A recent survey shows around 90% of medical practices have fired at least one patient in the last two years. If the need arises in your practice, it is something that needs to be executed in only the proper scenarios and in the proper fashion.

Here are the reasons that justify a provider dismissing a patient, as well as the proper protocol for doing so.

Do Not Rush Into Dismissal

First of all, make note that a patient cannot be discharged due to a disability. You also cannot discharge them if you find their condition off-putting (such as refusing to treat HIV+ patients). A more in depth discussion of the legal issues can be found in this guide written by a dual healthcare/legal expert.

Before dismissing the patient, try to exhaust all means to preserve the relationship. There are some exceptions: never tolerate threats nor actual actions of violence, sexual assault, or other crimes inside your facility.

First Try to Remedy the Situation

Explain to the patient why their actions are not acceptable. Depending on the behavior, offer a compromise. Offer payment plans for delinquent statements. If a social worker is available ask the patient to meet with them to see what assistance is available.

Tardy and no-show patients should be reminded of the tardiness/cancellation/no show policy and the penalty for each including the risk of being dismissed. Make note though that in some scenarios we are ethically obligated to overlook tardiness if the patient arrives in the lobby with a life-threatening condition.

When non-violent but off-putting actions are the problem, offer a behavior agreement plan outlining the actions that will not be acceptable and their consequences.

Patients on narcotic pain management should enter into a narcotic agreement outlining expectations of each party, including 24 hours notice for refills, but no early refills, even for lost or stolen medication.

In each case, make it clear that violation of such agreements may could be grounds for dismissal. Always remember to document these attempts to rectify the relationship in the patients chart. Only after every discussion and viable option of correcting the aberrant behavior is attempted should you consider taking action toward termination.

How to Begin the Dismissal Process

Patients who continue their actions of souring the doctor-patient relationship should not be released from your care while under the treatment for an acute disease or while in the third trimester of pregnancy. In these cases, resolve the current medical issue before terminating the relationship to prevent accusations of patient abandonment.

Even after resolving the acute issues, the best option is to provide a letter giving 30 days notice to the patient that they need to find another medical provider, as they can no longer be seen in the practice. Explain that this is due to their actions and that assistance in finding another medical provider can be offered during the notice period. Do not direct the patient to go to the emergency room for their care though, as this indicates there is an ongoing critical matter, and your dismissal could be seen as unethical.

Furthermore, if the patient is discharged from a facility that has emergency care, EMTALA dictates the patient will be assessed in the emergency department when they present, regardless of any limits or dismissal the facility has implemented.

Cases That May Make Dismissal Impossible

There are issues that may prevent you from refusing to see a patient. In rural areas, the facility may be the only one available to care for a patient. Similarly, if the provider is in a staff model HMO system without another HMO facility in the area the practice may be the only one their insurance pays for.

In these cases an option may be that the current provider cannot see them in clinic, but a patient is willing to establish a fresh relationship. Selling this as a “fresh start” for both parties may actually help in rectifying the behavior.

If it is not possible to release the patient, and you are the only viable provider, you may have to get creative. Perhaps the angry/violent patient will be asked to call ahead of arrival so security can be present. The tardy/no-show patient may have to understand that given their history scheduling issues their time slot will be double booked and they should expect a wait on arrival. Finally, the patient racking up a bill may have to be allowed to do so.

First do no harm, and collect payment later.

Protect Yourself

Do not forget to look into the laws in your state before taking any action. If you have any questions, consult your facility’s lawyer before taking any action.

What other options do you think are viable for problem patients? Comment below your thoughts on the matter.

Sean Conroy started his career in the lab, but had a burning desire to enter the clinical side of medicine as a physician assistant. His memoir Through the Eyes of a Young Physician Assistant was published (Open Books Press) in 2016. He currently writes for Clinician Today, Barton Blog, Clinician1, as well as Gomer Blog.