Carefully discharge difficult patients
Develop and follow a policy for problem patients to avoid legal ramifications
In a perfect world, all physicians are perfect, all patients are perfect, and all doctor-patient relationships are perfect. But in the real world, this is not always the case. Patients can be a problem, and as a physician, you have a right to terminate your relationship with them.
 Terry Salz |
Once a physician-patient relationship is established, the doctor has an ongoing responsibility to the patient until that relationship is terminated. Patient abandonment occurs when a physician fails to provide the necessary medical care to a current patient without adequate justification. Therefore, a protocol for patient termination is absolutely necessary.
Never discharge a patient based on age, religion, gender, or ethnicity. Have strict guidelines in place as to what constitutes grounds for patient discharge. If the staff does not have guidelines, it could create legal concerns later; if discharge practices are inconsistent, your actions could be considered discriminatory.
REASONS FOR TERMINATION
Warning signs that a relationship with a patient is significantly challenged or consistently devalued include failure by the patient to comply with a recommended plan of care, including subsequent appointments, and consistent no-shows. Physicians can discharge a patient for several reasons, including continual no-shows for appointments, nonadherence with a prescribed treatment regimen, threatening behavior, and nonpayment for services rendered.
No shows. No-shows create a loss of revenue, but when they become a chronic issue, taking action is critical. If the patient continues to schedule appointments and fails to show up, you also may put your malpractice insurance carrier on notice when you initiate patient dismissal. If this patient has a serious medical problem in the future, you do not want a lawsuit claiming abandonment.
Violent patients. Training your staff and having an emergency response plan in place is your best defense against violent events should they occur. Staff members should be able to judge whether a situation has escalated and then be trained to call 911 immediately. Remember, a false alarm is better than a tragedy. Should you or your staff ever believe that your lives are at risk, leave immediately. Dismissal of these patients should be handled with immediate notifications to the proper authorities and your malpractice insurance carrier.
Patients who don't pay. A patient's failure to pay a bill can occur for several reasons. Nonpayment is often an early warning sign that a patient is unsatisfied with his or her outcome, or it can simply be evidence of lack of funds. Always consider both options, and always try to determine why the patient has not paid. Doing so can be a difficult and uncomfortable process and therefore should always be handled by a staff member with excellent communication skills.
Patients experiencing financial hardship will appreciate the opportunity to make arrangements to honor their financial obligations. Patients voicing an issue regarding care via nonpayment always should be referred to the physician, who should then seek risk management assistance from a professional liability carrier.
- Patients can be a problem, and as a physician, you have a right to terminate the relationship.
- Thorough documentation of your actions before dismissal is crucial.
- If your discharge practices are inconsistent, your actions could be considered discriminatory.
STEPS TO DISCHARGE
Taking the proper steps to discharge a patient is critical to avoid legal consequences:
- Put your dismissal policy in writing and practice it consistently. Make sure your staff members understand what constitutes a reason for dismissal and that you apply your own rules with consistency so no legal ramifications result.
- Check your insurance carrier contract regarding discharge, and inquire about any responsibilities you may have to it in the process. If you are the patient's primary care physician, send a copy of the discharge letter to his or her managed care organization or preferred provider organization and make note of your doing so on the patient's chart. Urge the patient to select a new physician without delay.
- Check your responsibilities to your malpractice insurance carrier. Document all correspondence of discharge. Carry out this policy without exceptions.
- State your reason for dismissal in a letter to the patient; be as objective as you can. Give the patient 30 days (recommended) continuance of care. Make a referral for other physicians, but never suggest a specific physician. Send a copy of your medical records transfer form for the patient to fill out so that the new doctor has the information necessary to provide continuing care without delay.
- Send the discharge letter to the patient via both regular and certified mail. Be sure to keep all documentation. Occasionally, a letter of dismissal does not reach a patient. Legal counsel has indicated that a physician cannot be held responsible indefinitely for a patient because of an unsuccessful attempt at notifying the patient via certified mail.
- If the certified letter is returned undeliverable, mark the return date on the envelope, and attach the letter and envelope to the patient's chart. Once a termination letter is sent via certified mail to a patient who has moved and left no forwarding address or to a patient who has refused to accept the letter, you are no longer responsible for the patient's care.
- Always offer to send medical records to the patient's new physician, whether or not the patient has an outstanding balance with you. Be sure to obtain a written request for the release of a copy of the medical records. If you elect to charge the patient for the copy of the medical records, inform the patient.
Should a patient subsequently request medical attention from you, agree to treat the patient only if the situation is a genuine emergency. If it is not an emergency, then inform the patient diplomatically but firmly that their physician-patient relationship is irretrievably damaged, refer to the letter previously sent, and indicate a willingness to find the patient another doctor and transfer his or her medical records. Document these actions in the patient's record, and send a letter confirming the conversation to the patient at the new address, with a copy of the original letter of dismissal enclosed.
BE PREPARED
We must be realistic about patient discharges. They can occur many times within a practice, for many reasons. The goal is to be prepared and handle these situations and patients with professionalism to mitigate any liability issue that may arise later.
- See more at: http://medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-feature-articles/carefully-discharge-difficult?id=&sk=&date=&pageID=2#sthash.SwIJurJR.dpuf
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