The federal law Emergency Medical Treatment and Labor Act (EMTALA) requires physicians who provide on-call services to hospital emergency departments to provide stabilizing treatment to a patient who is deemed to have an emergency medical condition.

According to the Centers for Medicare and Medicaid Services (CMS) Revised EMTALA Interpretive Guidelines:

“For those individuals whose emergency medical conditions (EMC) have been resolved, the physician or qualified
medical personnel (QMP) has several options:

• Discharge home with follow-up instructions. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care as part of the discharge instructions. The EMC that caused the individual to present to the dedicated ED must be resolved, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure the necessary follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital; or
• Inpatient admission for continued care.”

EMTALA does not fully address the issue of follow-up care for patients who have been treated, stabilized and discharged from an emergency department. From a risk management perspective, if a patient needs follow-up care after discharge from the emergency department, you should provide the patient with appropriate discharge instructions including what follow-up is necessary. Follow-up can be with another podiatric physician. However, if you instruct the patient to follow-up with you, then you would have a continued relationship with the patient and would have to see the patient until the relationship has been terminated, even if the patient does not have insurance or the ability to pay.

A physician-patient relationship usually begins when a physician begins to evaluate the patient’s medical condition. Therefore, in general, the physician’s right to refuse to accept the patient must be exercised before the physician evaluates the patient. If the physician evaluates the patient and determines that he/she is in need of immediate care, then the physician is responsible for ensuring that the necessary care is provided. If the patient is not in need of immediate care, the physician may terminate the relationship. (See the section on “Terminating the Physician-Patient Relationship”.)

Physicians do not have unlimited discretion to refuse to accept a person as a new patient. Federal laws prohibit physicians from refusing care for discriminatory reasons such as ethnicity, race or religion. Hospital by-laws, managed care organizations, other contractual arrangements and statutory requirements may limit a physician’s right to refuse to treat patients.

While you may have the option to choose to refuse to accept patients based upon their inability to pay for treatment or services, you should be aware that a decision not to accept a patient for financial reasons may be difficult to explain to a jury if the person suffered harm by a subsequent delay in receiving medical care.

Patients have the right to refuse treatment, including hospitalization. Even if a patient refuses your treatment recommendations, you still have a physician-patient relationship with that patient until the relationship has been terminated.

If a patient refuses your recommended treatment, it is important that you have an “informed refusal” discussion with the patient. The patient’s refusal may be due to a lack of understanding of the recommended treatment or the patient’s inability to comply with the plan of treatment for one reason or another. Therefore, patient education is necessary to make certain that the patient understands the recommended treatment, the benefits and risks of the treatment and any risks connected with the failure to undergo the treatment. Additionally, discuss with the patient any alternative treatment possibilities and the risks and benefits of each. All discussions and educational efforts should be documented in the patient’s medical record along with the fact that the patient was made aware and understands the risks of non-compliance with the recommended plan of treatment.

If you decide that you want to terminate your relationship with the patient for non-compliance (or for any other reason), you need to take steps to avoid civil liability or disciplinary action for patient abandonment by formally terminating your relationship.

If you agree to see a patient and provide treatment to that patient, then you have developed a physician-patient relationship. Therefore, you have a responsibility to continue providing necessary follow-up care to the patient until the relationship has been terminated. Try to work out a mutually agreeable payment schedule with the patient. If
you feel it necessary to terminate your relationship with the patient for non-payment, then you should follow steps to formally terminate the relationship to minimize liability exposure.

As stated above in the “Billing Issues” section, you should have a written policy regarding billing and collection procedures, and patients should be informed of the office’s billing practices prior to the initiation of non-emergent treatment.

Patients should be informed prior to any non-emergent procedure of their financial obligations and options for payment (for example, paying over time). The cost of a procedure will likely be a factor in the patient’s decision to have or not have non-emergent surgery and should be a part of the informed consent discussion. Additionally, any alternatives for treatment and risks and benefits of the alternatives should be discussed with the patient. If the patient consents to surgery and agrees to the payment terms, then you should proceed with the surgery and bill according to your payment terms. If the patient does not consent to surgery, then his/her refusal should be documented along with fact the patient understands the risks of refusing the surgery.

You cannot discriminate against a patient who has HIV. An HIV positive patient, as with any patient, should be evaluated and treated appropriately. For you and your staff’s safety, all patients should be treated as if they were HIV positive, which means utilizing universal safety precautions.

