The MD Daily Contract review

September 12, 2018 • By Guest

Enough is Enough

When (and how) to fire a patient


If you are considering firing a patient from your medical practice, you are not alone— physician say about 15% of patient-physician encounters are “difficult.”1 In many cases, “difficult” patients are just part of the job, something else to manage. In other cases, these interactions can cause misunderstanding and miscommunication, which can interfere with the patient’s medical care.2 It is therefore vital to open lines of communication that get to the root of a difficult patient-physician relationship and resolve it. When these fail, however, it is often far better for you and for the patient if you fire her from your practice.

When should you consider firing a patient?

Certain patient characteristics may lead to the need to “discharge” the patient from your clinical practice.1 Such characteristics include:

  1. Patients who are exceptionally risky to your clinical practice, such as belligerent, harassing patients or those who fail to reasonably comply with medical advice
  2. Patients who intentionally refuse to compensate you for care provided
  3. Patients who abuse prescription medications and/or break opioid contracts

Another reason to break the patient-physician relationship is in the case of a patient whose illness lies outside your scope of medical practice.

How should I fire a patient?

Communication is paramount; alert the difficult patient verbally and document this discussion in the medical record. Explain the difficult behavior and what the patient must do to rectify it. Convey to the patient that termination is an option if she does not rectify the problematic behavior.3

If you feel you have done all you can to rectify the patient-physician relationship, and want to fire your patient, follow existing guidelines. The American Medical Association (AMA) provides counsel via its code of medical ethics. Moreover, individual state medical boards often provide state-specific guidelines. Ideally, you should establish a standard process for notifying and firing patients well before you have to deal with a specific, troublesome patient. As with everything in modern medicine, document the process to demonstrate it applies to all patients in your practice equally.

Here are some basic tenets you should follow if you decide to fire a patient from your practice:

  1. Notify the patient or power of attorney in advance—usually 30 days—that you are terminating the relationship so she has time to find an alternative provider. Don’t rely on oral communication alone—send a certified letter with return receipt
  2. Facilitate transfer of care. Depending on your state, this may mean providing patient records to the new provider or you may need to refer patients directly.
  3. Once the patient is fired, communicate with office staff (especially schedulers) so the patient cannot make additional appointments
  4. Always refer to your state laws and third-party payer guidelines (including Medicaid/Medicare) to determine if there are further requirements before dissolving the relationship3

When should you absolutely NOT fire a patient?

While there are certain understandable reasons for refusing to continue patient care, be aware of the law. Civil rights laws (Civil Rights Act of 1964 and the Americans with Disability Act) bar physicians from refusing to care for patients because of race, color, religion, sex, national origin or disability. In addition, it is unlawful to terminate or refuse patient care in the setting of an emergency, acute episode of illness or during the 3rd trimester of pregnancy. In addition, the Emergency Medical Treatment and Active Labor Act (EMTALA) requires physicians to care for patients with communicable diseases even when there is some risk of harm to the physician.

When these laws are not upheld, patients have certain legal rights. They may:

  1. File a lawsuit citing physician negligence
  2. File a complaint under the Civil Rights Laws indicating discrimination or
  3. Report the clinician to the State Licensing Board for patient abandonment if they do not have reasonable time to find a new provider.

Discharging a patient from your clinical practice is the last step in a relationship that has been irrevocably damaged. If you have tried every reasonable avenue and all roads lead to termination, follow the applicable laws and communicate openly to maintain the health of your practice.

References

1. Hull SK, Broquet K. How to Manage Difficult Patient Encounters. Fam Pract Manag. 2007;14(6):30-34.

2. Boutin-Foster C, Charlson ME. Problematic Resident-Patient Relationships: The Patient’ S Perspective. J Gen Intern Med. 2001;16(11):750-754.

3. Willis DR, Zerr A. Terminating a Patient: Is It Time to Part Ways? Fam Pract Manag. 2005;12(8):34-38.

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