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,”

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.

23 Questions To Ask Before Creating A Finacial Policy For Your Medical Practice

Written by guest blogger, Mary Pat Whaley

Your financial policy is your roadmap and will determine how the practice will handle the collection of patient balances. The financial policy is the document your practice will come back to time and time again. If a question arises, ask “What does our Financial Policy say?”Screen Shot 2015-08-29 at 12.37.39 PMPublish it electronically on your website and physically in new patient packets and have your patients sign it and keep a copy of it.

Ask these questions:

  • What money, if any, will you collect before the patient is seen? Co-pays? Deductibles?
  • Will you take the patient’s word for it if they say they have met their deductible? If not, what action will you take?
  • Do any of your payer contracts stipulate that you cannot collect the deductible before the claim is adjudicated?
  • How will you handle patients with previous balances?
  • What insurance will you file? Primary? Secondary? Tertiary?
  • Will you give claim forms to patients to file themselves?
  • Will you check insurance eligibility before patients arrive?
  • What will you do if a patient arrives without their insurance card?
  • With what payers does your practice have contracts?
  • How will you handle patients who are electing to be seen out of network with reduced benefits, or out of network with no benefits
  • Can your practice management system calculate allowable charges so you can collect non-allowable charges and/or co-insurance at the check-out desk?
  • How will you disclose any fees that patients might incur (returned check fee, form completion fee, payment plan default fee, no-show fee, collection agency fee, interest or finance charges)?
  • Do you plan to offer a cash discount to self-pay patients who pay in full at time of service?
  • Do you plan to offer a financial assistance program to write-off a portion or all of the balance due to financial hardship?
  • Will you assist patients in applying for Medicaid or any other program for healthcare services?
  • What will you do if a patient checks-in without the desire or means to pay a co-pay?
  • Will you have a ready answer when a new patient calls the practice and asks how much a new patient visit will cost?
  • What will that range be?
  • Will your practice use a third-party collection agency as a last resort?
  • Will your practice dismiss patients from the practice once their account is turned over to a collection agency?
  • Will you accept all major credit cards including American Express and Discover?
  • Will you set a time limit on payment plans?
  • Will you require all balances to be paid out in 6 months, or 3 months?

Mary Pat Whaley is a blogger, consultant, and public speaker. With 30+ years managing physician practices of all sizes and specialties in the private and public sectors, Mary Pat Whaley is one of the preeminent practice management consultants in the United States today. Check out her blog for great information, like how to implement a credit card on file program in your practice. 

How To Implement A Credit Card On File Program For Your Medical Practice

mmp_logo_for_web53My friend Mary Pat Whaley from recently published a FREE 30-minute webinar where she introduces the concept of Credit Card on File exclusively for PediatricInc subscribers.

How cool is that? 

Actually, that is partially true. The webinar is in fact free. But it is not only for PediatricInc subscribers. It is available for everyone! (I got carried away).

Even though this is only a 30-minute webinar, Mary Pat covers a lot of ground. Below is a list of what she goes over:

  • What are the Four Steps to implementing CCOF?
  • Is it legal and PCI-complaint to keep a credit card on file?
  • How do you get the patient’s signature on a credit card transaction if they are not physically in the practice?
  • What if the patient refuses to give us a credit card or does not have a credit or debit card?
  • Credit card fees are expensive! Why would I want to increase my credit card merchant fees?
  • Do practices usually ask Medicaid and Medicare patientsto keep a credit card on file?
  • What impact will the Affordable Care Act (ACA or Obamacare) have on practices with or without a credit card on file program?
  • Is there a Payment Gateway or Credit Card Processor that you recommend?
  • What are the major benefits to using a credit card on file program in a practice?
  • What other resources are available if I want to implement Credit Card on File in my practice?
  • Attendee questions and answers

If you’ve followed me on social media for some time, you know I’m a huge fan of the CCOF program. At Salud Pediatrics, we instituted the COF in 2009 and never looked back. I’d say it has been one of the best decisions we’ve made.

Sure, we’ve ruffled some feathers. Some parents still get defensive. But the overwhelming majority of parents in our practice understand why it is necessary for us to do this.

Below, I’ve embedded the webinar. Make sure to visit after seeing the video. They have a lot of great resources and a fabulous, informative blog. Mary Pat was also an early guest on the Pediatric Practice Management AwesomeCast. You can check out the interview Chip and I did with Mary Pat by clicking here.




How to Deal with Unreasonable Patients in Your Medical Practice

Angry patients, customer service, medical practiceA while back, I was working the front desk when a dad of one of our patients came up to me and said he didn’t want to sign the credit card on file authorization. I politely insisted he needed to fill out the auth form. He cut me off with loud: “WHY? Who came up with this stupid idea?”

Awkwardly I uttered, “Ummm, me.”

Now, both of us felt awkward. Silence…

So the parent broke the silence and in a less aggressive manner he asked why we were doing this. He asked, “…don’t you get paid by my insurance company?”

I started explaining how insurance worked. I happened to have a collection report on my desk. I showed him the bottom sum. It displayed the number that we had written off due to bad debt for the previous months before the CC policy went into place.

His draw dropped. He said “I had no idea..” he then said, “…how can you run a business when you don’t get paid right away?

“Now you know why this policy is so important to our office,” I said.

He gladly gave me his card.

In my experience, very few people will have a problem with your practice policies, whether it is collecting a charge for forms or instituting a credit card on file program. The ones that have an issue, will have less or no issue once you explain to them why you are doing it.

