Are You Following These 10-Steps Before Terminating A Physician- Patient Relationship?

This post was originally published on the Verden Group’s Blog. Written by Sumita Saxena, Senior Consultant, The Verden Group

It unfortunately can happen to anyone: You go above and beyond to provide your patients excellent care with uncompromising accessibility, and yet something somewhere goes wrong and the relationship quickly deteriorates.

Screen Shot 2015-08-29 at 12.13.02 PMAfter trying your best to mend the problem it becomes clear – the relationship has broken down beyond repair and for whatever reason you reach the tough decision to terminate the patient from the practice.

Before you act and send notice, please take a look at some helpful steps we have compiled for you to consider as you navigate this difficult subject.

Step One: Try to Work It Out With Your Patient.

Practically speaking, when faced with a difficult patient situation, the best course of action is to avoid a unilateral termination of the physician/patient relationship by addressing the problem quickly.

Communication is the key.

The patient should be advised of the situation and given a reasonable opportunity to correct the problem. You should make it clear that failure to correct the problem may result in the dismissal of the patient from the practice.

Step Two: Review the Applicable State Medical Licensing Rules.

State licensing boards govern the practice of medicine and the relationship between a physician licensed in that state and his or her patients. Accordingly, it is essential to review the medical board rules carefully before you terminate a patient from your practice.

Step Three: Consider AMA Guidance. 

The American Medical Association (the “AMA”) has provided guidance on terminating the physician/patient relationship. According to the AMA’s Code of Medical Ethics, physicians have the option of terminating the physician/patient relationship, but they must give sufficient notice of withdrawal to the patient, relatives, or responsible friends and guardians to allow another physician to be secured.

The AMA recognizes that there are times when a physician may no longer be able to provide care to a certain patient, including when the patient refuses to comply, is unreasonably demanding, threatens the physician or staff, or otherwise is contributing to a breakdown of the physician/patient relationship.

According to the AMA, terminating a physician/patient relationship is ethical as long as the proper procedures are followed.
The AMA has given the following advice for the termination process:

  • Giving the patient written notice, preferably by certified mail, return receipt requested;
    Providing the patient with a brief explanation for terminating the relationship (this should be a valid reason, for instance non-compliance, failure to keep appointments);
  • Agreeing to continue to provide treatment and access to services for a reasonable period of time, such as 30 days, to allow a patient to secure care from another person (a physician may want to extend the period for emergency services);
  • Providing resources and/or recommendations to help a patient locate another physician of like specialty; and
  • Offering to transfer records to a newly designated physician upon signed patient authorization to do so. American Medical Association (AMA), “Ending the Patient-Physician Relationship,” http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/ending-patient-physician-relationship.page

Step Four: Check Your Payer Contracts and Policies. 

A physician who is a participating provider (under contract) with the patient’s insurer (commercial or government payer) may be obligated to notify the payer and comply with additional requirements. You should review your provider contract(s) and policies in order to determine if the payer has a policy on patient termination.

For example, some insurance carriers require 60 or 90 days notice before dismissal (as compared to the 30 days notice required pursuant to certain state laws) and some require prior written notice to the carrier to enable the carrier to contact the patient.

There also may be specific requirements concerning pregnant or mental health patients. Medicare, Medicaid, and other government payers have strict policies on terminating a patient that should be reviewed before terminating a governmental plan beneficiary.

Step Five: Review Your Malpractice Carrier Requirements. 

Some medical malpractice insurance carriers have adopted rules or recommendations for terminating the physician/patient relationship. Accordingly, you should review your malpractice policy or contact the malpractice carrier when establishing the procedure for terminating the physician/patient relationship.

Step Six: Send Written Notification to Your Patient.

You should send written notification advising the patient that he or she is terminating the patient relationship. The notification should comply with the licensing board’s rules and the requirements of the applicable payer and the your malpractice carrier. Ideally the patient notification should be prepared or reviewed by experienced counsel before sending to the patient.

Step Seven: Provide Continuity of Care.

You should ensure that you provide the proper continuity of care when dismissing a patient from your practice, including any requirements under state licensing rules, their payer contracts and their malpractice policy. The AMA guidance recommends that the physician provide the patient with resources and referrals for other sources of care.
Step Eight: Do not Charge for Patient Records.

A physician who terminates his or her relationship with a patient should not charge the patient for copying the patient’s medical records.

Step Nine: Consider Risk Management.

Additionally, you should perform a risk management analysis before terminating the physician/patient relationship. You should consider the possibility (even if the patient’s position is without merit and you will ultimately be successful) of patient complaints, disciplinary investigations, litigation, or other action initiated by disgruntled patients.

Step Ten: Establish a Set Policy on Patient Terminations and Train Staff on the Policy.

In order to avoid any potential issues with former patients, the practice should have a set policy in place for the termination of the physician/patient relationship, including a sample termination letter. The policy should be applied to patients consistently and without discrimination. The staff should be trained on the policy and should document compliance with the policy.
By following the above steps you can be proactive and diligent in mitigating your risk if such a situation ever arises with a patient.

A Practice Manager’s Perspective on Health Care Reform

If Americans want the highest quality of care at the lowest possible price, there is going to be some trade offs.

