Firing a patient can be a scary prospect, but it is sometimes necessary. A practice may wish to terminate a patient for repeated non-payment. Further, disruptive, or worse, patients who are threatening, need to be terminated.
Terminating a physician-patient relationship is permissible, but it does expose the practice to claims of abandonment by physician licensing authorities. That is why it is necessary to ensure proper notice is given in writing and other i’s are dotted and t’s crossed. Generally, to avoid a claim of abandonment, a patient should be given at least 30 days’ notice and opportunity to return in the event of emergency. The formal notice of termination of the physician-patient relationship should be sent by all means available, including e-mail and postal mail. Letters that can be tracked (either overnight mail or certified, return receipt) are suggested, so the practice can retain proof of delivery in its records. Further, any prescriptions should be re-filled in the ordinary course for a reasonable period, and the patient should be advised in the letter that the final refills will be the last.
When notice is given, it should specifically include a directive for them to immediately review their insurer’s participating provider list and find an alternative provider. Any other resources that can help them find a new physician in their local area, if available, should be mentioned. An obvious issue is the 30-day notice requirement. The practice may not want to see the patient again. To hedge this, the letter should indicate in bold font that the patient should call 911 or go to an emergency room for any urgent issue requiring immediate attention. Thankfully, the dermatology specialty does not cater to immediate urgent matters, so the risk is low. When advising that the practice will be available for 30 days, it can limit such availability to telephone or other virtual assistance in addressing past medical matters that the practice has already provided care for, but future matters should be pursued elsewhere if timing allows.
The letter should also advise the patient that the practice will promptly deliver record copies to the patient’s new doctor, and the form for record release should be included along with the letter. If, however, the patient is threatening and the practice cannot deal with the patient, then the reason for this should be described in the letter. In other words, if the patient shouted at staff or uttered an insulting slur, the letter should detail the issue as a reason why the patient cannot be permitted to speak with staff or show up to the office anymore. This serves several purposes: (i) if the letter ends up in the hands of licensing authorities in response to an abandonment inquiry, it will tell them something the patient did not already tell them, (ii) it will inform other members of the household as to the reasoning, whether it be a spouse or parent, and (iii) it will dissuade the patient from posting the actual letter on the internet as backlash, because to do so may be embarrassing to the patient.
Unfortunately, terminating a patient may also spark further backlash from the patient in the form of bad online reviews. Some practices attempt to avoid this by issuing a refund and obtaining a general release from all claims along with a promise not to post bad reviews or file a report with licensing authorities. Refunds and signed releases of claims for malpractice may, however, qualify as a reportable event to the National Practitioner Data Bank (NPDB). A refund by a practice on behalf of one of its providers in response to a written request is essentially the same as a malpractice settlement. Technically, a refund by that very provider him or herself would not constitute such a settlement, as the payment is not made by a third party (the practice) on behalf of the particular provider. Often, however, the practice pays the refund from its own account. Further, covenants not to report issues to licensing authorities are generally unenforceable as against public interest, and just mentioning it may give them the very idea to do so. Finally, a covenant to remove and not post bad reviews is not only difficult to enforce because fake names are often used on the posting, or other friends or family members put it under their own accounts, but also may prove ineffectual because proving actual damages as a result of such postings can be extremely hard. Nevertheless, a release and covenant agreement may make the patient think twice about doing so, even if it lacks the teeth to enforce the claim or stop the behavior. It can also make it easier to justify the filing of a litigation complaint against the patient if it proves necessary. Be wary that they may post the release itself on the internet also, to try to embarrass the practice.
At the end of the day, a waiver of fees or a refund will at least stop harassment, and including an automatic dollar amount of damages for each online post will make obtaining a judgment of damages a bit more certain and less drawn out in the courts. The practice should instead focus on hiding negative reviews with positive ones. It should also never respond to a bad review with patient information that is identifying or relating to health conditions, as doing so will be a certain five-figure or even greater fine against the practice for HIPAA breach.
