Episode 138: When It Might Be Time to Part Ways

Voiceover:
You are listening to Your Practice Made Perfect. Support, protection, and advice for practicing medical professionals, brought to you by SVMIC.

Renee Tidwell:
Hey everyone, welcome back to Your Practice Made Perfect. My name is Renee Tidwell and I'll be your host for this episode. In today's show, we will discuss patient termination. What we're really meaning is discharging a patient from your practice, which seems to be a topic of concern for many of our policy holders lately. Today we have our very own Jeff Woods here to discuss this with us. Welcome, Jeff.

Jeff Woods:
Glad to be here. Thank you.

Renee Tidwell:
Great. Before we get started, let's kick this off with an introduction. Tell us a little bit about yourself.

Jeff Woods:
Okay. I'm currently the risk education manager at SVMIC. I've served in that role for approximately seven years. Prior to that, I was in our claims department where I was a senior claims attorney for approximately 13 years. And prior to that, I was in private practice defending physicians and other healthcare providers in medical malpractice cases.

Renee Tidwell:
You've got a lot of great experience, Jeff, to walk us through this conversation today. What would your initial advice be to our policy holders who are considering discharging a patient?

Jeff Woods:
If safety is not a concern, and I really want to stress that, if safety is not an issue, then I would suggest that providers try to work with their patients to determine what barriers may exist that might be causing the issue. Sometimes the barrier may be a result of a medical issue, it could be a physical, a mental or an emotional issue, and then sometimes it may be caused by a lack of resources such as reliable transportation, family and friends who cannot provide support or help to the patient, or maybe it's due to a lack of health insurance or money. Other times, especially when the patient is non-adherent, it can be due to a failure of communication between the physician and the patient or a lack of comprehension by the patient because of a language barrier or an education barrier. And these barriers that I'm talking about can often be overcome through understanding and discussion. It's important to remember that when you do try to determine what barriers exist and how to overcome those barriers, that you thoroughly document in the EHR your efforts and your discussions with the patient.

Renee Tidwell:
Why is that that it's so important to document it in the EHR?

Jeff Woods:
Well, I think your documentation in the EHR is going to be your best defense if there is a claim or a lawsuit later on. But also, providers very often dismiss a patient as an emotional response. They get angry and their first response is to dismiss the patient. And what they find out later is the potential consequences of that dismissal, whether it was right or wrong, as well as the hoops that they or their practice manager have to jump through to properly dismiss the patient, can be more time-consuming and more emotionally taxing than actually working with a patient to remove those barriers. Now understand, that's not to say that patients should not be dismissed from the practice. Just try to work with a patient first and document your efforts.

Renee Tidwell:
What are the potential consequences?

Jeff Woods:
There are several. What we see most often at SVMIC is claims of provider abandonment and this can be asserted as part of a malpractice claim or as something else. And then state board complaints where the patient is alleging unprofessional or unethical conduct. And we really see more state board complaints being filed than lawsuits being filed. And the reason for that is because a patient doesn't have to have an attorney to file a state board complaint, it's usually a form that they can access online. It's usually anonymous. So they know if they fill out this form and submit this complaint to the state licensure board, it just causes problems for the physician or the provider. So that's why it's probably one of the most frequent things that we see.
Other consequences are allegations of state and federal discrimination laws, violation of those laws such as the Americans with Disability Act, age discrimination, racial discrimination, also violation of third party payer agreements, and that's where patients will contact their own insurance carrier and try to get the physician or the practice kicked off the approved list. And then also something that's very popular now is negative social media posts and negative online ratings for the provider. And we've also seen patients who have been discharged from a practice constantly making harassing phone calls to the practice and actually showing up at the office and creating problems for the physician or the office staff.

Renee Tidwell:
Jeff, I know our policy holders are so busy right now, especially post pandemic. A lot has changed in medicine. The patient relationship as we're talking about has changed as well. What I'm hearing you say is just trying even harder than before to work with these patients and have these conversations so that hopefully we don't have to terminate the patient-physician relationship. But who has the conversations? Is that the physician adding this in? Is it an office manager? Is it a combination? Can you kind of talk me through that process a little bit?

