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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 clientโ€™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 clientโ€™s primary insurance, pre-auth is denied as there is no IQ score listed on the developmental pediatricianโ€™s evaluation. Additionally, there is not a standard assessment included on the developmental pediatricianโ€™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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