When A Patient’s Rx is Termination

terminating a patientBy: Dave Davidson

There will likely come a time in your practice when you find yourself considering whether you should maintain a relationship with a patient.   It may be that the patient is non-cooperative.  Or the patient may refuse to pay his or her bill, or to follow a reasonable payment plan.  Even more significantly, the patient may have engaged in behavior that is disruptive to your practice.  For whatever reason, you are questioning the value of the relationship.

In those situations, the law does allow a physician to terminate a patient from his or her practice.  However, careful analysis must be done in these situations, and there are several steps that should be followed. The risk of a claim of abandonment or of professional negligence makes it important to protect yourself, your practice, and the licenses of the providers within your group. You may already have a process spelled out in your policies and procedures, and if you do, that process should be followed.  However, make sure your policy at least covers the points below.

The first thing to consider is the timing of the termination.  Patients can terminate their relationships with you at any time.  It is not as easy for providers.  You are required to go through more of a process, and there are times when you should consider a delay.  For example, I do not usually recommend terminating a surgical patient if you have not completed all post-surgical follow up care.  If a post-surgical complication arises, you want to be the one managing the care.  Changing providers during an acute phase of care can give rise to a situation in which the patient, the patient’s subsequent treating physician, or the patient’s attorney blames a complication on you.  If at all possible you should therefore treat the patient through that acute situation before terminating the relationship.

Note that there are reasons for which a patient cannot be discharged from your practice.  Patients cannot be terminated for being a member of a legally protected class.  In other words, you cannot terminate a patient because of the patient’s sex, religion, race, color, national origin, age, pregnancy, citizenship, familial status, disability, status as a veteran, genetics, AIDS/HIV, or sickle cell trait.  I include the patient’s sexual preference and gender identity in that list as well.  A patient in a protected class can be terminated for a legitimate reason, but not because they are a member of a protected class.

With those exceptions, a patient can be terminated from a practice.  In the case of a group practice, I generally recommend terminating the patient from the entire group, and not just from a single physician.  It is very likely that the behavior that made you think about termination in the first place will not stop with another doctor.  A practice-wide termination also avoids putting the terminating doctor in a difficult situation if he or she is on call and that patient needs immediate care.

You also must be aware of those situations in which you are part of a limited panel, or are the exclusive provider for a health plan or HMO.  In those cases, the patient may not have as many options to choose from in seeking a new doctor.  In those circumstances I recommend that you enlist the help of the health plan right away.

In extreme cases, an immediate termination is acceptable.  For example, if a patient became violent, or threatened physical harm to you, your staff, your patients, or anyone else in your practice, you should end the relationship right away.  Likewise, if the patient has engaged in criminal activity on your premises, you can, and probably should, end the relationship.  Those situations should be considered on a case-by-case basis, but immediate termination under those circumstances is valid.  Remember that even then, you should still follow up with the patient in writing to avoid a claim of an abandonment.

In every case, once the decision to terminate your relationship with a patient has been made, you should notify the patient in writing.  I recommend the notice be sent with confirmation of delivery, or a return receipt, so you can prove it was delivered.

When I help draft this kind of letter, I generally follow the following outline:

– We have decided to terminate our physician/patient relationship,

– We made this decision because: you have failed to pay your bill/been non-compliant/not been able to work cooperatively with the practice, etc.   (Note that I stay pretty generic here.  The more specific points you provide, the more likely you will receive counterpoints from the patient.  You should provide a reason, but not too many details.)

– Our relationship will end thirty days from the date you receive this letter.

– We will continue to care for you during this time, but it is your responsibility to begin to seek a new doctor immediately.

–  It is important for you to have a new doctor right away because: (If applicable to the patient’s condition, I will emphasize the risk of not finding an alternative provider.  For example:  As you know, your diabetes needs continuous monitoring.  It is therefore imperative that you arrange for a new doctor immediately, to make sure your condition does not get worse).

– Please let us know if you would like our assistance in transferring your care.  (You may also include contact information for the patient’s health plan, other potential providers, and/or the patient’s primary care physician if applicable.  Obviously the more helpful you are, the better.  Claims of abandonment arise from patients who feel like they’ve been left hanging.)

– Due to our decision, we will only provide prescriptions or medication refills through the date of termination.

As you can see, a meaningful analysis should go into every instance in which you are considering ending your relationship with a patient.  The risk of opening yourself up to a malpractice action or a claim of abandonment warrants that these decisions not be made lightly.  However, by following the right process, you can continue to maintain a practice populated with patients the value of whom is not in dispute.


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