 

health-reformWhen I decided to start the blog, I made a commitment not to complain about how bad things were in the health care industry without at least providing some resolution to the issue at hand. 

So, when I was asked last week to give a practice manager’s perspective on health care reform, how doctors  ought to be paid, and what needs to change so people can get the best quality of care at the lowest possible price, I jumped on the opportunity to give my point of view on what needs to be done to move forward with health care reform.  

Trade Offs 

If Americans want the highest quality of care at the lowest possible price, there is going to be some trade offs. Health care is expensive to provide. How much does a person have to pay to become a doctor? How much does it cost to research and develop a drug or a vaccine?  How much does a doctor have to pay for malpractice insurance, rent, highly qualified employees, equipment, and all the other things that go along with providing care?

 

There is a lot of talk about reducing the cost of health care. And although I agree cost is an issue, I think we need to be careful not to pursue the lowest possible price while comprising quality health care. Otherwise, we will run into the Wal-Mart model. A product at Wal-mart is in fact the best quality one can get at the lowest possible cost. But we know that in order to provide the lowest possible price, quality is compromised. If one wants a higher quality product, then Wal-Mart is not the place. In other words, you get what you pay for. Health care is no different.  

An example of health care delivered at the lowest possible price is MinuteClinic. Their prices may be a little more affordable than visiting a primary care private practice (although their prices are not much less than our practice), but there is a trade off. Nurse practitioners staff MinuteClinics. In fairness, nurse practitioners do have advance degrees, but they certainly do not go through the rigorous training and cost that an MD has to endure to become a physician.

MinuteClinic’s model allows them to reduce health care cost because of several factors. For starters, they do not staff MD’s. Secondly, MinuteClinic can leverage the synergy afforded by CVS, a multi-million dollar corporation. The model also forgoes continuity of care, referral coordination, coordination of care, chronic disease management, counseling, and many other issues that primary care physicians deal with on a day-to-day basis.

 You see the trade off?

It is not about how much your make, but how much you spend

In financial business matters, we often hear experts say, it is not always about how much you make, but rather how much you spend.  Thus, before we can discuss payment reform concerning how doctors should be paid, we need to examine what drives cost in health care, particularly for private practice doctors.

Insurance Companies = Increase in Cost = Bad

We can achieve savings – and as a result drive the cost of health care downward –  by removing many of the excesses that hinder our ability as service providers to deliver health care. Therefore, I would consider removing the power health insurance companies have over doctors. Insurance carriers make up rules that suit themselves, and then change them whenever it is to their advantage, which happens frequently. 

To give you an idea of how many changes insurance carriers make, take a look at the Verden Group’s report (here), which outlines insurance carrier’s changes. Keep in mind the report only highlights quarterly results. Susanne Madden, president and CEO of The Verden Group, gave a great interview that summarizes the challenges primary care faces when dealing with insurance companies. You can check out the interview here.

Our small pediatric office of two doctors deals with about 80 different insurance companies. Each company has it own rules, forms, pre-requisitions, fee schedule, reimbursement rates and many other unique things for us to do in order to be paid. The larger insurance company have different product offerings within each plan. This adds to the complexity and uniqueness of each plan. We have patients, for example, that work for the same company and insured by the same insurance carrier, yet the insurance policy pays out differently for the same services.

Managing this process drives cost upward. By removing the administrative burden of dealing with insurance companies, doctors could increase revenues by spending less on administrative cost. The extra money and time can be spent caring for patients, which increases quality of care.  

The problem with insurance companies is that they decide the rules and make changes to their rules at will without letting anybody know about them. There’s no transparency in pricing; no transparency in contracting; no transparency in rules.

Who should set reimbursement fees?

Insurance companies ought not to be allowed to set reimbursement fees. They have a conflict of interest when deciding what is appropriate reimbursement for medical care. Therefore, in order for doctors to offer the best care possible, they must be paid fairly for their services without a third entity –who has a conflict of interest- decide what is proper compensation for their work.

 Malpractice insurance = increase in cost = Bad

Malpractice insurance is another area that should be looked at as well in an effort to reduce the cost of health care. Doctors spend outrages amounts of money on malpractice insurance. According to the AMA, 20 states have a true malpractice crisis. The reason for the high cost of malpractice insurance, is because of the US legal system; which does very little to protect honest doctors.

The current legal system encourages health care providers to practice medicine defensively. More often than not, test, labs, referrals are not necessary, thus in an abundance of caution, a physician will move forward with an unnecessary treatments to reduce the liability of a medical malpractice suit.

I do acknowledge that medical negligence does exist and some doctors are more careful than others. But what I am suggesting is that if doctors were protected from the legal system, they would not have to practice medicine defensively. Consequently, malpractice insurance premiums would decrease and as a result, so would health care cost. I also believe quality would improve because the doctor can focus without the distraction of a potential lawsuit.

But wait… there is more.

I’ve only begun to scratch the surface of how I think health care ought to be reformed. But from a practice manager’s perspective, these are the two main issues I consider hinder medical offices’ ability to provide high quality care at an affordable price.

Our leaders, the ones that can reform health care, are required to understand more than ever the need to carefully rethink each component of the health care system. For the survival will require bold and decisive actions.


How would you start to put health care reform on the right path?