The Alignment by ChiroPreferred

Chiropractors have the right to treat the patients they wish to treat. They also have the right to terminate relationships with patients for various reasons, such as:

• Numerous attempts at communication have proven unsuccessful.
• The patient frequently misses or cancels scheduled appointments.
• The patient has repeatedly refused to obtain needed screening or treatment.
• The patient or their family members are persistently rude, belligerent, or threatening to chiropractors or staff.
• The patient and the chiropractor are simply too different, in any multitude of ways, to work as a team.

Chiropractors should use caution when terminating from their care patients who are members of a protected class. Federal and state laws prohibit discrimination based on race, religion, color, etc., and other laws — such as the Americans with Disabilities Act (ADA) and the Rehabilitation Act of 1973 — also may apply.

Additionally, chiropractors should research whether the states in which they practice have other specific regulations related to discharging patients from care. When confronted with a situation in which federal or state laws might be applicable, consulting with an attorney is advisable.

Objectives

The objectives of this guideline are to:

• Review important considerations for terminating a chiropractor—patient relationship, such as documentation, timing, payment issues, and patient agreements
• Emphasize the importance of developing a formal process that establishes a framework for terminating patients from the practice
• Discuss the essential components of drafting, sending, and documenting notifications of termination
• Review other termination considerations, such as using ”no schedule” lists, following up with patients who initiate termination of the relationship, and establishing administrative oversight

Considerations for Terminating a Chiropractor-Patient Relationship

Documentation

When a chiropractor—patient relationship becomes untenable, the chiropractor should review the patient’s health record before deciding to terminate the relationship. Although it is true that chiropractors can terminate relationships with patients, it is wise for chiropractors to have objective and factual documentation that supports their decisions. For example:

• Have patient instructions and education been documented in the patient’s health record?
• Have patient complaints or accusations against the practice, or inappropriate remarks to chiropractors and staff, been documented? These issues should be objectively noted in the patient’s health record; use quotation marks where relevant to preserve the patient’s actual statements.
• Does documentation include dates of no-show/cancelled appointments and staff follow-up with the patient?
• Does documentation objectively note that the chiropractor and staff have attempted to resolve the problems or address the issues?
• Has the chiropractor consistently documented treatment recommendations and warnings to the patient about possible negative effects of nonadherence? (Note: Every occurrence of nonadherence should be documented, not just situations in which the patient experiences adverse outcomes.)

If the health record does not support the decision to terminate the relationship, then the chiropractor would be wise to continue treating the patient, at least until such time as the documentation supports the decision.

Timing

Timing of the termination might be critical in the defense of any allegation of patient abandonment. Abandonment is generally when a chiropractor terminates a provider—patient relationship without reasonable notice or in a manner that denies a patient necessary medical care. As such, terminating a relationship at a critical juncture in patient care is not recommended.

The chiropractor needs to consider the patient’s clinical status before determining whether to initiate the termination process; this will help facilitate a safe care transition. For example, a behavioral health professional should determine whether a patient is mentally stable before termination. In an inpatient setting, the provider should consult with the department/division chairperson and/or the facility’s risk manager.

Another consideration related to timing includes location. If a chiropractor is the only chiropractor in an area, or if they are practicing in a rural area, it might take longer to ensure a patient has appropriate care, which may result in a longer notice period prior to terminating the relationship.

Payment Issues

Terminating a chiropractor—patient relationship can be problematic if the reason for it is nonpayment of bills. Before taking this step, the chiropractor should first verify whether a contract (e.g., managed care organization [MCO], health maintenance organization, or a preferred provider organization) obligates the continued provision of care.

If no contractual obligations are in place, and if the patient is not undergoing active treatment, the chiropractor may advise the patient either by phone or letter that a payment plan must be established and followed — or the patient will be terminated from the practice. (Note: Chiropractors should take care to formally decide whether to terminate nonpaying patients rather than just refusing to see them because they haven’t paid an outstanding balance.)

The patient should be given adequate time to respond; however, if no response is forthcoming, the chiropractor can send a termination letter. If the nonpaying patient is in the midst of active treatment, the chiropractor should seek legal advice before sending any notice of termination.

