SAMPLE LETTER OF WITHDRAWAL OF CARE

(Office Letterhead)

Sent via Regular and Return Receipt Requested Mail *

Date

Patient Mailing Address

Dear _______,

Effective ___ (Date 3-4 weeks in future) __, I will no longer be able to treat you as a patient in my practice, and the doctor / patient relationship between us will be terminated.  I am terminating that relationship because ___- insert the reason in an objective**, non-inflammatory manner.  Hopefully the patient’s chart will reflect various occasions of non-compliance – failure to take medications, failure to keep appointments, failure to follow professional recommendations, refusal to meet financial obligations, etc. – which may be noted.  Otherwise, use a benign statement such as: “I do not feel that the trust and confidence required in a doctor/patient relationship remains between us.  Thus, I believe it is in your interest to seek care from another doctor or health care provider.”

You may contact the __(Name and telephone of local medical society or referral service) __ for names of doctors or health care providers in your area from whom you may seek care.  As soon as you have chosen a new doctor, please notify me.  With your written authorization, I will release copies of your records to him or her.

With respect to the balance you owe me for the medical services thus far provided __ (Insert what you expect: to be paid in full by (date), or that you intend to forgive any balance owed) __.

I wish you the best with your new doctor. (or can use “healthcare provider”)

Sincerely,

John/Jane Doe, MD

Print three copies of the letter: one for the patient’s record, one via regular mail and one via Return Receipt Requested mail (with the USPS return receipt card).  If the patient should refuse the Return Receipt letter file it in the chart. If the address is correct, courts have ruled that the patient was properly notified by the regular letter – even if they refused to read it.  You will then have a courtroom defense of proper notification if there is a later claim.

By Victoria Sterling, JD

There are very few circumstances in which a doctor is required to treat a patient merely because that person presents himself or herself for examination. As a physician, you may freely choose who you wish to treat. You may make your decision after completing an initial examination, and determining a presumptive diagnosis and the extent of possible treatment.

You can refuse to treat for any reason: lack of expertise, a demand for what you believe to be substandard care, an inner sense that the personal relationship between you and the patient will not be easy or pleasant, or if the patient simply acknowledges that he or she can’t pay for services

There are some caveats:

• Use good judgment in phrasing a refusal to treat someone who is protected under the Americans with Disabilities Act. Even if you lack the expertise to treat the patient, such refusal to an HIV-positive patient may lead to charges of discrimination.

• Read the fine print in your managed care contract. Some contracts require that any and all patients under that plan will be treated.

• If you believe the patient’s condition requires prompt treatment, don’t merely make an offhand suggestion that the patient seek further care. Casual advice to simply “See specialist ‘X’” is not often taken seriously, especially when the patient surmises future care will be either painful or expensive.

If you decide not to treat, the patient deserves an explanation of the situation or a referral to a practitioner who might treat. The following risk management suggestions will benefit both you the patient in this situation:

Walk the patient to your receptionist, who will call the appropriate specialist, hand the patient the phone to set up an appointment, and then confirm that an appointment is made. Offer copies of your exam records and any pertinent radiographs for the patient to take to that visit. Have staff chart that appointment, then use your tickler file to call on that date to check if the patient complied. If not, staff should call the patient to follow up.

• If a patient does not follow your direction, send an explanatory letter as you would for a patient who has refused care. Send the letter via both regular and certified return receipt requested mail.
• Chart the visit. Include an explanation of your reason for referral, as well as warnings of the consequences that could occur if the condition is not treated.  It is important that records protect you from a patient who doesn’t follow your guidance, then returns in a year or two to allege that you were the cause of the bad outcome. This is especially true for lesions requiring biopsy.

One significant caveat: If the patient being referred is in pain and you are concerned that he/she is suffering while awaiting care by your consultant, think twice about prescribing pain medication. If you prescribe medication (or offer office samples) you have treated the patient and a doctor/patient relationship now exists. The same applies to any prescription, including antibiotics.

Once a doctor/patient relationship has been established, you have a duty to treat that patient until the relationship is properly terminated. The law holds you responsible for protecting the patient until the relationship comes to a legal end. This means that a patient may bring a claim of abandonment against you if he/she suffers an injury due to your failure to continue treatment.

Your practice needs to get the word out, to attract new patients and retain your loyal patient base. So many mediums are available, from the Internet and other electronic communications, such as Facebook and Twitter, to the Yellow Pages and from billboards to cable television. When considering how to best represent your practice to your target market, one factor is often overlooked. How will the things we say about our practice influence a jury, if it is raised as an issue in litigation? First, Medical Practice Acts often contain laws regarding how a doctor can and cannot market the practice. Before using any new form of marketing or advertising, it is best to check with your medical board to ensure that you are not promoting your practice in a way that conflicts with your state’s Practice Act. Also be aware that your marketing materials may be scrutinized closely by your competition in your specialty as well as other specialties, and by outside agencies such as the Better Business Bureau.

