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    Firing a patient: When it's needed and how physicians can handle it correctly

     

    Barry B. Cepelewicz, MD, JD

    Most physicians have run into troublesome patients they would like to remove from their patient panels. They might be combative, unrealistic in their demands, or just unwilling to adhere to any of your health recommendations. While your patients are free to terminate their relationship with your practice at any time, with or without notice, and for any reason, you cannot necessarily do the same. Why? 

    Physicians have an ethical duty to promote the continuity of their patients’ care. So you need to follow some basic guidelines when terminating a patient, or you risk the patient filing a complaint against you for abandonment or medical malpractice; the state department of health finding you guilty of professional misconduct; and/or a third-party payer alleging that you breached its participating provider agreement.

    While the guidelines discussed below are relatively straightforward, it is surprising to see how many physicians fail to follow them and subsequently find themselves embroiled in audits, investigations or litigation that consume significant time and financial resources.

    What reasons justify termination?

    For the most part, any reason is justified, as long as it is legal. You cannot terminate a patient for reasons based on age, color, disability, gender, national origin, religion, sexual orientation, or any other discriminatory reason; but typical reasons include the patient being non-compliant (such as for not following your treatment plans and recommendations); being verbally or physically abusive; or not paying his or her bills.

    When do you terminate the patient?

    The decision to terminate should be the physician’s, and it should be determined on a case-by-case basis.  If the patient is in stable condition and any reasonable delay caused by the transfer of care would not adversely impact the patient’s care, then termination is appropriate.  However, if the patient is in an acute or critical stage of his or her care or requires continuous treatment, then you may have to delay the termination.

    For example, if you are in the middle of working up the patient, or the patient underwent an operation a few days earlier, or if the patient is in her last trimester of pregnancy or has a complicated pregnancy, or you are the only physician within a reasonable driving distance who can treat the condition, then you may need to wait until a more suitable time when the patient can be transferred (provided that another provider is available to accept the patient).  Moreover, if you are a participating provider with a third-party payer, you should review the agreement and the payer’s policies to determine what process, if any, must be followed when terminating a patient.

    Should you discuss termination with the patient?

    If the patient is verbally or physically abusive, you may need to terminate the patient immediately.  However, for other situations, a meeting could be beneficial.

    First, it should reduce the patient’s ability to legitimately claim that he or she was surprised by the termination notice.  Second, you need to discuss the termination process and the need for the patient to seek continued care and treatment (including medications).  Third, perhaps when you inform the patient that you are considering termination it will motivate the patient to become compliant.  You might even learn that the non-compliant behavior was based on the patient’s misunderstanding regarding the treatment he or she received from you or your staff and such information could prove valuable in terms of how you run the practice. 

    Any discussions you have with the patient should be witnessed (for example, by the office manager) and memorialized in detail in the medical record.  Even if you decide not to have a meeting or a meeting is not possible, you need to memorialize the reasons for termination. 

    If the patient is non-compliant you should begin recording the non-compliant behavior as soon as possible; do not wait until after you make the decision to terminate.

     

     

     

     

     

    The termination process

    You need to send the patient a written notice of termination. 

    If the reason for termination is for non-compliance or failure to pay, you could mention those reasons in the letter, but otherwise it’s best not to specify the reasons because it might make an already uncomfortable situation even worse (the reasons, however, should be memorialized in the patient’s record).

    The letter should provide an effective date of termination and offer the patient at least 30 days to find an alternate provider during which time you will continue to treat the patient for urgent issues.  This time period may need to be extended depending on the patient’s condition or availability of alternate care, or if a third-party payer contract requires otherwise. 

    The patient should be advised to seek continued care and informed of the consequences if he or she fails to follow your directions. You should also offer to provide a copy of the record (not the original) to the new physician and include with your termination notice an authorization form for the patient to sign.  While it’s up to you whether you charge the patient for copying the records (many providers choose not to bill the patient), under no circumstance should you withhold the patient’s records because the patient owes you an outstanding balance.

    Referring the patient to specific physicians is generally not a good idea. Why would you refer a problematic patient to a colleague of yours?

    Also, if the patient is not satisfied with your referral, the patient could blame you. Instead, refer the patient to the county or state medical society for a list of physicians in the patient’s geographic area.  If you are part of a larger practice, the termination notice must be clear that the patient is being terminated from the practice, not just you (if that’s the case).

    The letter should be sent by certified mail, return receipt requested, and a copy of the letter as well as the return receipt should be placed in the patient’s record.  If the patient refuses to accept the certified mail and it is returned to you, you should retain the original mailing as part of the record.

    Keep staff informed about termination decisions

    Lastly, make sure you notify your staff about the termination so they don’t inadvertently schedule the patient for another appointment after the effective date of termination, because that could result in a determination that the physician-patient relationship was extended. 

    While it’s never easy to terminate a patient, following these guidelines in a consistent manner should enable you to do what’s best for you, your practice, and even your patient. 

     

    Barry B. Cepelewicz, MD, JD, is a partner at Garfunkel Wild, P.C. in Great Neck, New York. Send your practice management questions to [email protected].

     

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