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Reimbursement and Practice Management

Patient Dismissal

Dismissing a patient from your practice is probably an infrequent event, yet it is one that you must take seriously.

After reading this article you will understand how to:

  • Identify reasons physicians dismiss patients from their practices
  • Properly document the dismissal process
  • Identify signals that a patient might litigate following dismissal
  • Recognize potential legal consequences of mishandled patient dismissal

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Dismissing a patient from your practice is probably an infrequent event, yet it is one that you must take seriously. Many physicians worry about being accused of patient abandonment when dismissing a patient. While that’s a legitimate concern, you have every right to dismiss a patient from your practice. All the same, it's wise to proceed in a consistent manner when ending these obligations.

Failure to keep appointments — so-called “no-shows” — ranks high on the list of acceptable reasons to terminate a relationship with a patient. Other suitable grounds to dismiss a patient may include repeated non-compliance in the following areas:

  • Financial: The patient is unwilling or unable to pay their balance
  • Clinical: The patient refuses to follow your orders
  • Behavioral: The patient displays abusive or violent behavior at the practice.

Although it is certainly acceptable and legally defensible to fire a patient from your practice, the patient's ethnicity, gender, religion or age are not considered legitimate reasons for dismissal.

Here’s how to avoid problems when dismissing a patient from your practice:

Create a guideline. Put the guidelines for patient dismissals in writing – and apply them consistently. Without written guidelines, you will have a harder time defending yourself against discrimination or abandonment charges.

Consult first. Seek advice from your malpractice carrier before implementing your patient dismissal guidelines. Ask the carrier to review your guidelines and dismissal notification messaging with an eye to issues unique to your specialty, practice and patient population. Also ask your carrier if it will provide written approval of your draft patient dismissal letter. It’s not necessary to consult with your carrier about each dismissal, but it is imperative to contact your carrier if you suspect a patient will seek litigation after being dismissed.

Communicate. Particularly when patients with serious medical issues display non-compliance, discuss your concerns with them before commencing the dismissal process. Hold face-to-face meetings, when possible, to repeat your recommended treatment plan, review the patient’s noncompliance, and share that dismissal from your practice is a potential consequence.

Document everything. Ask a staff member to sit in as a scribe during the conversation. This step is optional, and it is certainly not recommended when the patient has shown problematic or threatening behavior towards employees.

Dismiss, but don’t abandon. The Emergency Medical Treatment and Active Labor Act (EMTALA) prohibit hospitals from abandoning patients in the course of treatment until they are stabilized. Although EMTALA only applies to hospitals, the legal concept behind the legislation extends to physicians. Abandoning the patient is a form of malpractice. Patients who feel abandoned can sue your practice, even if their financial irresponsibility, clinical noncompliance or abusive behavior toward you led to the dismissal. To avoid accusations of abandoning patients, continue to treat them through the course of care even if they don’t pay. For example, if you treat an unassigned patient through an emergency department (ED) consultation, and if surgery is indicated for stabilization, you should provide the surgery and the appropriate post-operative care. If the patient won’t pay for those services or defaults on a payment arrangement, it’s permissible to dismiss that patient from your practice once the care is complete according to standard clinical guidelines. If there is any doubt about whether the dismissal may be perceived as abandonment, contact your malpractice carrier to discuss the circumstances.

Recognize the consequences. Be sure to follow the protocols you establish. You may believe that you’re doing patients a favor by rescheduling numerous times after repeated no-shows, but granting that leeway can become problematic when you do dismiss them. A dismissed patient with serious medical problems could decide to sue you for abandonment. Inconsistently enforcing dismissal guidelines might also leave you open to charges of discrimination if some patients are dismissed strictly according to protocols while others are allowed more leeway. Although it is tedious, thorough documentation of your actions prior to termination are your best protection against unwarranted accusations.

Inform the patient. Send a dismissal letter to your patient via regular mail and by another method, too, such as certified mail with return receipt requested – the key is to have the hard copy of your letter tracked. In other words, don’t use electronic mail, text messaging or a telephone call. Unless your malpractice carrier advises otherwise, don’t go into great detail about why you’re terminating the relationship with the patient. Simply state the general issue at hand, such as the fact that you have attempted to collect from the patient and they have neither paid nor made alternative payment arrangements. Be objective; documenting subjective reasons for dismissal may open the door for a case of abandonment on the basis of discrimination. To accompany the dismissal letter, include a copy of your HIPAA-compliant medical records release form in the envelope with instructions. Maintain a copy of the dismissal letter in the patient’s record, along with any confirmation of its delivery. Of course, if menacing behavior is the issue, don’t waste time penning a letter. Call the local authorities immediately if a patient makes threats or displays behavior that you consider violent or abusive, and follow the instructions of the police who respond.

Set a deadline. Inform the patient in the dismissal letter of the date that you will stop providing care to him or her. Divulge that you also will continue to see the patient for acute care needs while they find another provider (typically it is 30 days from the dismissal). Be sure to clearly highlight the termination of care date. There may be legal requirements for the time period (check your state’s laws), but most experts feel that a 30-day period allows enough time for the patient to find another provider while keeping the dismissing physician clear of abandonment charges. Setting a timeframe also is an issue about which you should consult your malpractice carrier.

Don’t refer the patient to a specific physician. You may feel that you are only being helpful but you may also leave yourself open to an accusation of patient dumping. Do, however, include in the dismissal notice the telephone number of your local hospital’s referring physician service or your county’s medical society.

Transfer records. Don’t delay releasing records if the patient finds another physician and provides the proper authorization for a records transfer. Above all, resist the urge to send a note to the new physician that could be seen as badmouthing the dismissed patient. Check with your malpractice carrier about what information to release to a new physician who is taking over the care of a patient whom you’ve dismissed for being disruptive or abusive to you or your staff.

Establishing and adhering to a dismissal process allows you to terminate your relationship with a patient while avoiding unfounded allegations of abandonment or discrimination. Having written guidelines on patient dismissals is not enough; you must apply the guidelines in a consistent manner. Errors, oversights or missteps here may leave you open to charges of patient abandonment or discrimination.

For more information about how to dismiss a patient, check with your malpractice carrier.

Pearl 08/01/14

Caution — Trouble Ahead?
Difficult patients — those more likely to litigate — tend be those who:

  • Fail to make payment arrangements in accordance with standard expectations
  • Don’t comply with recommended treatment plans, including return visits
  • Depart the hospital or other facility against medical advice
  • Act menacing toward you, your employees or other patients or otherwise display disruptive or violent behavior
  • Abuse drugs or controlled substances
  • Threaten to sue you

United States