Terminating the Prvider- Patient Relatinship Prvided by Cverys Risk Management
Terminating the Prvider-Patient Relatinship What s the Risk? An allegatin f abandnment may be brught against a prvider if the prvider ends an established prvider-patient relatinship withut reasnable ntice and withut reasnable pprtunity fr the patient t arrange fr medical care. When Is This Risk an Issue? Physicians encunter a myriad f situatins when caring fr patients that may trigger a need t terminate the physician-patient relatinship. Examples f such situatins include patient nncmpliance, failure t pay a bill, a drug-seeking patient, issues with minrs, verbal abuse, physical threats r harm, and criminal activity. The fllwing sectin includes infrmatin n sme f these cmmn situatins. Patient Nncmpliance While it s nt a hard and fast rule, terminatin f the prfessinal relatinship may be warranted if a patient misses three cnsecutive appintments. Extenuating circumstances in individual cases may indicate a need fr leniency and understanding. Nn-payment f Bills Chrnic nn-payment f bills may be a reasn fr terminating the prfessinal relatinship, unless extenuating circumstances indicate a need fr patience and/r the patient agrees t a payment schedule that wrks fr bth the practitiner and the patient. Drug-Seeking Patient Selling drugs prescribed by a physician is a criminal activity and grunds fr immediate terminatin f the prfessinal relatinship. On the ther hand, drug-seeking behavir fr persnal use is nt a criminal activity and requires nging medical treatment. Accrdingly, terminatin f the prfessinal relatinship shuld be a last resrt fr the patients in this latter categry. Minrs Frm time t time, a practitiner may want t cnsider terminating the prfessinal relatinship with a pediatric patient whse parents are abusive, nncmpliant r financially irrespnsible with respect t payment. Patient Wh Sues Sme patients will name a practitiner in a medical prfessinal liability lawsuit and still want t cntinue seeing the practitiner. Given the circumstances, sme practitiners chse nt t This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 1
Terminating the Prvider-Patient Relatinship cntinue treating the patient. Hwever, it is imprtant t reslve any acute cnditins befre terminating the prfessinal relatinship. Criminal Activity, Vilence and Abuse Criminal activity invlving the practice is reasn fr immediate terminatin f the prfessinal relatinship (fr example, theft f prescriptin pads). Verbal abuse, physical vilence, and threats f physical harm are, in almst all cases, als reasns fr immediate terminatin f the prfessinal relatinship. Criminal activity, vilence and abuse are nt subject t the guidelines gverning terminatin f the prfessinal relatinship fr nn-criminal activity and a 30-day ntice perid is nt required. In these instances, verbal terminatin is acceptable. Terminated Patient Presents fr Care Practitiners are ethically mandated t see any patient already terminated frm the practice wh presents in their ffice in crisis. A crisis visit des nt cmmit the practitiner t nging care. In additin, a physician wh is n call in the ED must see the ED patients he/she is called t see, including thse previusly terminated frm his/her practice. Hw Can I Reduce Risk? Althugh physicians may terminate a physician-patient relatinship fr varius and multiple reasns, certain steps shuld be fllwed t help avid a pssible allegatin f abandnment. These steps include establishing prcedures fr terminating relatinships, determining if a relatinship may be terminated, ntifying the patient in writing, cntinuing t treat the patient during the ntice perid, and aviding re-establishing a relatinship. The risk management recmmendatins fr each f these steps fllw belw. Establish Prcedures fr Terminating Relatinships Develp a written plicy and prcedures Develp a written plicy and prcedures fr discharging patients frm the practice; draft a standard terminatin letter. See the fllwing sample terminatin letters: Terminating the Dctr-Patient Relatinship Behaviral Issue Terminating the Dctr-Patient Relatinship Nn-cmpliance Terminating the Dctr-Patient Relatinship Nnpayment f Bill This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 2
Terminating the Prvider-Patient Relatinship Determine If Relatinship Can Be Terminated Evaluate each relatinship D NOT terminate the relatinship with a patient in crisis Use extreme cautin with pregnant and behaviral health patients Evaluate each relatinship n a case-by-case basis. Cnsider the patient s underlying state f health and the severity f the signs and symptms f the patient s disease prcess, the stage f the current curse f treatment, and the availability f cmparable medical care. Sme cnditins, such as pregnancy, require nging care and reslve after a perid f time. Accrdingly, the relatinship with a pregnant patient wh has reached 20 weeks gestatin shuld nt be terminated until after reslutin f the pregnancy and cmpletin f any requisite pst-partum care. Ensure that the patient is nt in a physical r emtinal crisis. Fr example, a psychiatrist may nt terminate a patient wh is suicidal r in a state f extreme agitatin r depressin. Use extreme cautin when circumstances, such as physician disability, require that a relatinship be terminated with a pregnant patient wh is past 20 weeks gestatin r with an acutely ill behaviral health patient. Help the patient find a new prvider. Cntact the new prvider t verbally hand-ff the patient, prvide medical recrds, and cnfirm that an appintment is scheduled. Refrain frm making inflammatry remarks abut the patient t the new prvider. Dcument the verbal hand-ff in the medical recrd. Assess the situatin Assess the situatin t determine if there are any underlying factrs fr the patient s behavir. The fllwing recmmendatins relate t cmmn situatins encuntered when cnsidering terminatin f a prfessinal relatinship. Patient Nncmpliance Develp a missed appintment plicy and define hw many missed appintments will trigger cnsideratin fr terminatin f the relatinship. Publish the missed appintment plicy in the practice welcme brchure. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 3