If you have paid for the press, it is advertising! Recently there was a report of a doctor who had given a donation to a local charity and in return, he was given a “write up” in a local health magazine. The “article” was a thinly disguised advertisement, complete with quotations from doctor, staff and happy patients. A nice, glossy layout and copy with words like “excellence” and “best” and glowing description of the facilities were all a part of this publication. Unfortunately, the feature contained a quotation from the doctor that stated that a specific procedure could be done without the need to miss a day of work. A patient who did need to miss more than a day due to a complication saw this ad (which was apparently displayed beautifully matted and framed in the doctor’s reception room) and it was used against him as a warranty of results.

Many physician practices are using Internet technology and social media to reach patients and prospective patients. While new technology can be an exciting opportunity for developing your practice and enhancing relationships with established patients, it can be an area for potential liability as well.

Here are some basic tips on managing risks that are created in marketing your practice and using social media to communicate with patients and potential patients. This information is meant to assist you in identifying areas of risk.

Websites

Use a disclaimer stating that the website provides general information and is not intended to offer specific medical or surgical advice to anyone. Make sure your disclaimer states that no doctor-patient relationship exists, no diagnosis or treatment is being provided and that the information provided is for educational purposes only and should be used in consultation with a physician of the inquirer’s choice.

Make sure to advise users that hyper-links do not imply relationships or endorsement and are not intended to infringe trademarks or copyrights of the hyper-linked sites. (A short simpler disclaimer is included at the end of this article)

Follow truth in advertising rules. Comply with state laws and ethical provisions (if any) concerning medical advertisement in the event websites are classified by the law as “advertisements” and not as “information services.” Clarify the location where the providers are licensed to practice medicine and consider explaining there is no intention to solicit or practice in non-licensed states.

Do not make disparaging remarks about competitors or their products or services, as this could be grounds for allegations of libel. Avoid innuendos or comparisons that imply superiority over competitors, these could be used to allege implied warranty or guarantees.

If trying to avoid being considered an advertisement, do not hyperlink websites to advertisements or accept commercial “sponsors” for your website. Obtain written agreements to link with other websites. Deny responsibility, if applicable, for other websites hyper-linked with your own.

Ensure information published on your website does not violate the rights of a copyright owner. Consider an on-screen warning that information and names within the website may be subject to copyright and trademark protection. Identify any limitations placed on further use of the website materials.

Provide interactive e-mail services only if transmitting general medical information. Advise those that use any e-mail functions that their inquiries and your responses are sent over the Internet are not considered privileged or confidential. If using interactive e-mail, obtain additional information concerning the e-mailer so you can update and correct information provided to them via the Internet. Do not send unsolicited e-mail advertisements, as these have been the subject of litigation. Be aware that you may have liability for defamatory statements made by third parties through e-mail or in chat areas that may be seen on your website.

Be aware of laws concerning advertising and labeling if specific drugs are promoted on your website, through e-mail correspondence, or if drug companies are accepted as sponsors of the website. The FDA and the FTC regulate advertisements and labeling for drugs and you will need to be in compliance with these regulations

Other Marketing

Marketing for your practice should be extremely cautious about promising or implying results in any form.

Listen to your “on-hold” phone message in its entirety to be sure you avoid making promises of specific outcomes, guarantees or warranties; these words will be used against you when something goes wrong.

Review any marketing text in brochures or other publications (such as phone book advertising) carefully and be cautious what you say to patients.

Be prepared to have your advertising used against you. Plaintiff attorneys especially like to use public advertising against health care providers. They see it as part of their job to portray you in the worst possible light. Ensure that any marketing efforts you use will not cause you harm years from now if presented in a courtroom.

Are you texting or “tweeting” your patients? Use a caution when using newer communication methods. When communicating with patients, or a patient’s family, it’s probably a good idea to take a minute to evaluate the privacy and confidentiality before communicating in such a manner.

All email communication with patients should be printed out and kept in patient charts (when the charts are maintained in paper form). Even if the communication is very short, it could be crucial to the care of the patient. It is part of the patient’s record and information that you receive from the patient as well as information that you send to the patient needs to be maintained in the chart. For electronic medical records, the communications need not be printed out as long as they are maintained in the record and can be retrieved.

Texting has become a very convenient method of communication. However, can you be sure that the information can’t be intercepted or seen by others? In addition, the texts are part of your patient care; how will you ensure they make it into the patient’s chart? In order to print out a text for the patient’s chart, it needs to be forwarded to email. It may not have an imprint on it that defines it as a text message, so you will need to indicate this in some manner in order to accurately reflect the communication method.

Additionally, a cryptic response to a patient may not sound the way you would want documentation of your care to be represented.

Sending a “tweet” to patients also engenders risk. Limited to 140 characters and meant for quick updates, these are not to inform someone about a medical condition or question. Tweets normally are sent to multiple people. We always urge doctors to communicate with their patients but the privacy and safety of those communications are as important as is the information being communicated.