Jeff Woods:
Absolutely. That's a good question. And the simple answer is it depends. It depends on what the barrier is. First and foremost, at SVMIC, we recognize that time is the greatest enemy to physicians, but very often these barriers can be discovered and overcome with just a couple of minutes of discussion. For example, if it's a situation where the patient is habitually late for appointments or is canceling appointments at the last moment, then it might be a situation where they're having transportation problems and you need to ask the patient, "Why do you keep missing appointments?" "Well, I don't have a reliable car, I don't have a reliable transportation and someone to help me." Well, at that point you can say, "Well, let me see if we can help." And then you refer to a nurse or someone in your office to maybe contact a social worker or some form of transportation in your area.
That's not something that the physician or provider necessarily has to do. If it's a situation where the patient is being non-adherent to the treatment plan, ask if they have a family member, a spouse or an adult child or someone that can accompany them, have that person come in because very often what we see is patients get home and they're overwhelmed. They don't remember exactly what medication they're supposed to take and they just don't follow up maybe with a diet because they get home and everyone else is eating the food they're not supposed to eat, so they eat it too. So if you can involve a family member, with the patient's consent, then they can help make that patient be more adherent to the plan. So as far as who should deal with it, the physician should try to determine the barrier initially, but then that doesn't mean the physician has to always be the one who follows up. Someone else in the office can.
Now, if it's a situation where the patient is not paying their bill, I would suggest that you let someone in the billing department or the practice manager address that with the patient. So again, these conversations shouldn't take but a couple of minutes. And let me say this, you shouldn't be having these conversations every day with most of your patients. These should be the outliers in your practice. If you're having this conversation a couple of times a week, a few minutes is probably not going to be that significant. Now, if you are having patients who are all constantly non-adherent and they're all late for their appointments, then you might look and see if there's some other issues going on. But generally speaking, these conversations shouldn't take a great deal of time.

Renee Tidwell:
Okay. Shouldn't be happening that often.

Jeff Woods:
Right.

Renee Tidwell:
Jeff, we've talked a lot about how to try to avoid this situation, but at the end of the day, I'm sure there are some circumstances where you may have to terminate a patient. Talk to us about that for a few minutes.

Jeff Woods:
Yes, assuming that you've tried to work with the patient to eliminate barriers, and if the patient is still non-adherent or still refuses to pay their bill and you've made the determination, you're going to have to terminate that physician-patient relationship. We recommend certain steps be taken, and let me say first off, there are no guarantees. In other words, the provider can do everything appropriately as far as dismissing the patient from the practice and still have the patient pursue some of the actions I talked about earlier on social media, state board complaints or even a lawsuit. But hopefully by taking the steps that I'm about to outline, the likelihood that there will be a negative consequence to the provider will be reduced. Also, let me throw in a disclaimer here. The steps I'm going to outline are general recommendations and providers need to be familiar with the laws, rules, and regulations of their individual state.
Finally, these steps apply if safety is not a concern. I will discuss later what to do if safety is a concern. To terminate the physician physician-patient relationship, it really should start before you have to terminate a patient. And what I mean by that is your practice should have a written dismissal policy in place so that any termination can be done consistently, legally, and in a non-discriminatory manner. And we would strongly suggest that you have your private legal counsel review that policy or help draft it. You also need to be familiar with the requirements of third party payers. The provider needs to know that or the practice manager, someone in the office needs to be aware of what requirements that third party payers have because some insurance companies require that certain conditions be met before one of their insureds can be dismissed from a practice.

Renee Tidwell:
Now, do those requirements change frequently or are they pretty across the board the same?

Jeff Woods:
It really depends on the insurance carrier. Medicare may have certain requirements, private third party payers, insurance carriers may have requirements, some may have no requirements, and these are all contractual obligations between the third party payer and the practice. So if you violate those, you could be off of their list. And that's why a lot of times we see patients contact their own insurance carrier and say, "This physician terminated me. I don't like the way they did it. It's unfair."

Renee Tidwell:
Trying to get them in trouble, right?

