Every so often, it becomes necessary to dismiss a patient from your practice.

I get several questions a month about the “legalities” involved; the usual wording is something like, “How do I dismiss a patient without violating any laws?”

Contrary to popular opinion, there are no statutory laws that I'm aware of that specifically apply to patient dismissal. While there is a remote (and quite preventable) chance of running afoul of antidiscrimination laws, you should be concerned mostly with leaving yourself open to civil litigation—charges of abandonment and the like.

There are no rules that dictate specific reasons for dismissal, so reasons will vary from practice to practice. A common reason is failure to pay legitimate and reasonable charges. This can include technical requirements in the event that you drop out of a health plan. Depending on the contractual rules of the plan, you may be forced to formally terminate treatment of participating patients if they have been given, and have refused, the option to pay out of pocket. Theft (including theft of insurance checks) also falls under this category.

Most patients, however, are dismissed because of interpersonal conflicts with the physician. Mostly that means persistent noncompliance with a reasonable treatment plan, but there are other valid reasons. These include unacceptable behavior, particularly in the presence of other patients, or a generally unruly or uncooperative demeanor. And most experts agree you can refuse to treat a patient who insists on treatment outside your area of expertise, or at a location other than your private office.

Since there are no hard and fast rules, your reasons for dismissal should be determined in advance, written out, and included in your practice manual. Once you have made your rules, follow them. Exceptions should be rare and made under extraordinary circumstances.

Even when circumstances warrant, dismissal should be a last resort. As with most interpersonal conflicts, your best option is reconciliation. Sit down with the patient, explain your concerns, and discuss what must be done if your doctor-patient relationship is to continue. Document this conversation in detail in the patient's chart and follow up with a letter reconfirming what you discussed.

Often, such patients are not aware (or willing to admit) that they are violating your office policies. Honest communication often will save such relationships. But be sure to make it clear that failure to address the problems you have outlined will result in dismissal from your practice.

Once again—this cannot be repeated too often—you should clearly document in the patient's chart exactly how he or she has violated your office policy. This will minimize your chances of being charged with discrimination of any sort. Be especially diligent about this step if the patient has any sort of obvious disability, whether physical or mental.

If, despite your best (documented) efforts, the problems continue and you feel you must remove the patient from your practice, following a few generally recognized guidelines will keep the process smooth and consequence free.

Begin by informing the patient, preferably via certified mail, of your decision to dismiss him or her. Clearly spell out your reasons, and include a reminder that these problems have been discussed, a warning has been given, and the problems have continued. If the patient belongs to a third-party health plan, be certain that you are acting within the stipulations of your contract with that plan, and inform the payer, in writing, of your action.

Give the patient a reasonable amount of time (30 days is common) to find another physician, and mention that you will address any emergent problems within the scope of your specialty during that 30-day period. Include a list of competent physicians in your area who might assume the patient's care (but don't guarantee that any of them will), or include the phone number of the local medical society that they can contact to find a replacement. This will minimize any potential allegations of abandonment.

Offer to transfer medical records to a newly designated physician upon written authorization to do so from the patient.

File a copy of the letter, the receipt for the certified service, and the returned signature card in the patient's chart. While the law states that a first-class letter, properly addressed and stamped, is presumed to have been delivered, you don't want any question as to whether the patient received the letter.

Finally, try to avoid dismissing a patient in the midst of a course of treatment. If this is unavoidable, you may wish to contact your malpractice carrier to review the case prior to doing so.

Forcibly ending a physician-patient relationship is a significant event, requiring the same serious consideration as any other important patient-care decision. Don't undertake it lightly. Remember, dismissing a patient should be a rare occurrence, a last resort.

Dismissing Patients Properly