Let’s call these two group the reasonable parents. 

There will still be a group – a very, very small percentage of those that will continue to have a problem despite your best effort to explain your reasons.

How about if we call that group unreasonable parents? 

For the reasonable ones, continue doing what you do best. In fact, bend over backwards for this group.

For the others, the unreasonable ones, let those skeptics go free. Let them pout, yell, scream,  and complain. But don’t be afraid of them. And what ever you do, don’t let them dictate what you know is the right thing to do. Also, and equally important, don’t let those bad apples influence how you will continue treating the reasonable ones. You don’t need the unreasonable ones . Let them go.

How To Improve Account Receivables In A Down Economy

Whether demand is high or low, learning how to effectively manage ones account receivable is important. Because we know that in any business, including a medical practice, cash is KING.

cash I’ve heard many times that health care is recession proof. People are always going to need health care regardless of the state of the economy. So, if you are running a medical practice, you shouldn’t worry about the economy… right?

Well, if you are running the practice like a traditional medical practice, then yeah, you don’t have to worry about the economy. But if you are running your practice like a business, then you ought to be concerned.

Why? Because even though demand for health care may be consistent – or maybe even increase – in tough economic times, your account receivables will rise disproportionally to demand as a result of the economic downturn. The need for health care may remain regardless of the economy, but your patients’ ability to pay for health care will certainly diminish as people find ways to reduce expenses, lose their jobs, or buy plans with higher deductibles in order to save on monthly premiums.  Which means the burden to collect from patients, has now shifted to the practice.  

But how do we go about working our account receivables? How can we ensure they do not get out of hand? I don’t have all the answers, but I can share what we’ve done in our practice; and that is establish a comprehensive policy. I’ve broken it down into two key points:

  1. Create A Financial Policy: I’ve talked about the importance of setting up a financial policy. Some people may think this step is obvious, but many practices do not have one. I’ll confess our practice didn’t have one until our third year. And I regret not having one for so long. If you want to improve collections, make sure you have a sound financial policy. The policy is important because it sets expectations. More on this later.
  2. Create A Collections Protocol. After you have a financial policy, create a collections protocol. The collections protocol defines the steps that a collector for the practice must follow. A collection policy enables you to be consistent in your collections efforts, as well as provide a predefined execution method.

Our practice’s collection protocol was designed so every 15 days we contact the patient/parent in some way (phone or mail). This is what we do:

Step 1: After insurance has processed the claim, we mail out statements. The statements go out every 30 days and they are mailed out no later than the 2nd of each month. It is important that you keep a schedule so people will know what to expect. Inconsistency in collections is a detriment to your efforts.

Accounts that are within the first 20 day period, but are larger than normal, we call the patient before waiting for the required days to expire. Usually larger balances within 30 days means either they have a high deductible they haven’t met, missing information from insurance holder (DOB, SS#, subscriber not found, etc) or something else is missing that insurance cannot process the claim. Either way, we address them as soon as possible with a phone call.

Step 2: 45 days after sending out statements, we mail a friendly reminder letter letting parents/patient know we haven’t received payment. The letter also ask patient/parents to call us if they need assistance in understanding the charges, or if they want to set up a payment plan. The intent of the letter is, we need you to pay us, but if you can’t, call us and we can work something out.

Step 3: 15 days after step 2, we call the patient/parent (for those that are counting, the account is already 60 days past due). In those 60 days, we have sent two statements and reached out twice to our patient/parent. Again, the purpose of the call is not to hound or hassle the patient/parent, but rather initiate a conversation about the balance.

Step 4: 15 days after step 3, we send out a second, more firm letter. If the balance is fairly high, we may give parents another call in addition to the letter. The account is approaching 90 days past due at this point. In this letter, we finally mention the words “collections company.” We tell them that we want to help them fulfill their financial obligations, but if they are not willing to work with us, we have no other choice but to send the account to a collections company.

Step 5: If parents/patients still have not paid the balance or made any effort to pay the balance after 15 days of step 4, we send out a dismissal letter (account is already 90 days old at this point). We essentially fire the patient from the office by sending them a certified letter. The letter advises them that because we have been unable to collect the balance and per our policy, we will only schedule them for emergencies only for the next 30 days. After that, they are fully dismissed from the practice.

The financial policy is important in many ways. But it is critically important during Step 5. Patients/parents ought not to get upset at the practice if they are sent to collections because the policy already told them we would if they did not pay their bill. The financial policy helps the practice be consistent as well as set expectations.

Step 6: After the 30-day emergency only period expires, we write the debt off the books and send the account to collections. However, before we send it to collections, we add 40% to the balance. This is to cover the cost of the collection company as well as some of the administrative cost of trying to collect the balance. Our financial policy clearly states the 40% increase. Whatever the collections company collects is icing on the cake. But as far as we are concerned, it is off A/R. 

The secret to patient collections is: the sooner you work the balance, the better. The longer it goes, the more difficult it is to collect.  

Later, I will post the success we’ve had with this system.

Any good financial or accounting class will teach you the principle of “time value of money.” This principle refers to the notion that a $1 today is worth less than a $1 in the future. Most successful businesses understand, and in fact embrace this principle fiercely. There is no reason for a medical practice not to operate under this principle. The sooner you start working the balance, the sooner you will get paid. 

If you have thoughts on how to improve collections, I’d love to hear them. Don’t be shy. Share it with me and the rest of my readers.

Whether demand is high or low, learning how to effectively manage ones account receivable is important. Because we know that in any business, including a medical practice, cash is KING.