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Bracing for Confrontation

I have a situation I need to deal with that I cannot seem to resolve over the phone. I’ve certainly tried, but despite my voicemails, I haven’t heard back from the gentleman who is in the position to make a key decision that will determine the placement of Maggie’s O.T. services.

I got a call on Wednesday afternoon from my daughter’s pediatrician’s office who kindly informed me that Maggie’s O.T. service will be denied by insurance. Mind you, her appointment was scheduled for the very next morning at 8 a.m., and the provider’s cancellation policy is 48 hours or you’re on the hook for the full amount. I called the insurance company and when I heard unsatisfactory responses to my concerns, I kept asking to speak to supervisors and decision-makers.

Here were my gripes: 1. We had been on the waiting list for O.T. for SIX MONTHS and the appointment was the very next day; 2. We had our O.T. evaluation at this particular center months ago, which consists of the top specialists who treat children with severe developmental delays and disabilities in the national. If it was going to be denied, why was the evaluation covered and why weren’t we told months ago when we had the initial evaluation?; 3. Maggie has a very complicated medical history and many of her existing therapies, including behavior and speech, are already in progress through this center, so continuity of care is a big concern; 4. We had issues with the primary care doctor from insurance that was originally assigned to Maggie when we first moved. We had an introductory appointment to establish care to which the doctor said frankly, “I don’t feel comfortable treating your daughter because of her complexity and co-morbidities.” I appreciated the doctor’s honesty, but the insurance fight to have Maggie’s primary care doctor renamed to a provider who was equipped to treat her was massively difficult at the time and involved countless phone calls and me physically parking myself outside of numerous offices to handle it in person.

When I asked for an explanation as to why Maggie’s many other services were covered with other providers but not O.T., I was told that they (meaning military medical facilities) did not offer the other services for pediatric patients, but they do for O.T. That being said, since Maggie could get O.T. from the military medical facility, that was the basis for their decision.

Luckily, the therapist emailed very last minute about needing to cancel our initial first appointment for personal reasons, so we didn’t have it and we weren’t on the hook for it since we didn’t initiate the cancellation. We’re still scheduled for next Thursday at 8 a.m. (it’s a recurring appointment), so this gives me a week to resolve the matter.

Insurance told me that the person that I would need to speak to is the patient advocate at the medical facility that would be offering the O.T. He could, in theory, state to the insurance company that they would not be able to meet Maggie’s needs which will default to her original appointment being approved. I left messages on Wednesday. No response. I left messages on Thursday. No response. If I don’t hear back sometime this morning, I’m going in person and not leaving until this is resolved. Luckily, Andy has an early day so I can go in the early afternoon without needing to bring my toddler companion. It’s hard to keep my game face in confrontational situations with Hazel when she’s trying to reach for my phone, ripping off her mask, or randomly busting out into song and dance to a surprise audience of the office staff.

Now, I’m not going in raging hot. I’m not raising my voice or causing a scene. That kind of behavior does not resolve conflicts, nor does that make others want to help you. Yet this is a real situation that requires confrontation and a solution. I’ve tried without success to handle it over the phone, but anyone I spoke to referred to this one gentleman and he has not returned my calls.

There is an important caveat to consider. Maggie’s appointments are currently weekly 30 minute sessions to be conducted virtually. I readily admit that virtual is not conducive for Maggie’s needs. If the center from the insurance readily understands Maggie’s medical history, her dynamic (Maggie does not follow simple commands, is nonverbal, and prone to seizures when emotional), and is willing to try in-person O.T. at a time that works, then I could be persuaded.

Coordinating the number of services Maggie receives is a fine balancing act on a schedule when I consider I need Hazel to come with me everywhere from lack of childcare and the COVID policies of most providers is for only a patient and parent go to appointments (no tagalong siblings). Andy is not available to watch Hazel except on rare occasions because of his work responsibilities. It’s difficult to schedule in the first place, which made the Thursday morning openings critical. For a kid, Maggie has a packed schedule.

I don’t have a solution. I thought I had one, but insurance threw a wrench into that one, at least as of right now. I’m just hoping I’m able to find something that works, is covered by insurance and also doesn’t take away from the many other services Maggie is currently receiving. I share this because I believe that the insurance complications and scheduling finagling are a frustrating but common experience for parents who are navigating the medical system to find solutions for their special needs children.

I ask for prayers that this will be resolved today with a solution that works for everyone and gives Maggie the help that she needs. Developing her pincer grasp amongst other skills are necessary for her to make progress in her therapeutic goals.


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