Terminating the Prvider-Patient Relatinship Cnsider terminatin f the prfessinal relatinship when the patient vilates the missed appintment plicy. Nn-Payment f Bills Ntify patients n their first visit regarding respnsibilities fr bill payment and cpayments. Include the name and phne number f the cntact fr billing infrmatin r questins. Prvide an adequate amunt f time t pay the bill (e.g., 30 days). Cntact the patient t determine why the bill has nt been paid. The patient may be unhappy with the treatment r there may be extenuating circumstances, such as the lss f a jb. Terminating the relatinship with the patient may lead t further anger and may even prmpt the patient t sue. Demnstrating persnal attentin and cncern fr the underlying prblem may help t prevent a cnflict with the patient frm escalating. Send the patient a 30-day ntice f terminatin if payment is nt received. If, after 30 days, the patient has nt cntacted the ffice t arrange payment, send a final terminatin letter. D nt deny medical care t a patient with an utstanding bill until terminatin becmes effective. Drug-Seeking Patients Assess the patient fr a medically indicated need fr piids. Vice cncern abut drug dependency. Refer the patient t an apprpriate specialist t help with detxificatin r help the patient enrll in a licensed detxificatin prgram. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 4
Terminating the Prvider-Patient Relatinship Minrs Discuss the situatin with the parent befre terminating the relatinship with the minr if the minr is nt emancipated. Send the terminatin letter t the parent if there is a decisin t terminate the relatinship with a minr wh is nt emancipated. Patient Wh Sues If yu are nt cmfrtable cntinuing t treat the patient, cnsider terminatin f the prfessinal relatinship after reslving any acute cnditins. Explain t the patient that, given the circumstances, anther practitiner might be better able t meet his/her needs. Criminal Activity, Vilence and Abuse Cnsider immediate verbal terminatin fr verbal abuse, physical vilence, threats f physical harm r criminal activity invlving the practice. Cnsider seeking the reasn fr abuse r vilence, rather than resrting t immediate terminatin f the prfessinal relatinship, if the behavir ccurs as a ne-time event in a lng-term relatinship. Send a fllw-up letter indicating the reasn fr terminatin, directins t btain nging care at a lcal urgent care facility r emergency department, and assurance that the medical recrd will be frwarded t the new practitiner selected by the patient. Terminated Patient Presents fr Care D nt deny care t a terminated patient when the patient presents t the ffice in crisis r t the ED when yu are n call. Fllw-up with the patient t ensure that nging care is prvided. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 5
Terminating the Prvider-Patient Relatinship Ntify the patient s primary care prvider f the visit and advise f the need fr fllwup. Recgnize limitatins fr terminatin f a prfessinal relatinship Check health plan cntracts D nt terminate a relatinship because f gender, race, religin r sexual preference. Furthermre, relatinships with patients cvered under the Americans with Disabilities Act (ADA) may nly be terminated fr reasns similar t that f a nn-disabled patient. Relatinships may nt be terminated because f the disability r illness r csts that the disability r illness might invlve (e.g., prviding an interpreter fr a deaf patient). Check the prvisins f any cntract yu have signed with the patient s managed care rganizatin r health plan t ensure cmpliance, as third party payers may als have their wn plicies and prcedures which need t be fllwed when a prfessinal relatinship is terminated. Reslve acute cnditins Cntinue t treat patients wh have an acute medical cnditin. Reslve acute medical cnditins prir t terminating the prfessinal relatinship. Ntify Patient in Writing Send a certified letter Ntify the patient in writing via a certified letter t the patient s hme address, return receipt requested. The ntice may r may nt include the reasn fr terminating the prfessinal relatinship. If the patient refuses t accept the certified letter, file the returned letter and place it in the medical recrd r scan it t the electrnic medical recrd (EMR). Mail a duplicate letter in a plain envelpe with n return address. State the effective date Clearly state the date upn which the terminatin f the prfessinal relatinship will becme effective. Prvide resurces Prvide infrmatin abut resurces, such as the lcal medical sciety r a lcal medical center, that are available t help identify ther physicians in the same r similar specialty. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 6
Terminating the Prvider-Patient Relatinship Specify the relatinship that is being terminated Determine exactly with whm the prfessinal relatinship is being terminated when the practitiner is in a grup practice. Specify whether the prfessinal relatinship is being terminated nly with the practitiner signing the letter r with the entire practice. Name all f the grup members r the entire practice if the relatinship is being terminated with the practice. File a cpy f the letter Place a cpy f the terminatin letter and the return receipt in the patient s chart r scan it t the EMR. Dcument prcess Dcument each step in the terminatin prcess, including cmmunicatin with the patient. Include qutes whenever pssible. Nte what the practitiner said and the patient s respnse. Cntinue t Treat Patient During Ntice Perid Treat fr 30 days Cntinue t treat the patient fr a reasnable perid f time, such as 30 days, while the patient makes arrangements fr the services f anther physician. During these 30 days, treat patients wh are in crisis and present either t the ffice r the lcal emergency department. Release Cpy f Medical Recrds t New Prvider Use an authrizatin frm Offer t transfer recrds t the new physician upn receipt f a signed authrizatin t d s. Include an authrizatin t release recrds with the terminatin letter. See sample Permissin Frm t Send Medical Recrds. D NOT withhld recrds D NOT refuse t prvide a subsequent treating physician with a cpy f the medical recrd because the patient has nt paid fr medical services. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 7
Terminating the Prvider-Patient Relatinship Avid Re-establishing Relatinship D NOT make new appintments Infrm all practice staff members that a terminatin letter has been sent. If a new appintment is made after the effective terminatin date, it may arguably re-establish the relatinship. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 8