or psychologist or senior psychological examiner or a certificate to practice as a psychological assistant under the provisions of this chapter and the provisions of Chapter 1 of this title, commits a Class B misdemeanor”. There are provisions in (c) (1) that allows students in training to practice psychology without a license or certificate, but these are the ONLY exceptions, and DOES NOT INCLUDE folks commonly called “testing technicians” (these folks are not licensed nor do they have a certificate to practice psychology in our state). In short, there is no ambiguity in our statute for the Board of Examiners in Psychology to interpret the law any differently than what you were told in that letter from the BOE on 8/16/00. IF neuropsychological testing technicians were going to be an exception in our licensing law, legislation would have to change our law –the Board cannot do it through either their rules or regulations or declaratory order processes. The position of the Board has been the same since the passage of our Health Service Provider law in 1992. In the “old days” (before 1992), psychometricians and “testing technicians” ( bachelor’s level folks or people with lesser training) did perform certain testing functions in our state but this practice was changed nearly twelve years ago. Some of our colleagues are still unaware of the change in our licensing law in 1992, and may unfortunately find themselves practicing illegally. Dr. Pusakulich’s letter is a polite way to warn folks “don’t do it”. Naturally, TPA supports practicing psychology in accordance with our state licensing law.
(3) Levels of Licensure and Certification in Tennessee
Discussions of “testing technicians” vary from state to state, depending on the levels of licensure and certification to practice psychology in any given state. There is a major difference between those states with multiple levels of licensure and certification such as ours versus those states where only doctoral level licensure exists. We are aware of Division 40's position on the use of testing technicians as well as the recent actions in Arkansas, Oregon, New York and North Carolina. Succinctly, the issue of “testing technicians” must be looked at on a state-by-state basis due to the lack of a national licensing and certification law. As it applies to Tennessee, there are four levels of health-related psychological practice relevant to discussions of “testing technicians”: psychologists, senior psychological examiners, psychological examiners, and certified psychological assistants. The latter is certified; the other three levels are licensed.
(4) TPA’s Agreements with TAPE and University Teaching Programs in Tennessee
TPA and TAPE achieved the historic agreement of single level licensure in 2000, a law meriting unanimous approval by literally every member of the Tennessee General Assembly. Decades of internal strife ended with the unification of psychology practitioners under TPA. The language of that law was painstakingly reviewed in minute detail, including the consideration of testing technicians. Both TPA and TAPE agreed to reaffirm the traditional view of psychological testing as an endeavor requiring a certain degree of formal education, training and experience. As you know, psychological testing is much, much more than merely the “giving of a test”. Other professional groups in our state (licensed professional counselors) already are permitted by statute to do certain kinds of “assessments”, but not “psychological testing”. TPA and TAPE wanted to preserve certain standards for psychological testing and to keep this competency under the authority of the Board of Examiners in Psychology. As such, we created a new category of health-related practice specifically trained to complete the tasks often rendered by “testing technicians”. The new level of practice is called “certified psychological assistant”. There are certain education requirements (masters level training) and required practicum experiences in order to merit the certificate to practice as a psychological assistant. TAPE and TPA fully supported the crafting of this position on psychological testing in order to distance ourselves from deprofessionalizing psychological testing. Market forces, particularly managed mental health care, has promoted the use of lesser trained people as testing technicians. Both TAPE and TPA believed there were other more productive ways to approach today’s economic challenges to psychological testing than utilizing undertrained technicians. We sought to establish a minimum standard for these tasks in our licensing law and hence, the certified psychological assistant was created. With the attainment of single level licensure, our University people who had been training psychological examiners and others no longer had a pool of future students. By creating the certified psychological assistant, we were also able to help insure future students for these masters level psychology programs in our state.
(5) TPA Board’s Conclusions on January 23-24,2004 related to neuropsychology issues
Given the above, the TPA Board (1) reaffirmed its support for practicing in accordance with our psychology practice act and its rules and regulations, (2) acknowledged the proper term for “testing technicians” in Tennessee should be certified psychological assistants, (3) recommended that if neuropsychologists were going to use “testing assistants” they should employ certified psychological assistants, senior psychological examiners or psychological examiners and (4) directed the Legislative/Professional Affairs Officer to both respond to your letter to TPA and to begin to generate some solutions to the economic problems encountered by colleagues performing neuropsychological testing.
Future Directions for Neuropsychological Testing in Tennessee
Managed mental health care has had devastating effects on reimbursement for all forms of psychological testing, including neuropsychological testing. Our association is keenly aware of the plight experienced by colleagues in these difficult economic times and we believe we have crafted an option with our certified psychological assistant which will be of much assistance on these matters. Since you are examining matters pertaining to neuropsychological testing, I’ll restrict my recommendations to solely these aspects of psychological testing.
For neuropsychologists seeking to deal with economic barriers to reimbursement, the solution is NOT to deprofessionalize the speciality by using undertrained employees but instead, to demonstrate how the intricacies of a neuropsychological assessment requires highly trained specialists, and as such, demands appropriate reimbursement. For neuropsychologists, appropriate reimbursement means being paid on the “medical benefit” of the patient, not their “behavioral health benefits”. Such a calculus will permit the use of highly trained certified psychological assistants that the neuropsychologist can better afford since the payments on the medical benefit side of the equations will be much higher than the traditional mental health benefit. For some time now TPA has been working on assisting changes in the marketplace and I am pleased to share with you some good news which will have far-reaching effects on these matters.
I am faxing to you a statement published by Blue Cross Blue Shield of Tennessee on 1/30/04
titled “Important Information - Neuropsychological Testing Guidelines”. In this memo are several important statements:
Neuropsychological testing is considered for reimbursement under the member’s
medical benefits. These services are not considered a part of the member’s behavioral
health benefits.
Participating providers do not have to obtain prior authorization for the testing; however,
a neurologist or neurosurgeon must recommend the evaluation.
Certain acceptable diagnostic code for reimbursement are provided.
The Blue Cross Blue Shield of Tennessee medical provider number should be used when billing for these services. Many neuropsychologists have a medical provider number and a behavioral health provider number assigned to them.
I am going to recommend to the TPA Board of Directors that we write a formal letter from our association supporting this development, as well as some additional suggestions. For example, while they are likely self-insured and can therefore establish whatever gatekeeper arrangements they desire, we’ll see if we can get them to broaden access to these evaluations (i.e., not just neurologist or neurosurgeon recommendation). Additionally, in physician offices, physicians bill for services rendered by their employed nurses or physician assistants. Similarly, for work rendered by neuropsychologists that is reimbursed on the medical benefits side of the equation, neuropsychologists would bill and be paid for work rendered by their certified psychological assistants. We have a good opportunity here to help these developments with Blue Cross Blue Shield become standard operating practice for other carriers as they tend to follow Blue Cross Blue Shield’s lead on these matters.
As soon as I get authorization from the TPA Board to pursue this option with Blue Cross Blue Shield, I’ll get a draft of the letter for your review and input.
I hope this letter comprehensively addresses the issues you’ve been bringing to our attention and provides some “light at the end of tunnel” for colleagues struggling with neuropsychology reimbursement struggles. Thanks again for your enthusiastic pursuits on these matters. Let me know what you think. I look forward to working with you further on these issues in the near future.
Best regards,
Lance T. Laurence, Ph.D.
TPA Legislative/Professional Affairs Officer
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