CASE STUDY 1
A 35-year-old patient “no showed” for her appointment the third time in a year. Your office has a firm policy of termination after three missed appointments (without proper notification to office staff). You have clearly discussed this policy with the patient at two previous visits with no apparent change or good explanation for her nonadherence. You decide to discharge her….
CASE STUDY 2
A 60-year-old patient is openly frustrated in the office waiting area. Previously, he was involved in a couple of incidents where he was abusive and threatening to the front desk staff. During this latest encounter, he loudly muttered that he is going to bring a gun to his next visit. You decide to discharge him….
TERMINATING THE PROVIDER-PATIENT RELATIONSHIP
These two case studies provide examples of situations that are the most frequent type of call COPIC’s 24/7 Risk Management Hotline receives—the question of how to terminate the provider-patient relationship. In the practice of medicine, there are several situations where the patient relationship has deteriorated to the point where terminating the relationship is a relevant option.
In these cases, it is vital to end the relationship in an appropriate manner. The relationship itself is voluntary, so ending it may be appropriate, but it is necessary to proceed properly to avoid a claim of abandonment. Ending the provider-patient relationship typically revolves around situations that include:
- Patient nonadherence
- No shows to appointments
- Bill nonpayment
- Abuse and/or threatening behavior
- Before getting to the point of termination, providers should make an effort to repair the relationship, particularly when it involves nonadherent conduct or financial issues. Other more extreme situations, such as threats of violence, may call for quicker action in terminating the relationship.
THINGS TO CONSIDER BEFORE TERMINATION
When you decide to discharge the patient there are a number of issues to consider:
- Abandonment: Allegations of abandonment are the most serious consideration and the one most likely to be considered by your state medical licensing board. The patient must be in a stable condition. You must give adequate notice and be available for emergency care, generally for 30 days. Records should not be withheld and should be expeditiously provided to the next clinician, even if there are monies owed. Examples of situations that may require longer times before termination include a hospitalized patient, a patient in late pregnancy, an immediate post-op patient or someone receiving chemotherapy. In these situations, it may be necessary to arrange for further care.
- Discrimination: Termination may not be based upon gender, race, religion, disability, ethnic origin, national origin, or age. Disability status can be complex and contentious.
- Contract Issues: Be cautious when terminating patients who are members of managed care plans. Your contracts with health plans might specify the manner of termination with a member patient. This is especially true if the method of payment is capitation. Plans might need notification of the reason for termination to prevent allegations of dismissing a patient because he or she is “too expensive to treat.” The patient might also have different time constraints for the health plan to complete reassignment to a new physician/provider. Medicaid has a specific process for termination of Medicaid patients, and health care professionals need to consult their provider participation agreement for details.
WRITING THE TERMINATION LETTER
All terminations should be documented in writing so that the patient understands the need to find another health care provider. A termination letter should:
- Be professional and succinct.
- Spell out that emergency care will be provided for a period of 30 days.
- Reasonable refills for non-controlled substances should be given. For controlled substances, a one-month time frame is desirable.
- State that a new provider should be sought and suggest that the medical society and/or the patient’s health insurance might assist them in finding a new physician or health care provider.
- Make sure your office staff knows of your plans. The patient should be reappointed to see you only if there is an emergency medical condition.
- Assure the patient that all medical records will be provided at his or her request.
- Avoid editorializing or restating your side of a dispute in the termination letter. A simple “It has been determined that I can no longer function as your health care provider” is adequate. The documentation in the medical record can be more detailed, but should remain factual and avoid pejorative or emotional statements regarding the termination.
- Send the letter via certified U.S. mail. For specific clinical situations (i.e., the need to follow up on a critical lab/image or to complete a procedure or consultation), the letter can include the reasons for the necessary actions and the risks of not complying with them.
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in 4Q22 Copiscope.
