When, where and how to 'fire' a patient

Ever entered a restaurant with a sign on the door reading “We reserve the right to refuse service to anyone”? Ever wished you could hang one of those in your office entryway?

When it comes to dealing with problem patients, we don’t recommend turning folks away at the first sign of trouble. But when real, recurring issues with a patient just won’t go away, it’s within your rights to terminate that relationship.

And not only is it in within your rights -- in some instances patient dismissal is a wholly appropriate, necessary step. That being said, exercise caution when you consider firing a patient, and make sure you do it properly to avoid incurring any adverse consequences.

The when

While there are no exact legal rules governing patient termination, there are ethical standards that call for doctors to accept ongoing responsibility for their patients’ medical care.

When is it OK for that responsibility to end? While it’s tough to pinpoint, there are some generally agreed-upon guidelines.

The most common situations surrounding dismissal involve patients who:

  • repeatedly refuse to pay,
  • no-show for scheduled appointments or constantly reschedule them,
  • consistently behave hostilely toward you or your employees, or
  • refuse to follow treatment plans.

For circumstances like those above, try to make the patient relationship work before firing a troublesome individual. Offer payment plans, discuss behavior issues or warn the patient that he’s on thin ice. Document your efforts and then, if nothing changes after the situation has been addressed, take action.

More dramatic situations merit less caution in dismissal. If you’re faced with a violent patient, whose substance abuse issues are compromising your practice or your ability to deliver care, who divulges a significant conflict of interest, or who has taken legal action against you, more abrupt discharge measures can and should be taken.

The why

Even in the face of appropriately terminable situations, some doctors, concerned with legal repercussions and ethical expectations, hesitate to fire patients. But often continuing to keep a patient carries more of a legal threat than letting him go.

“It’s not the patient who’s terminated who keeps the doctor up at night,” according to Susan Keane Baker, a patient relations and risk management consultant. “It’s the one who should have been terminated but wasn’t.”

The legal and financial repercussions of continuing to care for a major problem patient can be significant -- unpaid bills, malpractice-suit potential and employee dissatisfaction can wreak havoc on your practice. Yet when it comes to terminating a patient, your malpractice risk is minimal, so long as your actions are founded, nondiscriminatory, and don’t put the patient’s health in danger.

Terminating a problematic relationship often proves beneficial for the patient as well, since the patient can start over with a new practitioner who may be a better fit. You shouldn’t both be saddled in a situation that just doesn’t work.

You should, nonetheless, solicit your attorney’s advice and assistance for good measure. That's especially true if it's the first time you’ve encountered this type of situation, if you have any doubts about the legality of your past or current dealings with the patient, or if you don’t already have a firm patient-dismissal policy in place.

The how

Since neither doctor nor patient signs a legal document upon entering into the relationship, you’re not legally obliged to provide a letter of termination -- but you still should.

“The patient-physician relationship, while not a written contract, should be treated as one by the physician in order to avoid legal trouble upon its termination,” advised healthcare law expert Steven M. Harris.

Start by verbally communicating your reasons for dismissal to the patient directly as soon as you’ve decided to formally end the relationship; don’t saddle a front-desk staffer with taking the patient’s phone messages while you wait and keep the patient in the dark.

Provide the patient with a reasonable amount of time to find a new provider before you completely cut him off, provide resources for his search and make known the deadline upon which the relationship will end entirely -- a date of your choosing that feels appropriate considering the patient’s conditions and needs. In the interim period, continue care and contact as necessary.

When your deadline arrives, send (through certified mail) a formal letter confirming the termination to the patient -- preferably one drafted by your attorney. Throughout the entirety of the process, document your actions in the patient’s record to minimize your risk.

While it’s never pleasant and it’s rarely easy to fire a patient, so long as you conduct yourself with directness, professionalism and compassion, your risks should be minimal and your consequences few. Still, it never hurts to exercise caution – and call your lawyer – to make sure you’ve got all your bases covered.

How have you handled firing a patient at your practice?

Madelyn Young is a content writer for CareCloud who specializes in covering practice management, medical billing, HIPAA 5010, ICD-10 and revenue cycle management. You can read her work on Power Your Practice and the CareCloud Blog.