Patient Agreements

In some instances, even though a patient or family might be problematic, the chiropractor may not be ready to terminate the relationship. In these cases, the chiropractor might want to consider using a patient agreement with the patient or family.

A patient agreement can help preserve the chiropractor—patient relationship, or — if the patient agreement is not followed — it can support the decision to terminate the relationship. For more information, please see MedPro Group’s guideline titled Patient Agreements in Clinical Practice.

Violent, Abusive, or Threatening Behavior

If a patient or family member displays violent and threatening behavior that includes a physical or verbal threat of bodily harm to the provider, any staff member, or another patient, the chiropractor should immediately contact local law enforcement. When law enforcement responds, they should inform the patient or family member that they cannot return to the provider’s office again.

The chiropractor should follow up by mailing a formal termination letter to the patient that includes a records release authorization form to sign and return indicating the new provider’s name and address to which to send the health records.

If a patient or family member uses abusive or discriminatory language, including racial slurs, the provider should ask them to refrain from doing so. If a patient or family member refuses to stop the offensive language or behavior, the provider can ask them to leave the practice. The chiropractor or practice management may then determine how best to handle the situation.

Discussing the matter with your ChiroPreferred senior risk solutions consultant is recommended to explore appropriate options. If termination of the provider–patient relationship is ultimately chosen, the chiropractor should give a 30-day notification in writing while providing care and treatment for the patient’s ongoing and emergent needs.

Whether or not the chiropractor–patient relationship is terminated, chiropractors always should carefully document in the patient’s health record the circumstances regarding the patient’s behavior, language, and any discussions between the chiropractor/office staff with the patient or family member to address the unacceptable and inappropriate language or behavior.

The Process

Chiropractic practices should develop formal processes for terminating chiropractor—patient relationships to avoid allegations of patient abandonment. Part of the process should include careful consideration of the patient’s situation and review of the patient’s health record prior to termination actions.

Contractual and Legal Obligations

Chiropractors should review managed care contracts or other procedural documents prior to withdrawing from a patient’s care. MCOs may require compliance with additional steps before a chiropractor can unilaterally terminate a patient from his/her care. For example, the MCO may require warning letters or an extended waiting period to ensure that the patient has adequate time to select another chiropractor from the MCO panel. Often, the MCO will seek to refer the patient to another chiropractor within its network.

Additionally, some state health programs may have special grievance procedures that chiropractors must follow. Each practice should research contractual and legal requirements before finalizing its termination policies.

Notification

Once a chiropractor has made the decision to terminate a patient from the practice, the chiropractor will need to notify the patient in writing about the decision.

Drafting the Notification Letter

The notification letter should be professional and nonconfrontational, and it should set a tone that aims to maintain the best possible relationship with the patient. The tone should focus on the long-term benefit for the patient.

Generally, the chiropractor is under no obligation to provide a reason for withdrawing from the patient’s care. Some chiropractors may wish to do so, but the statement should be brief. It should not be argumentative or punitive in tone.

The letter should clearly state the date upon which the termination will become effective, and it should commit the chiropractor to helping the patient through the transition period by offering to provide emergency care only for a specified time, such as 30 days. In most instances, this notice allows the patient sufficient time to obtain the services of another chiropractor.

However, because state requirements and patient needs differ, a local professional society might be able to offer guidance as to how long it could take a patient to transition to another chiropractor’s care. During the transition period, the patient will remain the responsibility of the original treating chiropractor.

Whenever possible, include resources in the notification letter that the patient can use to access another chiropractor. Local organizations or public health services might provide the names of chiropractors who are accepting new patients. The patient’s insurance panel may also provide names of available chiropractors. Generally, it is not a good idea to refer the patient directly to another chiropractor.

The notification letter also should describe the process for transferring or forwarding health records, and it should include a records release authorization form. The patient should be informed that, once a written authorization is received, copies of his/her health records will be forwarded to the new chiropractor.

Some organizations charge a reasonable fee for copying health records. If your practice plans to impose a fee, review federal and state regulations first. HIPAA and most state laws limit the amount that can be charged for duplication and searching services.

