By Sumita Saxena, Senior Consultant, The Verden Group
It unfortunately can happen to anyone: You go above and beyond to provide your patients excellent care with uncompromising accessibility, and yet something somewhere goes wrong and the relationship quickly deteriorates. After trying your best to mend the problem it becomes clear – the relationship has broken down beyond repair and for whatever reason you reach the tough decision to terminate the patient from the practice.
Before you act and send notice, please take a look at some helpful steps we have compiled for you to consider as you navigate this difficult subject.
Step One: Try to Work It Out With Your Patient. Practically speaking, when faced with a difficult patient situation, the best course of action is to avoid a unilateral termination of the physician/patient relationship by addressing the problem quickly. Communication is the key. The patient should be advised of the situation and given a reasonable opportunity to correct the problem. You should make it clear that failure to correct the problem may result in the dismissal of the patient from the practice.
Step Two: Review the Applicable State Medical Licensing Rules. State licensing boards govern the practice of medicine and the relationship between a physician licensed in that state and his or her patients. Accordingly, it is essential to review the medical board rules carefully before you terminate a patient from your practice.
Step Three: Consider AMA Guidance. The American Medical Association (the “AMA”) has provided guidance on terminating the physician/patient relationship. According to the AMA’s Code of Medical Ethics, physicians have the option of terminating the physician/patient relationship, but they must give sufficient notice of withdrawal to the patient, relatives, or responsible friends and guardians to allow another physician to be secured.
The AMA recognizes that there are times when a physician may no longer be able to provide care to a certain patient, including when the patient refuses to comply, is unreasonably demanding, threatens the physician or staff, or otherwise is contributing to a breakdown of the physician/patient relationship. According to the AMA, terminating a physician/patient relationship is ethical as long as the proper procedures are followed.
The AMA has given the following advice for the termination process:
- Giving the patient written notice, preferably by certified mail, return receipt requested;
- Providing the patient with a brief explanation for terminating the relationship (this should be a valid reason, for instance non-compliance, failure to keep appointments);
- Agreeing to continue to provide treatment and access to services for a reasonable period of time, such as 30 days, to allow a patient to secure care from another person (a physician may want to extend the period for emergency services);
- Providing resources and/or recommendations to help a patient locate another physician of like specialty; and
- Offering to transfer records to a newly designated physician upon signed patient authorization to do so. American Medical Association (AMA), “Ending the Patient-Physician Relationship,” http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/ending-patient-physician-relationship.page
Step Four: Check Your Payer Contracts and Policies. A physician who is a participating provider (under contract) with the patient’s insurer (commercial or government payer) may be obligated to notify the payer and comply with additional requirements. You should review your provider contract(s) and policies in order to determine if the payer has a policy on patient termination. For example, some insurance carriers require 60 or 90 days notice before dismissal (as compared to the 30 days notice required pursuant to certain state laws) and some require prior written notice to the carrier to enable the carrier to contact the patient. There also may be specific requirements concerning pregnant or mental health patients. Medicare, Medicaid, and other government payers have strict policies on terminating a patient that should be reviewed before terminating a governmental plan beneficiary.
Step Five: Review Your Malpractice Carrier Requirements. Some medical malpractice insurance carriers have adopted rules or recommendations for terminating the physician/patient relationship. Accordingly, you should review your malpractice policy or contact the malpractice carrier when establishing the procedure for terminating the physician/patient relationship.
Step Six: Send Written Notification to Your Patient. You should send written notification advising the patient that he or she is terminating the patient relationship. The notification should comply with the licensing board’s rules and the requirements of the applicable payer and the your malpractice carrier. Ideally the patient notification should be prepared or reviewed by experienced counsel before sending to the patient.
Step Seven: Provide Continuity of Care. You should ensure that you provide the proper continuity of care when dismissing a patient from your practice, including any requirements under state licensing rules, their payer contracts and their malpractice policy. The AMA guidance recommends that the physician provide the patient with resources and referrals for other sources of care.
Step Eight: Do not Charge for Patient Records. A physician who terminates his or her relationship with a patient should not charge the patient for copying the patient’s medical records.
Step Nine: Consider Risk Management. Additionally, you should perform a risk management analysis before terminating the physician/patient relationship. You should consider the possibility (even if the patient’s position is without merit and you will ultimately be successful) of patient complaints, disciplinary investigations, litigation, or other action initiated by disgruntled patients.
Step Ten: Establish a Set Policy on Patient Terminations and Train Staff on the Policy. In order to avoid any potential issues with former patients, the practice should have a set policy in place for the termination of the physician/patient relationship, including a sample termination letter. The policy should be applied to patients consistently and without discrimination. The staff should be trained on the policy and should document compliance with the policy.
By following the above steps you can be proactive and diligent in mitigating your risk if such a situation ever arises with a patient.