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In this episode, Dr. Jeremy Sharp shares a personal and professional deep dive into the opaque world of InterQual and prior authorization. After experiencing a near-total rejection rate of clinical prior authorization requests within his own practice, Dr. Sharp investigates the history, logic, and evidence—or lack thereof—behind the criteria that dictate medical necessity for neuropsychological services. He breaks down the “checkbox” workflow used by utilization management reviewers, explains the origins of the controversial eight-hour testing benchmark, and highlights critical gaps in the system regarding clinical complexity and social determinants of health. Most importantly, the episode provides listeners with concrete, strategic language and documentation tips to help navigate these administrative hurdles and maximize the likelihood of securing the care their patients need.

Main Topics Covered

00:01: The personal story of 100% denial rates and the motivation for investigating InterQual.
02:25: The history and objective of InterQual as a measurable indicator for standardizing care.
04:43: The massive scale of InterQual within the Optum and UnitedHealthcare ecosystem.
07:01: Decoding the “Black Box”: The decision-tree and checkbox software used by reviewers.
09:20: Why common referrals like ADHD and autism struggle to pass first-level screening.
11:43: Exploring the GRADE approach and the evidentiary standards used to build the criteria.
14:09: The eight-hour benchmark: Concept of testing fatigue vs. clinical complexity.
16:33: Critical gaps: Social determinants of health and the failure to account for environment.
18:57: The Appeals Paradox: Why the totality of the record wins when criteria fail.
21:18: “Playing the Game”: Specific keywords and strategies for successful prior authorizations.

Cool Things Mentioned

The Testing Psychologist mastermind groups and business consulting
Reverb: the premier AI-powered report-writing platform for testing psychologists

Featured Resources

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The Testing Psychologist podcast is approved for CEU’s!

I’ve partnered with At Health to offer CE credits for podcast episodes! Visit this link to access current and past episodes available for CE credit. You can use code “TTP10” for a discount on ALL the course credits you purchase from At Health!edit. You can use code “TTP10” for a discount on ALL the course credits you purchase from At Health!

About Dr. Jeremy Sharp

I’m a licensed psychologist and Clinical Director at the Colorado Center for Assessment & Counseling, a private practice that I founded in 2009 and have grown to over 20 clinicians. I earned my undergraduate degree in Experimental Psychology from the University of South Carolina before getting my Master’s and PhD in Counseling Psychology from Colorado State University. These days, I specialize in psychological and neuropsychological evaluation with kids and adolescents.

As the host of the Testing Psychologist Podcast, I provide private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. I live in Fort Collins, Colorado with my wife (also a therapist) and two young kids.

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551. The Gatekeepers: Unpacking InterQual and the Battle for Medical Necessity