Jeff Woods:
Exactly. And if you have violated your contract, that could create problems for the provider. So those are things that you need to do beforehand. Some other things before we get to the actual termination part of it, is I would say do not terminate care at a critical stage of treatment. For example, if you're an OB-GYN and you have a patient who's in her eighth month and she hasn't paid her bill, I wouldn't terminate because the risk involved there. You just may have to go ahead and after the baby's delivered, try to deal with the financial aspects of it. And again, I keep stressing when safety is not a concern, discuss with the patient the reasons for the termination and document your discussions in the EHR.
You want to be professional, you want to be objective. You want to make sure the temperature in the room doesn't rise. Review what steps you've taken previously to try to remove any barriers and help the patient. And then include the identity of any witnesses who were present when you were having this discussion. It could be your practice manager or a nurse, or it could be a family member of the patient, but you want to document specifically what you said in your discussion with the patient and then also who was present at the time.

Renee Tidwell:
Does SVMIC make any recommendations on if this is a face-to-face conversation or a phone call, or does it just kind of depend on the situation?

Jeff Woods:
It depends on the situation.

Renee Tidwell:
Okay.

Jeff Woods:
Now, this is assuming that the patient has come into the office and you have the opportunity to speak to him or her face-to-face. Sometimes you don't have that opportunity. In those cases, we would recommend a telephone call and a follow-up letter, or at a minimum a follow-up letter or just a letter to the patient, discharging the patient from the practice. And we're going to get into the requirements of the letter a little later. But again, assuming that the patient is sitting in your office and you can have that face-to-face discussion, you want to be sure and tell the patient about any specific ongoing care issues, including medications and referrals. Make sure that that's taken care of. If safety's not an issue, agree to see the patient for 30 days to allow the patient time to establish with a new provider and agree to provide a copy of the medical record to that new provider or to the patient.
30 days is a general time period that we recommended at SVMIC, but understand that some states may have different requirements. So you need to, again, be familiar with the requirements in your individual state. So after you've had your discussion with the patient, assuming it's a face-to-face discussion, you want to follow that up with a letter to the patient. That letter needs to be sent by a first class mail and certified mail return receipt requested. The purpose of the letter is to confirm the dismissal. And the reason that we recommend that it be sent two ways, it's basically the same letter. You just run it through the copy machine. You send it first class mail, which is just regular mail with a stamp on it, address to the address that you have for the patient, and then you put the copy in an envelope and you send it certified mail return receipt requested to the same address.
It's sort of a built-in suspenders approach because a lot of times when patients receive a certified letter, they know it's bad news, so they refuse to sign for it or they fail to claim it at the post office. That's proof that they never got the letter, but they can't refuse a first class letter. So if you send it both ways, the certified letter comes back refused, then there's a legal presumption that they received the first class letter. And you want to be sure and put any letters that come back or the green card, the return receipt, you scan a copy of it and place it in the EHR. As far as what needs to be included in the letter, unless it's required by state law, a specific reason for the termination does not have to be stated in the letter. And it's often advisable to state something generic like, "We have been unable to maintain an effective physician-patient relationship."
That covers a lot of things. It could be you're not paying your bill, you're not showing up on time, you're non-adherent. But sometimes when you get into specific reasons, it could lead to claims of discrimination or it could lead to other claims by the patient. So that's why we say it's often advisable to just make it generic. The letter should reiterate any specific ongoing care issues or conditions, the necessity for the patient to continue care with another provider. And you also need to include in the letter the specific date that your services will end, including any medication refills. You need to recommend that the patient contact a local physician referral service or the medical society or their own insurance carrier to locate a new provider and state in the letter that the patient's medical records will be transferred with an appropriate release signed by the patient.
Also, after a patient has been discharged from the practice, be sure to notify your frontline staff and your scheduling person that this patient has been discharged so that the patient won't call in and make a new appointment. They need to note not to schedule another appointment, that services have ended for this patient.

Renee Tidwell:
Jeff, that's all good and helpful information. A lot, though, probably if you're listening and trying to take notes if you're facing this situation. Does SVMIC have any resources or information for our policy holders on this?

Jeff Woods:
If you look on SVMIC's Vantage website, we do have a form letter. It is a generic form letter, but it'll give you an idea of what you need to include in your follow-up letter to the patient or if the patient didn't come in for a face-to-face meeting, what you need to put in the discharge letter. You need to make sure that this is applicable to your practice. For example, this is a generic letter, but if you're a pediatrician, you may want to tailor it to having a minor as a patient or if you have a certain specialty, make sure that it's geared toward your practice.

Renee Tidwell:
We'll be sure to link all that information in our show notes today.

