Procedures for patient discharges

I recently received an inquiry from a physician whose practice administrator had discharged three patients for failure to meet their financial responsibilities. The physician inquired as to whether or not it should be his signature on the letters to the patients and what other issues he might need to be familiar with when a patient is discharged.

I have addressed the discharge of patients from medical practices several times in my blogs over the years. There are generally several reasons why a patient might be discharged from a practice, such as creating disruption in the practice, repeated failure to show up for appointments, failure to follow treatment instructions, and even drug-seeking activities. Of course, one of the most common reasons a patient is discharged from a practice is for failure or inability to meet financial obligations.

In providing the following guidance, I assume that: (a) every appropriate effort has been made to address the patient’s ability to meet his or her obligations and to remain in the practice, and (b) discharging the patient from the practice will not violate any payor contracts. Generally, I recommend the following steps be taken when discharging patients:

• A letter must be sent to the patient advising him of his discharge from the practice. I always recommend that at least 30 days’ notice be provided; however, it is prudent to offer more time in the event that the physician is a specialist (and the patient may have trouble receiving continuing care), the patient has a chronic health condition requiring close monitoring, or the practice is located in a rural area where it might be difficult to find a replacement physician. In some types of practices, such as oncology, some of my clients feel more comfortable offering 60 to 90 days as a transition period to a new physician.
• During the notice period, it is essential that the practice continue to offer emergency care, necessary treatment (which can’t wait until a new physician can be found), and fill prescriptions. These rights should be spelled out in the letter to the patient. Some physicians and practices may disagree on how this issue should be handled; however, I always urge my clients to make the decision based upon the patient’s perception of how he is treated so as to avoid a complaint against the physician or practice with the state licensing authority.
• When sending a letter to a patient, it does not really matter whether the letter is coming from the physician or the practice as long as it is properly written. Typically, the patient “belongs” to the practice and not the physician individually. Thus, the practice may be on top of financial issues and responsible for the decision to discharge a patient. The larger the practice, the more likely this decision may be made without the physician’s consent. However, I think it is advisable for the physician to be identified in the letter, even if the physician is not signing the letter itself. The practice should also determine, after consultation with the physician, whether any special steps should be taken related to the particular patient in terms of his health, fragility, ability to understand the letter, and other considerations. While a practice is engaged in the business of medicine, sensitivity to the plight of the individual patient is still ideal.
• Even if a patient is discharged from a practice for financial reasons, it is essential that an appropriate transfer of medical records be made in accordance with state and federal laws. Medical records cannot be held hostage for payment.
• Many physicians are wary of recommending new physicians to a patient discharged from the practice. If the reason for discharge is financial (and based on an inability to pay, rather than an unwillingness to pay), sharing information about local charities or other providers who may charge less or accept different coverage can help a patient feel less abandoned and contribute towards continuity of care. Many of my clients also recommend that a patient contact the state medical society, local physician referral service or his insurer (if any).

Sometimes discharging a patient from a medical practice for financial reasons is necessary, whether a physician agrees or not. Following the proper steps will protect both the physician and the practice and hopefully provided needed time for the patient to find alternative care.

Ericka L. Adler is a partner at the firm Roetzel & Andress. Her primary practice focus is in the areas of regulatory and transactional healthcare law.