OD offers advice on terminating the doctor/patient relationship

March 13, 2012

By Sam Quintero, O.D., Practice Advancement Committee member

Terminating the doctor/patient relationship–unknowingly to many health care providers– requires codified guidelines within the practice. These guidelines should be developed to keep the practice from running afoul with contractual agreements between the doctor and third-party payers and with patient abandonment claims.

Optometric physicians in general look toward developing positive and cooperative relationships with their patients, but on occasion challenges develop.  The staff and doctors are not always sure how to best address the situation.

The circumstances surrounding the need to terminate the doctor/patient relationship may range from behaviors that annoy the doctor and staff, such as multiple missed appointments, unpaid balances or threatening gestures made by a patient.

Benign incidences can usually be addressed by discussing them with the patient or through a discussion between the patient and office manager and in some cases with service representatives from the third-party payers. 

The more severe incidents may require more immediate attention and subsequent action.

It is best to be deliberate in a decision to terminate the doctor/patient relationship. Assess the reasons for contemplating severing a relationship with your patient and explore strategies to salvage the relationship, if possible. 

If the issues can be reconciled with the patient, the relationship between the patient and the practitioner’s office may be considerably improved to the extent that the patient promotes the practice in a positive manner and drives additional patients to the practice.

It is important to consider that patients may be difficult or uncooperative because they feel they are not receiving services they expect, or interpret staff actions as not meeting their needs. 

There are a variety of reasons that can lead to a strained doctor/patient relationship – frustrations from the manner in which patient care is delivered in the practice or by other aspects of the health care delivery system. 

Some of the patients’ issues may be due to other providers, health care entities or third-party payers. 

Providing the patient the opportunity to articulate their feelings may help improve how care is delivered within a practice and perhaps allow one to assist the patient in navigating through the myriad of processes encountered in the health care system. 

In the end, one will have an improved relationship with the patient and be a better patient promoter for the practice. 

Angry patients generally present greater challenges because of the offensive remarks they make about the doctor and the staff. 

These types of patients generally elicit defensive responses from the office that tend to be inflammatory to the patient and consequently escalate the adversarial relationship. 

These confrontations are best diverted to a more neutral party within the practice who can rationally interact with the angry patient. 

If this opportunity is not available within the practice, it may be desirable to refer patients to their health plan service representative who may serve as a useful intermediary.

Dissatisfied patients are one source of patients who may be considered for terminating the doctor/patient relationship. 

Patient noncompliance may also be cause for seeking to pursue terminating the relationship.

Examples to consider fall within the following categories: treatment noncompliance, the patient does not adhere to the treatment plan; follow-up noncompliance, the patient frequently cancels or misses follow-up visits and/ or fails to make arrangements for reappointment (“no-shows”); noncompliance with regard to office protocols (abuses refill policies and document generation); and failure to comply with payment policies (fails to pay or uses accounts that are consistently identified as ”accounts with insufficient funds”).

Care must be taken in terminating a patient so that state and federal civil rights laws are not violated.

One cannot terminate a patient for the following reasons: “sex, color, creed, race, religion, ethnic origin, national origin, sexual orientation, age or any other protected class subject to discrimination.”

If it is necessary to terminate the doctor/patient relationship with a patient in a protected class it would be wise to consult with an attorney to assess ones risk of liability.

Other reasons to avoid terminating a patient or for reconsidering the action include: patients involved in the acute phase of treatment, driving distance to another provider offering the same services that are needed by the patient, no other practitioner with specialized skills to care for the patient, and patients who are members of a prepaid health plan.

The process used by the practice should protect against a claim by the patient regarding abandonment of care. 

Leaving a patient without appropriate care or guidance when it can be recognized by others that the doctor/patient relationship is ongoing may prove to be problematic for the practice.

Timing, communication and record-keeping are essential elements to consider in avoiding the abandonment of the care as one proceeds to terminate the professional relationship with a patient. 

Without a documented process, the practice may become exposed to a litagation and potential punitive damages.

Developing the process of terminating a docto/ patient relationship begins with a conversation with the members of the practice and with the patient’s insurer (third-party payer) about plans to terminate the relationship of the patient with the practice (staff and professional care providers). 

The process must be consistent within the guidelines of the insurer in order to avoid cancellation of a contractual provider agreement. 

Some payers have narrowly defined circumstances under which termination is acceptable, and working with representatives of the different payers will allow for an appropriate process to be formulated with specific measures as deemed necessary in order to comply with different payer guidelines. 

The process does not need to be elaborate but it should be comprehensive and consistent. 

All communication with the patient should be in writing, via certified letter, informing the patient that the doctor/patient relationship is terminated, the reason(s) and specific date of termination, willingness to continue to direct the patient’s care for emergency reasons for a specified period (30 days) from written notification, willingness to forward copies of the patient’s records, at no charge, upon written request from the patient, providing instructions to the patient regarding unpaid balances, methods for locating a new doctor and, finally, the date and signature of the doctor. 

The patient record, held in custodial service by the practice, should reflect the reason(s) for terminating the patient, include a copy of the termination letter and should be placed in a special file to facilitate access for future reference.

The attending doctor, unless specified by the patient’s insurer, generally does not have further obligations to assist the patient in finding another provider. 

Providing for a smooth transfer of patient’s records is an important indicator for facilitating the continuity of care. 

The dissolution of the doctor/patient relationship should be held in confidence and not shared with others.

In the event the patient does not receive the certified letter or fails to pick it up from the postal service and schedules an appointment with the practice, show the termination letter to the patient and pleasantly inform them that care will no longer be available at your office.

It is important to note that third-party payers quite often have already developed procedures regarding terminating the doctor/ patient relationship. 

The process within a practice may be influenced by such procedures and will need to be incorporated into the practice process. 

These third-party payer procedures are readily available upon request if not already included in the provider manual. 

In many states, the third-party payer must be notified prior to initiating the notification to the patient. 

The practice’s malpractice insurer should also be consulted for insights and experiences from prior occurrences with other practitioner clients where the liability insurance carrier was involved.

Terminating the doctor/ patient relationship is not a pleasant experience and should be avoided at all costs. 

But when the need arises, it is best to have an established process in place to enable the practice to attempt to salvage the relationship or to at least protect itself from possible litigation.

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