Jeff Woods:
And so as you can see, Renee, when I said earlier that it's often easier and less time-consuming to actually work with the patient than it is to terminate the patient, because the consequences and all of the things I just outlined.

Renee Tidwell:
Probably fewer consequences too, if you're able to work through whatever issue or barrier is happening at the time, fewer consequences to the practice or the policy holder as well.

Jeff Woods:
Hopefully, yes. And especially if the patient feels like you tried to work with them on the front end, they may accept more responsibility for the determination than if you don't try to work with them.

Renee Tidwell:
I know that when patients feel just heard and recognized that they may be going through a hard time can sometimes just defuse the situation right there. So I can absolutely see where it's maybe easier for the physician in the long run to try to work through that than just jumping to terminating the patient-physician relationship. You mentioned several times that what you were just saying was only if safety was not a concern. So I'm interested to know, what if safety is a concern? Can you speak on that a little bit?

Jeff Woods:
Yes. If you have a very angry patient, if you feel like that safety is a concern, whether it's your safety, the safety of your staff or your other patients, you need to try to deescalate the situation, keep things calm. If you terminate the physician-patient relationship on the spot, it could be like throwing gasoline on a fire. So my suggestion is, number one, don't antagonize the patient. Don't mention terminating at that point, let them leave the office and then follow up with a termination letter.
Another important thing, if safety is a concern, don't worry about some of the things I said. For example, agreeing to see the patient for an additional 30 days. If you're concerned about safety and you've documented that in the chart, maybe some of your staff has witnessed this patient being angry and using profanity or whatever, these would be situations that need to be documented and then you don't have to worry about seeing the patient for an additional 30 days, for example. At SVMIC, we would much rather defend a claim or a lawsuit by a patient who's alleging that you abandoned them in a situation where the physician or provider's safety was a concern, than we would to have that physician or provider harmed.

Renee Tidwell:
So let's say for a minute, I'm a physician facing this situation. Can SVMIC help me? Do you provide guidance? I think we've talked about this a little bit. Any other information you want to share with our listeners today?

Jeff Woods:
Yes, I would say that especially if you're anticipating terminating the physician-patient relationship with a difficult patient. I mean, a lot of these are complicated, some are simple, but most of them nowadays are complicated. I would strongly suggest that our policy holders contact an SVMIC claims attorney. Our claims staff does a lot more than just handle and oversee malpractice lawsuits. They are there to answer your questions. Our entire claims staff, they're all attorneys, and they can help guide you through the process on an individual basis as what to do with a specific patient as far as terminating that relationship goes. And hopefully it will help to avoid some of the consequences that I discussed earlier.

Renee Tidwell:
Jeff, I just want to reiterate just based on my own experience at SVMIC in different roles that I've had, I know a lot of times when policy holders call in and they may have a situation they want to talk about, if we tell them we're going to connect them to the claims department, that is scary. We call it our claims department because they do deal with that. But really what you just said, our attorneys are here to help physicians through situations that aren't claims yet, and this is a great example of a time when I think they should call in. So listeners, I just want you to know you're not going to be penalized for calling in and asking if you can talk to an attorney about a specific situation that you have going on. That's what we're here for.

Jeff Woods:
That's absolutely correct. I can tell you from my experience in claims and just my experience in the company, we encourage our policy holders to contact our claims attorneys.

Renee Tidwell:
Right.

Jeff Woods:
So we're not going to penalize our policy holders for calling in and asking questions or even reporting potential claims. We encourage you to do it. We want you to do it, and we don't increase your premiums. There's no penalty to our policy holders for calling in to ask questions, to report potential claims.

Renee Tidwell:
We want you to, right.

Jeff Woods:
Absolutely.

Renee Tidwell:
That's great. I really appreciate you being here with us today. I know it's a hot topic, something that our policy holders are researching, searching our website for, calling in about, and we just appreciate your time today. Thanks, Jeff, for being with us today.

Jeff Woods:
Thanks for having me.

Renee Tidwell:
Listeners, if you have any questions or are looking for resources, give us a call. Some information will be linked in the show notes today. And on that, thanks for listening.

Voiceover:
Thank you for listening to this episode of Your Practice Made Perfect. Listen to more episodes, subscribe to the podcast and find show notes at svmic.com/podcast. The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policy holders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time