Ironically, with all of the mediums available, the best form of advertising still remains a happy patient and strong relationships with your colleagues. Your patients talk to their family, friends and coworkers. Keep your patients comfortable and happy, and they will send others to you. Word of mouth is the best kind of promotion. Whatever forms of marketing you use, make sure that it does not create more long term harm than short term gain. Advance the goals of your practice wisely and safely

Here is a short model disclaimer which can be used in any public access website for your practice:

NOTICE TO WEB SITE VISITORS

This website is provided for information and education purposes only. No doctor/patient relationship is established by your use of this site. No diagnosis or treatment is being provided. The information contained here should be used in consultation with a physician of your choice. No guarantees or warranties are made regarding any of the information contained within this website. This website is not intended to offer specific medical advice to anyone. Dr. _________ is licensed to practice in the State of __________ and this website is not intended to solicit patients from other states. Further, this website and Dr.__________ take no responsibility for websites hyper-linked to this site and such hyper-linking does not imply and relationships or endorsements of the linked sites.

Did you (physician, physician assistant, or nurse practitioner) successfully e-Prescribe and report G8553 on 10 Medicare billable E&M office visits by June 30, 2011? If not, read below to see if you qualify for the “significant hardship exemptions” recently finalized by CMS. If you can answer “yes” to any of the following, apply for the hardship exemption by November 1st (details below)

• Do you have and use an EHR and have registered to participate in the Medicare or Medicaid EHR Incentive Program for 2011?
• Did you have an e-Prescribing system in place by June 30, 2011 and found that you were unable to electronically prescribe due to local, State or Federal law or regulation (i.e. large volume of narcotics)?
• Did you have limited prescription activity, meaning you prescribed less than 10 Medicare prescriptions from Jan 1 – Jun 30? (total prescriptions, regardless of whether they could be electronically prescribed or not) Or are you a non-physician provider (NPP) who does not write prescriptions under your own NPI?
• Did you have an e-Prescribing system in place by June 30, 2011 and found that there were insufficient opportunities to report the e-Prescribing measure due to limitations of the measure’s denominator (i.e. you primarily prescribed medications during non-billable pre-op or post-op visits).
• Do you practice in a rural area without high speed internet access?
• Do you practice in an area without sufficient available pharmacies for electronic prescribing?

If you answered “yes” to any of the above, you are eligible to apply for the “significant hardship exemptions”.

• Physicians MUST make this request themselves (not your staff). CMS has announced that billing managers, office managers, receptionists, and other office staff cannot submit an eRx hardship exemption request on behalf of their eligible professionals. Click here for the CMS reference.
• CMS will review requests for exemptions on a case-by-case basis. You have 250 words or less to justify your exemption request – take this seriously as there is no appeal process if CMS denies your request. Keep in mind if your request is approved, you will have to reapply annually to keep the exemption.
• Click here to apply for the significant hardship exemption request. Deadline is November 1, 2011.

If you answered “no” to all of the above and

Your Medicare E&M Visits > 10% of total Medicare dollars

Your Medicare E&M Visits > 100 for Jan 1 – Jun 30, 2011

You had prescribing privileges as of Jun 30, 2011

You will be subject to the 1% Medicare payment reduction for 2012. However, there is still the opportunity to e-Prescribe NOW and earn the e-Prescribing incentive of 1% for 2011. e-Prescribe and report G8553 (indicating you e-Prescribed during the visit) at least 25 times for Medicare billable office visits (non-billable pre-op and post-op visits don’t count) between now and December 31, 2011. Not only will you earn the incentive for 2011, but you will avoid the penalty for 2013. (Note, you cannot earn the e-Prescribing bonus and receive the EHR Meaningful Use incentive in the same year).

Don’t have an eRx system? Visit www.nationalerx.com to learn about a FREE internet based system.

Want more information?

Click here to read the Federal Register.
Click here to visit CMS’s website.

Need personalized assistance as it relates to e-Prescribing, Meaningful Use, or PQRS? KZA Consultants are available under hourly contract to assist your practice in implementing these Medicare programs. Contact your KZA Consultant or Cheyenne Brinson at cbrinson@karenzupko.com for more information.

Karen Zupko & Associates specializes in advising surgeons about the business side of their practice. They provide coding education and auditing for practices across the country, from solo surgeons to academic departments and publicly traded entities. Call Colleen Gallagher, (312) 642-5616, to discuss the scope and cost of services.

The society addresses issues of importance to our membership including physician ethics, physician/patient relationship, patient advocacy, and state and national legislation. We represent physicians in every specialty of medicine.

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• Excellence in patient care
• Adherence to a high level of ethical conduct and professionalism
• Dermatology related research
• A spirit of community among its members
• Public interest relating to dermatology

Find DDI at other 2012 Events

Find DDI at other 2012 Events