If the state law permits photocopying fees that are greater than the fees permitted under HIPAA, then the HIPAA fees preempt state law and must be used. Further, HIPAA prohibits charging patients for handling fees, chart-pulling fees, or per-page fees in excess of the direct cost of materials, even if state laws permit it.¹

Because the circumstances for providing copies of health records may vary, the chiropractor should evaluate whether a charge makes sense relative to the patient. If the chiropractor intends to charge for copying health records, he/she should clearly state this information in the notification letter.

In no case should a patient be required to pay a fee for copies of his/her health record prior to release. Further, no practice can require a patient to pay on any account balances before releasing his/her health records.

For more information, see the U.S. Department of Health and Human Services’ information about individuals’ right under HIPAA to access their health information.

Sending the Notification Letter

Once the notification letter is finalized, send it to the patient via certified mail, with return receipt requested. Because some patients may refuse to accept delivery of a certified letter, the chiropractor should also send a copy of the letter via standard mail at the same time.

Documenting the Notification

A copy of the letter should be retained in the patient’s health records. The return receipt, when obtained, also should be maintained in the file. If the U.S. Postal Service returns the letter because it is undeliverable or because the patient fails to pick it up, file the unopened letter in the patient’s record.

Other Considerations

Other factors to consider when developing a policy for terminating a chiropractor—patient relationship include the following:

• Staff should be trained to place the names of patients who have been terminated from the practice on a ”no schedule” list so that these patients are not inadvertently readmitted to the practice.*
• On occasion, a patient may announce that he/she is terminating the relationship with the chiropractor because of dissatisfaction. In these circumstances, it is recommended that the chiropractor confirm the dissolution with a follow-up letter.

For large group or multisite practices, consider having administrative oversight of termination procedures that includes a review of the following circumstances:

• Does the termination apply to only one chiropractor? Was this a personality conflict, and could the patient be successful with another provider?
• Does the termination apply to only one location, or could the patient be treated successfully at another location?
• Was the issue egregious enough that the termination is for the entire practice (i.e., for all providers at all locations)?

Terminating a Chiropractor-Patient Relationship With a Minor Patient

Not only can chiropractors terminate professional relationships with adults, but chiropractors also might consider dismissing minors (pediatric patients) from the practice. Reasons for such dismissal might include that the minor’s parents are difficult, demanding, nonadherent, or financially irresponsible with respect to payment.

Unless the minor is emancipated (standards for emancipation vary by state), termination of the chiropractor—patient relationship should be preceded by a discussion with the parent(s). Further, the termination letter should be sent to the parent(s) or guardian(s).

Conclusion

A chiropractor may choose to terminate a provider—patient relationship for many reasons, such as nonadherence to treatment regimens or appointments, refusal to obtain needed screening or treatment, or inappropriate behavior and language.

To avoid allegations of abandonment, chiropractors should ensure that their practices have formal, well-developed termination processes in place. These processes should establish a framework for reviewing each patient’s health records, documenting essential information, and notifying the patient of the termination.

Further, because the circumstances with each patient will differ, chiropractors should carefully consider their approach and actions relative to each situation.

Resources

• American Academy of Pediatrics: Addressing Common Patient Concerns
• American Medical Association: Code of Medical Ethics Opinion 1.1.1: Patient–Physician Relationships
• Dental Economics: Dental Risk Management: The Doctor/Patient Relationship
• ENT Today: How to Appropriately Discharge a Patient
• Healthcare Training Leader: When and How to Terminate a Physician-Patient Relationship
• Medical Economics: Removing a Patient From Your Practice: A Physician’s Legal and Ethical Responsibilities
• Physicians Practice: Discharging Problem Patients the Right Way
• Psychiatric News: Avoiding Abandonment Claim: How to Properly Terminate Patients From Your Practice

¹HIPAA Privacy and Security Rule, 45 C.F.R. § 164.512(c) (4) 2016.

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This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

ChiroPreferred is the marketing name used to refer to the chiropractic-related products offered by MedPro Group. MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and/or may differ among companies. © MedPro Group Inc. All rights reserved.