Be careful if ending treatment agreement

August 10, 2011

As a physician, whether to treat a patient is up to you. And whether to discontinue treatment is up to you and your patient. The author discusses reasons why you may wish to discontinue treatment and the best way to handle each situation.

By walking into your office, the patient requests treatment. By taking a history and performing a physical examination, you accept. But you may wish to stop treating a particular patient for any number of reasons. Regardless, your first step is to talk with the patient.

NONADHERENCE

Document the entire conversation, including the patient's nonadherence, in the medical record. In your notes, use strong language, such as "Patient refused recommended treatment" or, "Patient failed to comply with recommendations" and, "I advised her of the risks. She has legal mental capacity and still refuses." Have the patient initial your note with a staff member as a witness.

NONPAYMENT

If the issue is nonpayment, then you could have a staff member call the patient as well as send letters. You could invite the patient to the office so that you can devise a plan together.

If the patient is indigent, then you can refer him or her to a free clinic. If the patient has coverage that does not extend to you, then you can refer the patient to doctors who are in the payer's network or are otherwise paid for by the patient's plan.

If the patient is having some cash flow problems, then your office can arrange a payment plan.

If the patient says the reason for nonpayment is dissatisfaction with care, then you may wish to examine the records and ask yourself this question: Is there any possible allegation of negligence on my part that could be supported in any way by evidence in this chart and/or by the patient's story of the care rendered? If the answer is yes, then you may wish to rethink strong collection tactics, and you will have to be careful what you document if you discontinue treatment.

You can note a conversation about payment in your billing records. If the patient simply refuses to pay, then you can send that patient a termination-of treatment letter.

The Hippocratic Oath addresses rendering care to the sick and the poor. The practice of medicine is a noble profession, but it is a business, too. Collecting fees is how your business stays healthy. If you are not comfortable or fear future problems, then treatment termination may be the right course-for you and possibly, long-term, for the patient.

AVOID ABANDONMENT

If terminating treatment, you need to do so in a way that avoids a patient claim of abandonment. You must follow a reasonable protocol.

In a worst-case scenario, a patient's condition deteriorates, the office staff has been instructed not to make appointments for her, and she sues you for abandonment. She may claim that she never had notice that you were terminating the treatment or an opportunity to seek care elsewhere. You will have to prove that the patient did have notice.

You will have to send the patient a termination-of-treatment letter, and you will have to create evidence. Send the letter by certified mail, return receipt requested, stating that you are withdrawing as her doctor. Be sure that a copy of the letter and the postal documentation are put into the patient's medical record.

If something goes awry and the return receipt request does not work, then send the letter again, call the patient for a new address, and keep trying.

The next time this patient makes an appointment, have your staff alert you beforehand. If that tactic does not work and the patient comes in for an appointment, take her to your office, explain the situation, then hand her the termination letter. Ask her to sign the letter to prove that she received it.

Be sure to document the entire process in her chart. Keep a copy of the letter and the postal documentation for your files. If the patient sends an authorization to transfer records, put that document in the chart as well.