Short Answers to Hard Questions about Firing Patients

Last month, my husband and I walked into a country club to meet our golfing family members for a quick lunch. Not golfers ourselves, we wore the standard Florida vacation uniform of shorts, a tee, and flip flops. As we walked through the door of the club, the eyes of grey haired retirees immediately scrutinized our arrival. Denim, which I was wearing, was prohibited in the dining room. Flip flops on men, which my husband was wearing, were also not allowed. Needless to say, we found ourselves eating on leftovers at home.  

While golf club restaurants may refuse service to customers who don’t comply with requisite dress codes, in healthcare, denying service to customers is a stickier situation. Medical care in many cases is treated as a right rather than a luxury. Furthermore, our healthcare system is complex with government entities, insurance companies, and employers themselves each enforcing a unique set of guidelines healthcare providers must follow.

If you are a nurse practitioner considering firing a patient, you likely have questions about the process. The following Q&A outlines the basics NPs must know before terminating a patient from a practice. 

When is it legal for a nurse practitioner to fire a patient?

Firing a patient for almost any reason is acceptable, provided it does not overstep legal boundaries. Nurse practitioners, for example, may not fire a patient based on religious affiliation or gender. Ethical standards also require that nurse practitioners maintain responsibility for individual patient’s care and should not be done without reason. Non-compliance and failure to pay bills are common reasons patents are fired from medical practices. A more complete list can be found here

How long does the process of firing a patient take?

The process of dismissing a patient from your practice may take months, weeks, or may occur in a more immediate sense. This depends on the reason for dismissal. Non-compliance, for example, must be demonstrated over a longer period of time and will not result in immediate termination of the patient-provider relationship. A hostile action towards staff, for example, may be grounds for immediate dismissal of the patient from your practice. 

Who needs to be involved in the process of firing a patient?

Employees of all levels in your practice must be involved in terminating a patient from your care. Nurse practitioners typically must get the OK from administrators to take such action. Front desk employees should be notified of the patient’s dismissal so the patient is not inadvertently scheduled an appointment with the nurse practitioner who has terminated the relationship with the patient. Nurse practitioners or their employers may also choose to seek legal counsel in the process

How do I notify the patient of termination? 

Patients should not be fired from your care without warning. In most cases, this initially involves a verbal conversation and/or written notice counseling the patient regarding the disruptive behavior. Ample warning, for example, should be given to patients at risk of termination of care for unpaid medical bills. Visits with non-compliant patients should include a discussion about the implications of continuing to stray from treatment plans. Each attempt to counsel or notify the patient, whether verbally, by email, phone, or in writing, must be thoroughly documented for future reference. Abrupt measures may be necessary in extreme circumstances. 

Additionally, provide the patient with a final letter of termination. Your practice may wish to keep a standard letter on file. The letter should communicate the reason for dismissal, outline next steps for finding a new provider, as well as delineate the date the patient’s relationship with your practice will be officially terminated. Advise the patient of his or her need for continued medical care if this is the case. Send the letter by certified mail with a request for a return receipt.

How do I document the dismissal?

Document, document, document. As in most things, documentation is of utmost importance if you are firing a patient from your practice. Documentation serves to justify your decision should it be called into question. Document each instance of the patient’s problematic behavior as it occurs. Keep a written record of verbal, phone, and electronic conversations about the behavior. Maintain this information as part of the patient’s medical record along with the a copy of the dismissal letter. 

Am I obligated to provide care to the patient after he/she is dismissed?

Facilitating the transition of the patient’s medical care to another provider and/or practice is essential if you are firing a patient. Except in extreme circumstances, before you cut the patient off completely, offer to continue to provide care for a brief period of time. Fifteen to thirty days is typically long enough for the patient to identify a provider to take your place. Refusal to do so can constitute patient abandonment. 

You may also want to provide the patient with names of other providers who can take over, however this approach is controversial. Your colleagues may not wish to accept care for a patient you have already identified as ‘problematic’. Patients unsatisfied with their new provider may blame you.   Offer to provide the patient a copy of his or her medical records to help facilitate the transition to a new provider. 

Can I be sued for firing a patient?

In short, yes. Your legal risk, however is low provided that you have fired the patient within ethical and professional standards as well as legal guidelines. Documentation is essential to proving these points. If you sense the termination of your relationship with the patient may be contentious, consider seeking legal counsel before taking action.

If handled correctly, firing a patient can be beneficial for both parties. Terminating the negative relationship allows patients to seek out a provider better suited to meet his or her needs. It allows the provider to maintain a healthy, positive practice. 

Have you ever fired a patient as a nurse practitioner?