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Client Pre-Authorization Denied For Much Needed Services

Post Series: Ethics Scenario Archive

Scenario

You receive an ABA referral from a pediatrician for a 3-year-old client; you call the parent listed and gather insurance details and enough background information to see if the client’s behaviors are within the scope of the practice. The client is severely impacted and engaging in high rates of SIB; your colleague that specializes in SIB has an opening on his caseload. When the team proceeds to obtain prior authorization from the client’s primary insurance, pre-auth is denied as there is no IQ score listed on the developmental pediatrician’s evaluation. Additionally, there is not a standard assessment included on the developmental pediatrician’s evaluation; an additional reason for the denial. The ABA team for the insurance company acknowledges the autism diagnosis on the report but state they cannot process the pre-authorization with the missing components. You explain the situation to the parent; he attempts to schedule another appointment with the pediatrician, but the next available appointment is in 9 weeks. The parent is extremely worried that the child might cause serious self-harm in the interim and is desperate for help. Does our code guide us in how to approach this situation? What are the ethical considerations?

Response

  • 2.01 accepting clients- business decision pro-bono work

 

  • Disseminating information to diagnosing physicians

 

  • Setting up contract to provide consultation in the interim
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