How to discharge a patient from your practice

Occasionally, you may encounter patients who you no longer wish to treat. Reasons for ending the physician-patient relationship may include chronic non-compliance, rudeness to office staff, or non-payment of bills.

While these patient behaviors can affect the interactive care-giving process, they may also identify patients with a propensity to file a claim against you. To help reduce the risk of a future claim, a physician may terminate or discharge a patient from the practice.

There are, however, certain exceptions that apply to terminating a patient.

  • You may not terminate your professional relationship for any discriminatory purpose or in violation of any laws or rules prohibiting discrimination such as the Americans with Disabilities Act.
  • You also are not permitted to terminate a patient where you know, or reasonably should know, that no other healthcare provider is currently able to provide the patient the type of care or services that you are providing to the patient.

Reduce the risk of abandonment for the patient

Abandonment occurs when a physician suddenly terminates a patient relationship without giving the patient sufficient time to locate another practitioner.

A patient, however, may withdraw from a physician’s care at any time without notifying the physician.

  • To reduce the risk of allegations of abandonment, it is recommended that you discuss with the patient in person the difficulties in the physician-patient relationship and your intention to discharge the patient from the practice.
  • Be sure to document the discussion fully in the patient’s medical record, also noting the presence of any witnesses such as a patient’s family member or a member of your office staff.

Write a formal discharge letter to the patient

You are required by law to notify the patient in writing of the termination. The letter must state that you will no longer provide care to the patient as of a date certain. The date certain must be at least 30 days from the date of the letter. You must also state in the letter that you will be available to provide emergency care or services, including provision of necessary prescriptions, during the 30 day notice period.

The discharge letter should also include:

  • A description of any urgent medical problems the patient may have.
  • An offer to forward copies of the patient’s medical records to the subsequent treating physician.
  • The name and phone number of a local physician referral service or the local/state medical society to assist the patient in locating a physician who is accepting new patients.

The care of a patient is a mutual agreement and is in many ways a team between you, the provider, and the patient, but when that relationship is strained and you can no longer feel that you are able to provide quality care to the patient, at that point it is time to end that patient-provider interaction. Make sure you have attempted all you can do to help and when you realize there is no more to do, discharging the patient may be the only course of action.

Adam Alpers is a primary care physician and blogs at Medical Billing & Coding for Physicians.

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  • http://aebrain.blogspot.com Zoe Brain

    Note though that Jesse Helms put through an amendment to the Americans with Disabilities Act that specifically excludes Transsexuals, and anyone with Gender Dysphoria, whether due to a physical problem or not.

  • soloFP

    I disagree with having the patient in the office to discharge the person. I had a patient who had 9 no show appointments, wanted more meds that I was willing to prescribe, and had not paid her last 2 copays come into the office. I gave her the discharge letter in person, and she sat in the waiting room steaming for the next 20 minutes. I rarely discharge patients, around 4-6 a year, usually for noncompliance or very high bills.
    Another note is that even if you are the only specialist in town, you can still discharge a bad patient. You just have to give them a little longer than 30 days, as another specialist may be 2-3 hours away. There is no reason to keep a belligerant or noncompliant patient in your practice, as you are setting yourself up for a malpractice suit if any little thing goes wrong.

    You can also turn away potential new patients for any reason. I have my front desk staff screen new patients about their previous docs. If a person has been discharged for drug overuse, nonpayment of bills, or noncompliance, then that person is turned away. It is best not to add bad patients, as rarely do they improve at the next practice. Unfortunately the last holdup for bad patients is the ER, but most places only require you to provide a one time follow up visit for the person and then discharge the ER follow up person.

  • ninguem

    Dr. Alpers is making up a whole bunch of new duties and obligations not required of physicians, anywhere in the country that I know about. Now he may have an employer who mandates that he jump through all those hoops. If you agree to practice in certain ways, because of an employer, or because of insurance, that’s a different story.

    “…..You also are not permitted to terminate a patient where you know, or reasonably should know, that no other healthcare provider is currently able to provide the patient the type of care or services that you are providing to the patient…..”

    Show my a regulation, anywhere, specifying this requirement.

