Is an Oceanside Evaluations (OSE) assessment the right next step?

You ended up here because of a personal struggle for you or your loved one. You are likely weighing your options for testing and wondering what you are willing and able to pay for. Know that you are not alone! If we here at OSE feel that we can help, we will. If we feel that other services may be a better fit at this point, we will let you know.

Our goal is to give clients a useful and readable report that explains strengths and vulnerabilities while giving recommendations and a diagnosis, if warranted, that will help you feel that you can finally move forward. For Private Pay clients, you may choose to have a free 15-minute phone consult with one of our doctors to ensure that we are the correct next step before setting up an intake session.

Why Oceanside Evaluations (OSE)?

We are here for you! We are an assessment center, first and foremost!

Our private pay clients have an advantage over people getting insurance evaluations in that our testing can be more complete and thorough than insurance-based evaluations. We look at the client as a whole and adjust to what we are assessing on the spot if necessary.

All of our clients are able to get actual diagnoses through the oversight of our Doctors of Clinical Psychology. Some other testing psychologists are not able to do this.

OSE tries to connect you to the services you need and provides some services if appropriate.

You can easily wait nine to twenty months to get an assessment done elsewhere.

Others will often only narrowly look at the exact question asked and do not allow the freedom to gather more in-depth information that can help lead to long-term success.

Other groups shorten their testing battery, hoping that they will break even on the assessment, or their focus is on therapy and do evaluations on the side.

When are you scheduling?

We are scheduling out 2-3 months. However, if we can move clients forward, we will do so. We do not "pack" our schedule with clients, so you will get more personal attention by waiting. It may take longer for a Tricare appointment due to when those appointments are offered.

How do I get started?

You can call the office or email. We are a small and personal operation, and we do our best to get back in 2-4 business days if we cannot answer right away. Phone: 757-771-0269 Email: office@oceansideevals.com

Are you in-network with my insurance company?

If you have Tricare as your only insurance, then yes, and we can run a benefits check to ensure we can file claims for you. If you have Tricare and want educational testing, there will likely be an additional cost associated with that portion of the testing. We are not in-network with any other providers.

Our goal is to give you an evaluation that is comprehensive, timely, and affordable. We don't want decisions about your evaluation made by insurance employees. We want decisions about your care to be made by you and me. We want to be able to do the assessments that we feel are best, not ones that are more likely to be paid by an insurance company. Insurance companies require a diagnosis and then make it a permanent part of the client’s medical record. We feel that our clients should be able to choose if they want to do that. Insurance companies do not cover testing for learning concerns and some other areas that we assess.

You pay Oceanside Evaluations directly. Your provider may cover out-of-network (OON) benefits for behavioral health testing. We will be happy to provide you with a Superbill after paying for the evaluation to see if your insurance company will reimburse you for any of what you paid. There is more information below on how to talk to your insurance company about possible partial reimbursement.

** See below for how to talk to your insurance company and why we do not accept insurance to get more information on this question.

What is a Superbill?

Essentially, a Superbill is a record of all of the procedures (CPT codes) Oceanside Evaluations used as part of the assessment along with any diagnosis (ICD-10 codes) found during the process. Superbills are different from receipts/invoices because they provide additional information regarding the visit (diagnosis and procedure codes) needed to get a claim approved. This superbill can then be submitted to the client’s insurance company to see if the client can get reimbursed for the evaluation costs.

How much does an evaluation cost?

Oceanside Evaluations is committed to providing quality assessments to the community. We know that not all assessments are as involved as others and, therefore, do not have a one-size-fits-all approach. We will be happy to give you an estimate based on what you tell us about your concerns or questions. We also offer add-on options and concierge evaluations for people who want these services without charging those fees to all of of clients. The average cost for a full assessment is $2,800. (The average private pay evaluation in 2008 was over $2,000.) See Assessment Costs

Clients who pay for the evaluation in full at least two weeks before the intake session are entitled to a 5% discount.

Do you accept Health Savings Account, Flexible Savings Account, or Health Reimbursement Account (HSA/FSA/HRA) debit cards?

Yes. If you have a pre-tax account set aside for healthcare expenses, you can use the debit card associated with that account. You can also pay by check and submit your receipt to that account for reimbursement. If you do not have this kind of account, ask your human resources department if you can start one.

Do you do payment plans?

Some clients choose to apply for a credit card through www.advancecarecard.com. This is a credit card for medical payment. They are often able to give clients up to 15 months interest-free. Oceanside Evaluations does not get anything additional from them and does not even know if you are using that card unless you tell us. Clients have told us that they have used this option to take advantage of the 5% discount for paying in full at least three weeks before intake and then paying it off before the terms of the interest-free time they were approved for runs out.

Yes, we allow clients to break up payments - $375 to book the intake and testing session, 1/2 of the remainder on intake day, final amount due on feedback day. We can adjust the booking schedule if you need more time between intake and feedback. We also can allow clients to do a 4 or 6-month payment plan through us, with the final report written and delivered after the final payment.

