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Ethical Allocation of Resources in Provision of Occupational Therapy Services

Case

Jeanette is a pediatric occupational therapist working in a hospital-based outpatient clinic. Over the last 5 years Jeanette has seen a reduction in the number of reimbursed visits through third-party payers.

Jeanette has evaluated a 4-year-old boy who presents with developmental delays resulting from a sensory processing disorder. Although the insurance company paid for the initial evaluation, the company is denying payment for ongoing services as there is a coverage exclusion related to "developmental disabilities."

Jeanette's employer, the electronic medical record, and the insurance company require entry of an ICD-9 code corresponding with the therapy diagnosis. There is not a code specifically related to sensory processing disorder. Complicating her situation further, the most relevant codes include the word "developmental" in the disease/injury explanation.

Therefore, while Jeanette believes that the boy could benefit from occupational therapy intervention, the most appropriate diagnosis code indicates to third-party payers that the condition will improve with time with or without intervention, resulting in a denial of coverage. Ethically, Jeanette feels she must provide services, yet the family does not have the resources to pay out of pocket for ongoing therapy, and Jeanette signed a non-compete clause with her employer. However, now the boy’s mother asks Jeanette not to abandon them as they need her assistance.

• In the ethical dilemma facing Jeanette, is she abandoning the child if she does not provide treatment she deems to be beneficial?
• If she continues to treat the child is she not in violation of fiduciary responsibilities posed by her relationship with the organization?
• Finally, what are Jeanette’s ethical responsibilities in ensuring fair access for recipients of occupational therapy services?