How to Discharge a Patient From Your Practice: Ethical and Legal Considerations and Procedures

Unfortunately, most physicians will encounter a situation where they are forced to consider discharging a patient from their practice for any number of reasons, including personal safety, breakdown of the patient-physician relationship, and non-compliance with office procedures or payments. These discussions come up often in our online communities for doctors as physicians ask whether it’s appropriate to discharge a patient under a particular circumstance or how to do it properly. Below, we’ll cover valid reasons to discharge a patient, how to give sufficient notice and in what form, required documentation and logistics, and more.

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Can you discharge a patient and terminate the patient relationship for any reason?

You can not discharge a patient without following appropriate legal, ethical, and professional guidelines and procedures. Doing so on a whim without following appropriate protocols can lead to legal issues or issues with the medical board or payers. You’ll want to make sure that you’re familiar with the laws and policies of your state and the insurance companies and payers you’re credentialed with. When in doubt, it’s important to consult a healthcare attorney for guidance on specific situations. You may also want to check with your malpractice insurance to ensure you’re not opening yourself up to risk in a particular situation. Nothing in this article is legal advice, but intended to give you a framework to contextualize your situation and raise awareness of the complexity of this topic.

What are valid reasons to discharge or 'fire' a patient from your practice as a physician?

While the laws and policies may differ depending on your state and local rules, as well as your payers, here are some reasons that members of our physician communities have cited as a reason to discharge patients:

• A pattern of no-shows to appointments or last minute cancellations - these can have a real financial impact on your practice and your scheduling template.

• Behavior that is inappropriate or criminal, such as physical or verbal threats or abuse, disruptive actions that impact other patients, inappropriate interactions with you or your staff, theft or other illegal activitiy, or hateful speech or actions that make you, your staff, or your patients feel unsafe (which may include bringing firearms to the practice)

• Repeated noncompliance with the treatment plans that you have agreed upon together and given clear instructions on

• Breakdown in the doctor-patient relationship or trust that prevents you from being able to effectively serve as their physician

• Drug seeking behavior or documented abuse after attempted intervention

• Change in office payers or patient insurance or location that renders you unable to accept their insurance going forward or a physical move by the patient out of your service area/out of network

• Failure to pay bills (as long as compliant with practice and payer policies and not discriminatory in nature): an example would be if the patient was on an agreed upon payment plan and wasn't making the payments, or refused to get on a payment plan

What are some reasons or situations for which you cannot discharge a patient from your practice without potential legal or ethical issues?

• Discrimination - this can violate either federal laws or medical board ethical guidelines

• Retaliation - while there are certain reasons why you may be able to argue that a patient’s actions have led to the breakdown of the doctor-patient relationship and it’s therefore better to part ways, you should be careful about discharging a patient because they left a poor patient review or filed a complaint against you, because they didn’t go forward with a proposed treatment plan, because they refuted or contested a bill or practice policy, or because they requested a second opinion

• If you don’t provide adequate notice or facilitate a transfer of care - as we’ll discuss below, it’s important to give a transition period, and provide for transfer of medical records

• If they have an active emergent medical situation where not treating them would constitute abandonment - it raises ethical (and potentially legal) concerns if you could be considered as abandoning a patient while they are hospitalized, in the late stages of a pregnancy, or otherwise needing time sensitive care

• For nonpayment reasons under specific circumstances (conditions apply, but certain payers such as Medicare and Medicaid have rules about denying care for non-payment, and other payers may require a particular notification process with opportunities to reconcile the payments)

How do you ethically and legally discharge a patient from your practice?

You'll want your practice to have a set procedure or checklist for doing this to ensure that all steps are covered. It should include:

Ensure that the reason for discharging the patient is legal, ethical, and in accordance with payer policies

We covered this above.

