Discharging Problem Patients the Right Way

Discharging patients is not fun, but it is often prudent and necessary. Because of the legal and ethical implications in patient dismissal, it is helpful to possess practical guidance on just how to correctly terminate a patient.

I find that most patient terminations fall into one of four buckets:

• Patients who are verbally abusive or threatening to providers or staff;

• Patients who are noncompliant with their care - missing appointments and/or recommended testing;

• Patients who "doctor shop" and often are most interested in obtaining medications; and

• Patients who do not pay for the care you provide.

Regardless of why the patient is being terminated, the letter itself is straightforward and contains four elements:

1. The notification itself

2. The effective date

3. The reason for the termination

4. An offer to provide a copy of the records to the physician assuming the patient's care

Notification and effective date

Begin with a straightforward sentence stating the patient is being discharged from the practice. The letter should include an effective date that is at least thirty (30) days beyond the date the letter is mailed. Healthcare attorney, Rodney K. Adams recommends that this period be extended 45 days to 60 days if you practice in a specialty or geographic area where it may take patients longer to find another physician, or if you are providing current care for an ongoing condition.

During the period between your letter and the patient termination date, offer to provide emergency care only. Our practice refills necessary prescriptions but otherwise avoids the provision of non-acute care during this period. 

You are notrequired to suggest alternative providers in your letter, nor do I recommend doing so. I do not like it when other groups refer their "problem" patients to us, so I do not advise our problem patients to contact specific physicians or groups. Our discharge letters simply say we are providing ample time for the patient to find another provider.

Transparency

I think it is appropriate to provide a reason for the patient's discharge. Even if the patient does not like the reason, they have a right to know why they are being discharged.

More patients are being discharged because they are unable to pay their bills. It's unfortunate, but it is a reality. There is nothing illegal about doing so, notes Adams. Just as patients who do not show up for appointments are breaching the physician-patient relationship, so too are patients who receive care but do not pay for it.

Finally, patients have a right to a copy of their medical records. Your letter should offer to make a copy of these records available to the patient or their new physician. You do not need to provide a copy of your medical records with the termination letter.

Other points to remember

• You should document the patient's termination in your practice management system to alert your staff not to make appointments going forward.

• It is not necessary to send a discharge letter via certified mail, notes Adams. Many patients will not accept or open certified mail.

• A small subset of payers require that you notify them when discharging a patient. I have never found this to be an issue, but you might review your payer agreements for such language.

Rodney K. Adams, JD,is a healthcare attorney with LeClairRyan in Richmond, Va. He is the author of "Virginia Medical Law" and other publications and may be reached at Rodney.adams@leclairryan.com.  

Lucien W. Roberts, III, MHA, FACMPE, is administrator of Gastrointestinal Specialists, Inc., a 23-provider practice in Central Virginia. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He may be reached at muletick@gmail.com.

Click the following links to download sample patient discharge letters. Sample Discharge for Rudeness; Sample Discharge for Non-Payment; Sample Discharge for Non-Compliance; Sample Discharge for Doctor Shopping.