Terminating the Physician-Patient Relationship

Executive Summary

Dismissing a patient from a medical practice comes with risks, and terminating the physician-patient relationship should be undertaken only under limited circumstances. This article analyzes the potential liabilities of improper termination of the physician-patient relationship and how to reduce those risks.  

Recommended Actions

• Determine whether a patient is experiencing a medical crisis. Consider obtaining risk management input or attempt to repair the relationship prior to dismissing a patient.
• Provide all patients who are dismissed with a written letter including a 30-day window for emergency care, a method to locate another provider, and an authorization form to obtain a copy of their medical records.
• Maintain a copy of the physician dismissal letter and any correspondence in the medical record.
• Consider designating a practice administrator who is knowledgeable about terminating physician-patient relationships and the associated risks to manage the process, correspondence and documentation.

Severing a relationship with a patient is often a difficult decision and can lead to difficult conversations. Physicians may decide to dismiss a patient for a variety of reasons such as nonpayment, non-compliance and/or inappropriate behavior. Whatever the reason, a patient dismissal is a subject of concern for everyone and should be handled carefully.

Because the physician-patient relationship is voluntary for both parties, either side can end the relationship at any time. However, providers should be aware of the three main areas of risk when terminating a doctor-patient relationship: medical malpractice litigation stemming from a patient claiming mistreatment or an adverse outcome, a Medical Board complaint alleging patient abandonment, or retaliation from a disgruntled patient.

Risks to Consider Before Dismissing a Patient

Patient Abandonment Risks

To avoid an abandonment complaint, a physician should ensure that the patient is in stable condition and not experiencing a medical crisis or emergency before the physician terminates care. However, if the physician feels that dismissal is necessary while the patient is in an unstable treatment course, the physician should obtain risk management guidance prior to any actions.

Most medical licensing boards provide guidance for their specific states on how to appropriately terminate the physician-patient relationship and thus avoid an allegation of abandonment. Generally, medical licensing boards recommend that a physician give adequate notice, provide emergency medical care for a specified period, and assist with the continuity of care by expeditiously providing the patient’s new physician with copies of medical records when requested. We recommend an emergency care period of at least 30 days.

However, it may be necessary to offer a longer period in certain clinical situations due to ongoing medical care issues and the availability of other medical resources. Physicians should exercise extreme caution when terminating any obstetrical patient. Additionally, physicians who have an obligation to treat patients coming to the hospital with emergency medical conditions under EMTALA cannot terminate the physician-patient relationship until they have stabilized or appropriately transferred the patient.

Notification with a Written Termination Letter

All decisions to terminate the physician-patient relationship should be documented in writing so the patient understands the need to find another physician. The letter should:

• Avoid editorializing or restating your side of a dispute. A simple “I find it necessary to inform you that I will no longer be able to provide medical care to you” is adequate. Documentation in the medical record can be more detailed, but should remain factual and avoid pejorative or emotional statements.
• Offer to provide emergency care for a minimum of 30 days.
• Recommend that the patient seek care with a new physician and suggest that the patient’s health insurance company might assist them in finding a new provider.
• Assure the patient that all medical records will be provided at their request with a valid authorization. Include a medical record release form.
• Send the letter via certified U.S. mail.
• For specific clinical situations (i.e. the need to follow-up on a critical lab/image or to complete a procedure or consultation) the letter can include the reasons for the necessary actions and the risks of not complying with them.

You can find a sample termination letter on page 12 of the Resource Checklist for Medical Practices: Practice Closure and Physician Retirement Guide.

Failure to adequately comply with this process could lead to a professional misconduct complaint for patient abandonment to your state’s medical board. After an investigation, if the medical board finds that such patient abandonment did occur, the physician could then face either corrective or disciplinary actions.

Finally, after successfully terminating a doctor-patient relationship, a physician cannot withhold the transfer of medical records for any reason, including a patient’s failure to pay for medical care. However, if a patient requests copies for personal reasons, you may charge them a reasonable copying fee, depending on your specific state’s laws.

Other Risks with Dismissing a Patient

Anger, disagreements, poor communication, failure to comply or follow-up, billing issues and allegations of abandonment often trigger patients to initiate legal action. Therefore, physicians should proceed with caution when terminating patients and ensure that they document the entire process.

Additionally, physicians cannot end a patient relationship for any discriminatory reasons, including gender, race, religion, disability, ethnic origin, national origin or age. Disability status can be complex and contentious. In addition, local laws might protect against discrimination based on issues such as sexual orientation or HIV status. Physicians who end a relationship based on any discriminatory reasons face litigation risks and the associated high costs of having to defend and respond to such a complaint. 

Breach of Payer Contract Risks

Be cautious when dismissing patients who are members of managed care plans, as your contracts with health plans might specify the manner of terminating a relationship. This is especially true if the method of payment is capitation. Plans might need notification of the reason for termination to prevent allegations of dismissing a patient because he or she is “too expensive to treat.” Failure to follow the payer contract could lead to a breach of contract claim and even a cancellation of the payer contract.

In addition, the patient might have different time constraints for the health plan to complete reassignment to a new physician. Medicaid has a specific process for termination of relationships with Medicaid patients, and physicians need to consult their provider participation agreement for details.

Lessons Learned

• Address a patient’s continuity of care before terminating a physician-patient relationship.
• Ensure that all staff members are continuously updated regarding the dismissal of any patients to avoid any mistaken reappointments. A patient should be given a reappointment only if they are experiencing an emergency medical condition.
• If possible, review your payer contract before ending relationships with patients who are members of managed care plans. Your contract might specify the manner in which relationships must be terminated.

Potential Damages

Whenever a healthcare provider ends a relationship with a patient, there is the risk of the patient initiating legal actions or a Medical Board complaint. The consequences of these legal actions or complaints can be costly, even if the physician has committed no error. Therefore, physicians should proceed with caution when terminating their relationships with patients.