How do I ask my insurance about out-of-network benefits? 

Even though Oceanside Evaluations does not bill insurance (other than Tricare) directly, most families who see us get some reimbursement for an evaluation from their insurance company.​ Contact your insurance and ask about "Out-of-Network Coverage" for behavioral health testing. You may be able to get reimbursed for all or at least some of the evaluation costs. If nothing else, you can submit the receipt to a flexible spending account or claim it at the end of the year as a medical expense on your taxes (if appropriate).

It may be important to note that you are asking for an evaluation to have a professional precisely figure out what is going on, not to document what you already know. Otherwise, the insurance company will see no need for testing.

​Here's what to ask: 

• What are my out-of-network benefits for behavioral health testing for a medical concern? (They will not pay for educational testing)

• How much is my deductible?

• Can this go towards my deductible even if I do not receive a reimbursement?

• After I meet my deductible, what percentage of the visit cost will I be reimbursed for?

• Up to how much can I be reimbursed for:

  • 50-minute intake appointment (CPT Code 90791)

  • Possible Neurobehavioral Status Examination (CPT Code 96116)

  • Neuropsychological Testing (CPT Code 96136 for the first 30 minutes, CPT Code 96137 for each additional 30 min)

  • Neuropsychological Services to include the feedback session and writing (CPT Code 96132 or the first 60 minutes, CPT Code 96133 for each additional hour)

• Do I have a limit on how many units of 96137 or 96133 I can get reimbursed for?

• How do I submit a superbill?

• Am I required to submit any prior referral or authorization to have this approved?

​Sometimes, insurance companies want to know our NPI number (138-610-8876), EIN number (82-2758091), or possible diagnosis codes. We're happy to provide you with this information if you need it. An official diagnosis is only determined after all testing has been completed and assigned based on the evidence provided. We are happy to give you possible diagnosis codes for the purposes of talking to your insurance company ahead of time (like F90.2 for ADHD or F41.1 for Anxiety).

Please note that insurance companies usually only accept paying for assessments that they deem “medically necessary.” For example, they will say that you can have 8 hours of neuropsychological testing but then deny the testing if the diagnosis is “educational” in nature.

** Another possibility for you is that a learning disability evaluation may be able to be deducted as an educational expense. You can check with your tax adviser to see if this is an option for you.

Why do you not accept insurance?

Our goal is to give you an evaluation that is comprehensive, timely, and affordable. We don't want decisions about your evaluation made by insurance employees. We want decisions about your care to be made by you and me. We want to do the assessments that we feel are best, not ones that are more likely to be paid by an insurance company. Insurance companies require a diagnosis and then make it a permanent part of the client’s medical record. We feel that our clients should be able to choose if they want to do that. Insurance companies do not cover testing for learning concerns and many other areas that we assess. Although they would tell us that the evaluation was covered, they would often leave us without compensation.

It is not the responsibility of Oceanside Evaluations to ensure getting paid for services rendered. We tried accepting insurance and found that we were paid a small fraction of the assessment billing in most cases. Our focus needs to be on the assessment quality and not on negotiating payments from lots of different insurance companies. As professionals, we have no legal rights in the contract you have with your insurance company so that they can deny payment, and we have no recourse.

So, what are the essential things to keep in mind?

• Neuropsychological testing often consists of both educational and neuropsychological testing. Even if your insurance company covers the cost of neuropsychological testing, educational testing is rarely covered.

• Most insurance companies will only cover neuropsychological testing if thy deem it medically necessary to make a diagnosis.

• The referring clinician needs to highlight any relevant medical issues in the referral form. These can include issues such as a head injury, premature birth, stroke, epilepsy, congenital abnormalities, head trauma, memory problems, and any relevant medical diagnosis.

• Having a medical doctor make a referral for a neuropsychological assessment can help with the insurance company’s willingness to pay for these services.

• Some insurers will not cover neuropsychological assessments if the child has already undergone a similar assessment in the past 12 (or 24) months.

• It is important for you to call the number on the back of your subscriber identification card to inquire about coverage for behavioral health testing.

Will this evaluation have a negative effect on my child’s records?

Another aspect of dealing with insurance companies is the issue of confidentiality. Oceanside Evaluations holds your records very confidential based on professional standards. Insurance companies do not. If the bill is going to be submitted to insurance, then a diagnosis must be a part of that and be on the medical records.

** If you have Tricare but choose to pay directly and not file with insurance, you may choose to do so by signing the appropriate forms with Oceanside Evaluations. You would not be eligible to receive a superbill.

What if I still have questions?

No worries! We are here to help! You can call the office or email. We are a small and personal operation, and we do our best to get back in 2-4 business days if we cannot answer right away. Phone: 757-771-0269 Email: office@oceansideevals.com