    “……To reduce the risk of allegations of abandonment, it is recommended that you discuss with the patient in person the difficulties in the physician-patient relationship and your intention to discharge the patient from the practice…….”

    You can terminate the physician-patient relationship for any reason or no reason. Exception is the protected class/civil rights issues described. Most physicians put in no reason. To reduce allegation of abandonment, you give the patient adequate notice, usually defined as 30 days. During that time, you provide care.

    The patients almost invariably know precisely why they are being dismissed from the practice. Usually, it’s not the first time for such people. To put in reasons accomplishes nothing, except to inflame emotions. It turns into an argument. Forget it. There are plenty of physicians in the USA, plus the midlevels with fairly unrestricted licensure in many states. To act like you are the only physician the patient can possibly see is nonsense. Maybe the ship doctor on a submarine or an Arctic station. Not in civilian practice in the USA.

    It is reasonable to add in a letter….”A description of any urgent medical problems the patient may have….” That would likely help with any abandonment complaint.

    This is standard most everywhere: “……An offer to forward copies of the patient’s medical records to the subsequent treating physician…..”

    “…….The name and phone number of a local physician referral service or the local/state medical society to assist the patient in locating a physician who is accepting new patients…..”

    No. The patient found you, the patient can find another doctor.

    Sorry, I have a problem with people who try to add to the duties and obligations physicians already have.

  • Diora

    What do you define as non-compliant? It’s is one thing when you have say someone who is ill and doesn’t take medication than comes to you with issues related to this non-compliance or someone who endangers other people’s health, but I hope that you don’t include screening/preventive treatments in it.

    Most of the preventive treatments are used to reduce a risk of a certain bad thing happening or find something early have fairly large NNT/NNS, yet they also have risks, so it should really be a patient’s choice and not an obligation. Do it or I’ll dismiss you as my patients sounds a little like extortion to me.

    • imdoc

      ” Do it or I’ll dismiss you as my patients sounds a little like extortion to me…”
      If you think that sounds like extortion, you should hear the theories of liability cast at doctors for continuing to care for patients who refuse to follow a treatment plan. Most experienced doctors know that if you carry a chronically non-compliant patient for a long time and there is an untoward outcome, there is liability risk. Even if the doctor prevails by having excellent documentation, the trouble is not worth it.

      • http://Www.twitter.com/alicearobertson Alice

        It has been written about, and discussed openly that if a doctor does not like you to RUN, not walk from them.

        Dr. Groopman in his book, How Doctors Think, discussed his own question to doctors about this. Every doctor said if they see a conflict with another doctor they move on and quickly. Be grateful, as a patient, you can move on….but it is quite a dilemma for a doctor. If a patient needs a doctor they would do well to behave themselves. Recently a doctor behaved so badly we considered moving on…but he is actually quite a good doctor. The next visit was wonderful. I did not know he was ill and in pain. Really glad we did not do something rash.

        Moving on would be hard though because where I live it can take weeks to order medical records (they come from a state a thousand miles away). No walk ins allowed for medical records and doctors are not required to share test results via the EMR portion the patient can see.

        Why can’t a doctor have a talk with the patient before sending a quit letter? Another doctor here shared about being new in a town and his wife went to the recommended OB and waited forever. She asked about the wait and they received a quit letter after the visit. Some docs are trigger happy.

        • ninguem

          Alice “…….if a doctor does not like you to RUN, not walk from them……”

          Perfectly reasonable, of course. I’d do the same.

          But, common sense is not common. Unfortunately.

          Of course it works both ways. So from time to time, I tell the patient to find another doctor.

          Dismissal in the midst of treatment…….it’s all relative. A patient with high blood pressure, diabetes, emphysema, you’re always in the midst of treatment. That’s different from, maybe, a patient you operated on last week, and the stitches are still in place.

          Addicts. If doctors were put in the position where they could never dismiss an addict, they would all refuse to treat with narcotics.

          You have a patient with obvious addiction, maybe misrepresented the medical history, maybe doctor-shopping, you can dismiss. It is recommended to offer detox treatment or detox referral.

