Practice Tips

A physician's improper termination of the physician-patient relationship may put the physician at risk for a claim of abandonment. Following the guidelines below may mitigate this risk.

Policy

• Identify situations that may prompt consideration of termination. Common causes of termination include non-payment, excessive missed or canceled follow-up appointments, failure to follow agreed upon treatment plan and the refusal of a patient to maintain acceptable behavior.
• Formalize your termination process in a policy and procedure (sample termination policy).
• Provide all patients (active and new) with written policy expectations including the termination policy.

Considerations

Consideration should be given to the following:

• Evaluate whether all options have been exercised to salvage the relationship. Don't act hastily in making a decision.
  • For "patient noncompliance", facilitate a face-to-face conversation with the patient to clearly communicate expectations. Allow the patient to voice their understanding and expectations. Clarify any misunderstanding or misperceptions. Facilitate a mutual agreement to a plan. Provide the patient with a copy of the written agreement.
• Review the documentation in the patient record to determine if the documentation supports the decision to terminate the relationship.
• Review managed care contracts to determine if the relationship with the patient can be terminated.
• If the patient is in a protected class or disabled, consult an attorney to determine if the termination is prohibited.

Termination should not be pursued if:

• The same type of medical care cannot be found within a reasonable geographic area.
• The patient has an urgent or emergent condition or is being treated for an acute condition requiring continuous care. The patient must be treated until the acute phase has stabilized.

Process

When proceeding with termination:

• Author a termination letter (sample termination letter) that contains the following:
  • Notification that the physician patient relationship is being terminated. In a group practice, specify if the terminated relationship is with one physician or all physicians in the practice.
  • A deadline for end of coverage, from the date of the termination letter. Thirty days is a general guideline, but longer may be necessary based on patient circumstances. Threats of violence, actual violence or criminal acts (stealing prescription pads) may necessitate verbal and immediate termination. Follow up verbal dismissal with a termination letter.
  • Clarification that the physician is available to provide care during the transfer period.
  • Resources to assist in locating another physician of like specialty.
  • The need for ongoing care and the consequences of forgoing continued care and treatment (as appropriate).
  • An authorization for release of records and a statement that the office will facilitate a transfer of records at the patient's request. It is not advisable to charge the patient for copying the records. Stating the reason for termination in the letter is not necessary. If a reason is stated, it should be clear, concise, and objective.
  • The physician with whom the relationship is being terminated should sign the letter.
  • When appropriate, discuss termination with the patient prior to processing the letter to foster acceptance and an understanding of the reasons for ending the relationship.
• Send the written termination letter via certified mail, with a return receipt requested.
  • If the certified letter is rejected and returned, resend it in a plain envelope with no return address.
  • The second letter will serve as proper notice.
  • The letter may also be hand delivered during a visit.
• Document a full account of the termination process in the patient's record. Include copies of letters sent or hand delivered, receipts received and letters returned. Inform your staff that the patient has been sent a termination letter. Advise staff not to schedule the patient after the effective termination date. Consider alerting the patient's other healthcare providers, such as specialists and the patient's primary care provider, that you are no longer treating the patient.

Patient Dismisses a Physician

• When a patient dismisses the physician, send a letter to the patient to confirm that the relationship has been terminated.

Physician On-Call to the Emergency Department

• When a physician is on-call to the ED, the physician must respond to the ED's request to treat a patient even if the patient has been terminated from the on-call physician's practice.

Resources

• To address situations with noncompliant patients, refer to the MMIC Practice Tip: Strategies for Effective Communication
• For complex situations, consult with the Risk Management department or Claims department at MMIC, or an attorney.