By Jillian Pedrotty, MHA, Senior Specialist, MMS Physician Practice Resource Center
When physicians encounter patients who routinely don’t pay their bills or are extremely difficult to work with, they may think about dismissing these patients from their panel. This is not an easy decision. Physicians have an ethical duty to promote continuity of patient care, and may fear being accused of patient abandonment. The medical profession is increasingly, and appropriately, tuned into the factors that can make self-care and appointment adherence challenging for patients. Sometimes physicians may continue to work with problematic patients, even to the detriment of their own well-being. In certain circumstances, however, physicians can reasonably terminate a patient relationship.
Identifying the Reason for Termination
Typically, a physician’s relationship with a patient ends for one of several reasons: the patient seems unable to follow the treatment plan and care recommendations; the patient is verbally or physically abusive; the patient continuously does not pay their bill; or the patient repeatedly misses appointments. Patient-provider relationships cannot be legally terminated for discriminatory factors, such as race, ethnicity, gender, disability, age, religion, or sexual orientation.
Physicians considering the termination of a patient have several factors to weigh. Increasing recognition of the social determinants of health has provided insight into why patients may not make their appointments or follow treatment recommendations. Barriers outside patients’ control may include certain disabilities or illnesses, reactions to medications, literacy or language issues, financial hardship, social challenges (such as domestic abuse), and logistical or environmental factors (for example, inadequate transportation or housing). For this reason, the term “noncompliant patient” has fallen out of use. Contemporary practice models and standards of care emphasize respect for the “whole
patient,” shared medical decision making, and the patient-centered medical home as a means of lowering or navigating some of the barriers.
Allowing Course Correction
When considering terminating a patient-physician relationship, it is good practice to allow patients an opportunity to rectify the situation. Physicians cannot terminate a relationship with a patient because they haven’t paid a bill, for example — but if the patient continues to receive care and
not pay for it, the practice staff should attempt to work out a payment plan with the patient. If the patient continues not to pay, the practice can consider terminating the relationship.
Clarifying Patient Abandonment
Patient abandonment is typically defined as the unilateral severance by the physician of a patient-physician relationship, without giving a patient sufficient advance notice to obtain the services of another practitioner. These claims are a tort, similar to negligence, and can induce significant liability, fines, restrictions, and/or the loss of a professional license.
Steps to an Ethical Termination
Once a physician has identified a reason for termination, they should consider these steps:
- Review contracts and communicate with health plans: It’s important for physicians to review their health plan contracts, especially for the patient in question, and check for clauses regarding the termination of a patient-physician relationship. Alternatively, a physician can contact the patient’s health plan and discuss next steps to ensure the termination is handled according to the terms of the contract.
- Provide written notice: A physician should send a written notice to the patient, preferably by certified mail with a return receipt requested. This provides evidence that they communicated the end of the relationship with the patient. The notice to the patient should include the following:
- A brief explanation for terminating the relationship; the details should be documented in the patient’s record
- An agreement to continue to provide treatment for a reasonable period of time to allow a patient to secure care from another person
- The date the termination will be effective; typically, 30 days is sufficient, but the time period may need to be extended based on the patient’s condition, payer contract, or access of care
- Advise that the patient contact their health plan for a list of alternative providers within their network
- An offer to transfer records to a newly designated physician upon signed patient authorization to do so
- Communicate with the entire staff: A physician should inform the entire practice staff of the end of a relationship with a patient to avoid accidentally re-establishing that relationship.