Document, document, document

You’ll want to keep very clean documentation about everything in this process, including the reasons for discharging the patient, what was done or attempted to avoid the situation and why it was not possible to keep the patient on, how the notice was given and any communication with the patient regarding the notice itself, transfer of medical records and any referrals given, and care given after notice was given.

Provide written notice to the patient

You will have to provide written notice to the patient of the intent to terminate the doctor-patient relationship. This must be clear and state the reason why you are doing so (the level of specificity can vary), when the termination date is effective (generally 30 days notice unless extreme circumstances), that the patient must find another doctor or clinician, that you are willing to transfer their records to another clinician of their choosing and instructions on how they can initiate that process, how you will handle medication refills, and a statement that you are willing to provide emergency care during the notice period. You may also choose to provide them with a referral to another physician, if appropriate.

There are some situations where you can terminate the relationship immediately, which will vary from state to state. Some of these include:

• The relationship was actually ended by the patient (this should be stated in the notice).

• There is a safety concern for the physician, staff, or others that raises fear for violence or stems from a direct threat; this may include sexual misconduct or other inappropriate behavior.

• There is criminal activity such as drug diversion or other illegal activities.

This written notice is typically sent by certified mail with a return receipt requested. Some states require that both certified mail and first class mail is used. Copies of both the notice and the proof that they received it should be kept in or uploaded into the patients chart for documentation purposes. If the patient refuses to sign for the certified letter and it is returned, that should also be documented. Some practices also send to choose these notices in multiple formats, including through the patient portal or email.

Help facilitate transfer of medical records and an appropriate transfer of care to another physician or clinician

You may or may not be a part of finding a new clinician for the patient through a referral. Once a new clinician has been identified for their ongoing care, transfer the patient’s medical records. When you do this, make sure you follow all applicable procedures and laws about HIPAA, records release, and appropriate fees (if any). Document everything. If appropriate, you may need to do a verbal handoff to the new clinician to facilitate a smooth transition.

Note that many practices will have it as a policy that a patient is discharged from the entire practice, not just from the care of a particular physician, to avoid an instance where the doctor or the staff has to interact with the patient in an on call or coverage situation.

Provide emergency care if needed during the transition and notice period

Typically, once a patient has been discharged, they themselves will seek care elsewhere if available, but you should be prepared to provide emergency care if necessary during the transition period. This is often 30 days but can vary. While you may be legally or ethically obligated to do this in emergency situations, you aren’t typically required to provide routine non-emergent or non-acute care. It is also acceptable to direct them to call 911 or to the emergency room if the situation is beyond your capacity to address in the office.

What are ways to avoid escalation of situations that result in termination of the patient relationship, and protect yourself if you do have to discharge the patient from your practice?

One thing that legal teams suggest is having a signed agreement with the patient on file that is signed when the patient joins the practice. This agreement should outline your practice's policies and procedures, and specifically state that violations of these may result in discharge from your practice. You can also post these expectations in the waiting room and/or practice webiste.

You should also do your diligence into why the patient may be having a hard time complying with practice policies. For example, ensure that there's not a language barrier and that the patient has capacity to follow directions.

Unfortunately, sometimes inappropriate beavior or other concerns are beyond your control, and the safety of you, your staff, and your other patients are important, so you may have no choice, but when possible, try to see if you can reconcile the situation. When in doubt, always consult a healthcare lawyer, the risk department at your malpractice insurance company, and/or your payer agreements.

Conclusion

Discharging a patient from your clinical practice can be stressful for a number of reasons, not just legally and ethically. No doctor enters into a physician-patient relationship hoping for it to end, but if it does, especially under non-ideal circumstances, you must ensure that you follow appropriate procedures for doing so to avoid legal issues or complications with your payers, as well as medical board concerns. When in doubt, consult your healthcare attorney, your malpractice insurance’s risk department, and/or your payer policies as applicable.

If you need an attorney, we have a listing of attorneys for physicians that may have someone who can help. Remember, nothing in this article is official legal advice!