          I treat chronic pain, and real-live addicts will pop up in such a practice. I also do the outpatient detox. I offer it. Usually they just leave. They’re not interested in getting better, they’d rather be addicted……or they’re selling the drug. You do get the occasional person who really admits addiction and asks for help……and I help them.

          • http://Www.twitter.com/alicearobertson Alice

            Ninguem…I like your posts…you are reasonable. If you dispense meds…looks you have to go back to school. The Drug Czar wants to make mandatory schooling.

            I remember naively stating to a doctor who changed our lives…he could hear my silent cries…decode my emotional SOS…..I said I could not imagine anyone ever being upset with him. What he shared was jolting. He is so exceptional I still can’t comprehend these types of reactions…so the best doctor I have ever met has been devoured. Pesky humans:)

  • http://www.dialdoctors.com Dial Doctors

    While we never discharge patients from our practice, we do refer them within the company. The relationship between a doctor and a patient, e.g. empathy, has shown that it helps with compliance. We transfer around 10 patients a month because doctors consider they may have a better experience with someone from our staff. They are given a single consultation as a tryout and if the patient doesn’t like then they can use their old doctor. I’d say this work around 50% of the time but it does help. There are still rules which prevent patients getting bounced around but this system works for us. It avoids malpractice suits as well because patients adhere to their treatment plans.

  • http://Www.twitter.com/alicearobertson Alice

    There are sites that say a doctor cannot patient dump in the midst of treatment. So…that is untrue?

    I asked my doctor what do they do with patients who blow up and rant. He said he never dumps…but offers a replacement. Disgruntled patients usually want to switch and others take the hint…most move on without prodding.

  • Easton, MD

    I discharge 4-6 patients per year. It’s usually over abusive behavior to staff, drug-seeking and lying, and occasionally over unpaid bills or chronic no-shows.

    The quickest way to get fired is to curse out or threaten my receptionist or nurse. They don’t get paid to take that sort of abuse.

    When drug seeking is the issue, I tell the patient that I’ll be happy to continue seeing them but will not be prescribing any controlled substances for their chronic issues. They usually leave.

    In my discharge letter, I simply state that I will no longer be able to be their physician and they will need to receive their care elsewhere. I offer to see them for urgent or emergent issues over the next 30 days. I recommend they call their insurance customer service number to find other physicians they may want to see. I offer to send a copy of their record to their new physician after I get a signed record release. That’s all it says.

    The statement that you can’t discharge someone if, “no other healthcare provider is currently able to provide the patient the type of care or services that you are providing to the patient”, is ridiculous. Since I’m a primary care doctor, it’s a non-issue.

    I’m aware of some physicians discharging patients for continuing to smoke or for refusing vaccinations, especially in kids. I think that’s a bit harsh. If I felt that I couldn’t care for smokers, I’d screen for smoking at the first visit.

    I feel very strongly that children should be vaccinated against preventable diseases (we’re in the middle of a measles outbreak here at the moment). But I wouldn’t discharge the child. I think it’s wrong to punish a child just because their parents are idiots.

    • http://Www.twitter.com/alicearobertson Alice

      Last week I listened to the Drug Czar share about the new legislation that will make it mandatory every doctor who prescribes certain painkillers, etc. to go back to school. He said doctors are not taught in medical school how to understand addiction, and it’s detection, and prevention. It seems more people die each from prescription drug overdoses than car accidents (28,000). I find myself wondering how far reaching this will be. Will you be able to quit an addict?

      I try very hard to get along with my doctors. My children’s pediatrician did not immunize her kids, so I used her. She is one of the top doctors in the state. I mention this because there was no friction…just intelligent discussion and agreement. My friends in academia flocked to her and would say they wish she was their own adult doctor. I do not know one patient she quit, or who quit on her. She is doing something very right. She has great empathy and people skills.

    • Dave

      This will happen more if we do move to outcomes based measures. If the government gives you incentives based on the proportion of your patients that smoke, you might as well get rid of the ones that refuse to quit. Same goes with people who refuse to test/control their blood sugar.

      I don’t think people have thought their brilliant plan for saving health care all the way through.

      However, I am fine with getting rid of any patient that chronically no-shows or is verbally abusive. That should be unacceptable.