By Stephen C. Schultz
The thump, thump was unmistakable and annoying all at the same time.
With my eyes closed and my head in that fog that only happens as you are coming out of sleep, I was beginning to realize the thumping was the sound of cars on the 10 in Southern California, driving over an uneven crack in the cement.
Yes, it was early.
Still dark outside.
I rolled over and looked at my phone. As is usually the case, my five o'clock alarm was about to go off in about 30 seconds.
There was a quick awakening and a sharp focus as I reached for my phone, hoping I could turn the alarm off before I actually had to hear it.
I had a reason for being up so early.
I was attending a conference in Southern California, but I needed to speak with a family living in the Eastern time zone. Their day was already well underway.
Mine was just beginning.
I got out of bed, made my way to the small hotel desk, opened my computer, and started preparing for our call.
They had a 12-year-old son.
Three days earlier, their world had changed.
They were trying to make sense of something they never imagined they would have to make sense of. Their son had been receiving outpatient treatment, but his therapist had reached the point of recommending a higher level of care.
And now the family was trying to figure out what that actually meant.
Where do you go?
What kind of treatment does a 12-year-old need?
How do you know whether residential treatment is appropriate?
How do you explain what is happening to insurance?
And perhaps the question that sits underneath all of those questions:
How are we going to make this possible?
I have these conversations often enough that some of the questions are familiar to me.
For the family, none of it was familiar.
And that distinction matters.
The first question isn't always about insurance
When a family first begins looking for residential treatment, one of the first things they are often told is to check their insurance network.
That makes sense.
Insurance matters. Cost matters. Benefits matter. Families need to understand what their plan covers and what their financial responsibility might be.
But there is a question that should come before the insurance conversation:
What does this child actually need?
That sounds obvious, but it can become surprisingly complicated.
A 12-year-old may technically meet the age requirement for a residential program. That does not mean the program is equipped to treat his particular clinical needs.
A program may treat children with behavioral problems. That does not necessarily mean it specializes in problematic sexual behavior.
A facility may provide residential treatment. That does not necessarily mean it has the clinical expertise, supervision, assessment, family involvement, academic support, or treatment structure that a particular child requires.
And a provider appearing in an insurance directory does not necessarily mean there is an available bed today.
Or next week.
Or even within a reasonable period of time.
This is where the phrase “in network” can sometimes create a false sense of resolution.
A provider can be in network and still not be clinically appropriate.
The question I encouraged this family to ask
As I talked with this family, I wasn't trying to convince them that Oxbow Academy was the answer.
That distinction is important to me.
There are many good treatment programs. Oxbow is a very specialized program, and whether a particular child belongs at Oxbow is something our clinical team has to determine.
The first question is not:
“How do we get this child into Oxbow?”
The first question is:
“What does this child need, and where can those needs be appropriately addressed?”
That is a much better place to begin.
For this particular family, their son had been in outpatient treatment. His therapist was now recommending a higher level of care. They were living with circumstances that had become difficult to manage safely and effectively at home.
So the conversation needed to move beyond simply finding a facility that accepted 12-year-olds.
It needed to consider the whole picture.
Does the program understand problematic sexual behavior in children?
Can it provide the level of supervision the child requires?
Does it have the clinical expertise to address the underlying issues rather than simply manage the behavior?
Can it involve the family?
Can it address academics and developmental needs?
Can it assess what is actually happening rather than assuming that the most recent crisis tells the whole story?
And perhaps just as importantly, is there actually a place available?
Those are clinical questions.
Insurance comes next.
Then comes the maze
Once a family understands the level of care being recommended, another challenge begins.
Insurance language can make an already overwhelming situation even more complicated.
A family may be told that their plan has residential treatment benefits.
They may be given a list of in-network providers.
They may be told that the insurance company does not normally authorize out-of-network treatment.
On paper, that can sound like the answer.
But there is another question worth asking:
Is there an available in-network provider that can actually meet my child's clinical needs?
That question changes the conversation.
Instead of saying, “We want to go to this particular program,” the family can say:
“Here are my child's clinical needs. Can you identify an available provider within the network that can meet them?”
That is a very different conversation.
If there is an appropriate provider, then perhaps that is where the conversation should go.
But what happens when there isn't?
What happens when the providers listed by the insurance company don't treat the child's particular condition?
What happens when they don't accept the child's age?
What happens when there is no available bed?
What happens when the program is technically capable of providing residential treatment but does not have the specialized clinical expertise the child needs?
Those questions matter because the goal should not simply be to find a provider that checks an insurance-network box.
The goal should be to find clinically appropriate care.
Families shouldn't have to become insurance experts overnight
One of the things I have learned over the years is that families can become remarkably resourceful when their child needs help.
They start making calls.
They keep notes.
They learn acronyms they never knew existed.
They learn about deductibles, out-of-pocket maximums, authorizations, medical necessity, single case agreements, in-network and out-of-network benefits.
They become advocates.
They have to.
But I also think there is something important about recognizing how unreasonable this can feel when you are three days into a crisis.
That family I spoke with at five in the morning didn't wake up that week thinking, “We need to understand residential treatment financing.”
They woke up trying to figure out how to help their son.
They were parents first.
Everything else came afterward.
Sometimes the hardest part is simply knowing what question to ask
I have had families call Oxbow believing they need to figure out everything before they can take the next step.
They don't.
We can have the clinical conversation.
We can talk about whether the referral appears appropriate for further review.
We can explain the evaluation process.
We can talk about insurance and funding.
We can talk about school involvement.
We can talk about logistics.
And sometimes the answer is that Oxbow isn't the right place.
That is okay.
The important thing is that the family has taken the next step toward understanding what their child needs.
I think that is where we sometimes get lost in all of the terminology.
We start talking about residential treatment as though the goal is to find a facility.
But the goal isn't to find a building.
The goal is to find the right level and type of care for a child who needs help.
Back to that early morning
By the time my five o'clock wake-up had fully worn off, the sun was beginning to come up over Southern California.
The traffic on the 10 was still there.
The thump, thump continued.
But the conversation with this family had moved things forward.
Not because we had solved everything.
We hadn't.
There were still clinical questions to answer. There were insurance questions. There would be paperwork, phone calls, evaluations and decisions.
But they had somewhere to begin.
Sometimes that is what families need most.
Not someone telling them exactly what to do.
Not another person handing them a list of facilities.
Just someone willing to sit with them for a moment and help separate the questions.
What does my child need?
Who can provide it?
Is that care available?
And then:
How are we going to make it possible?
Those questions may not make the road easy.
But at least they put the family on the right road.
And sometimes, at five in the morning, with a water bottle of caffeinated Crystal Light and the sound of traffic pounding over a crack in the freeway, getting on the right road is a pretty good place to start.
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