If surgery is a treatment option for any patient, the risks and benefits of the surgery should be evaluated. If the patient’s medical condition places the patient at a higher risk for surgery, the risks of surgery may outweigh the benefits and you may feel the patient is not a surgical candidate. If the patient is a not a surgical candidate, document your rationale for making that determination. It is also important to discuss with the patient why he/she is not a surgical candidate and discuss other treatment options. As with any patient, if the HIV positive patient insists on having surgery against your better judgment, you may refuse and/or refer him/her to another doctor.

If you feel the patient is a not a surgical candidate or that surgery is not indicated, document your rationale for making that determination, discuss with the patient why he/she is not a surgical candidate, and discuss other treatment options. If a patient insists on having surgery against your better judgment, you may refuse and/or refer him/her to another doctor. While you do have a duty to provide the standard of care to your patients, you are not bound to provide treatment against your better judgment.

A long term care facility (LTC) is primarily responsible for the care provided to its residents by virtue of the fact that it controls who is allowed to enter the facility. If a LTC terminates the ability of a podiatric physician to continue providing care to residents, the consequences of that decision falls on the LTC, not the podiatric physician. You should do all that is necessary and prudent to transition and/or coordinate the care of the residents to the new care provider.

If any of the appointments were arranged directly between the patient/guardian and the podiatric physician, you should formally terminate your relationship with LTC patients the same way you would with a private practice patient.

If the LTC was arranging all the appointments for the resident, the LTC is responsible for informing their residents of any changes in their treatment. We suggest you give at least a 30-day written notice to the LTC stating your termination date and provide your office number and address in case any patients would like to continue treatment at your office. It becomes the LTC’s task to find another podiatric physician to continue on-site podiatric care for their residents.

You should provide the requisite standard of care for any patient. If in your judgment the patient should not require narcotics, then you do not have to write a prescription for him/her. Document the patient’s complaints, your objective physical exam findings, diagnostic test results, etc. in the patient’s medical record. If there is no objective evidence that the patient needs narcotics, or the patient is complaining of an unusual amount or duration of pain for which you cannot account, consider referring the patient to a specialist (e.g., pain management) for further evaluation and treatment.

It is important that you do not sign a release without restrictions if you feel the patient should have restrictions. If the patient ends up with a poor outcome as a result of working without restrictions, you would be exposed to liability since you signed a document stating the patient was able to safely return to full duty.

Discuss your rationale for your recommendations for restrictions with the patient, including the benefits and risks of the patient adhering to your recommendations. The patient may still refuse to accept your recommendations, and if so, you should document the patient’s informed refusal. However, you should not provide the patient with any release that is not in accordance with your professional judgment.

The passage of time since the patient’s last visit to the physician is not the sole factor in determining whether the physician-patient relationship has been terminated. The duration of the physician-patient relationship is measured on the individual facts of each case. Factors to be considered include:

• The level of dependency the patient has on the physician-patient relationship. A deep level of dependence can exist if the patient has had a long-term relationship with the doctor or a marginal level of dependence can exist if the patient was only seen one time. Generally, the more dependency a patient has on the doctor, the longer the relationship may be determined to exist, even after termination might otherwise appear to have occurred.
• Explicit termination by the patient or the doctor.
• Implied termination of care by the patient. If the patient begins treatment with another doctor and no longer keeps appointments with you, the patient implies that the relationship has ended.
• Mutual agreement between the patient and the doctor that the relationship has ended. For example, the doctor has nothing further to offer the patient and refers the patient to a specialist or another doctor for continued treatment, or there is no further need for the doctor’s services.

If you suspect a patient is interested in more than a professional relationship, let the patient know that your relationship is professional only and make the boundaries clear (e.g., no phone calls that are not of a medical nature, no gifts, etc.). Take precautions to make sure you are not in an unchaperoned situation with the patient. Avoid even the suggestion of impropriety by always conducting yourself in a professional manner. If the patient continues with inappropriate behavior, you may formally terminate the relationship. (See the section on “Terminating the Physician-Patient Relationship”.)

Situations that are personal and emotional may interfere with medical decision-making and objectivity. This is recognized by professional organizations, academic literature and regulatory bodies which agree that the treatment of family members is professionally unwise and ethically problematical.

The APMA Code of Ethics states “The podiatrist should refrain from providing care for any individual with whom he/she has a relationship of a nature that may cause him/her to provide care with reduced objectivity, interfering with the exercise of sound medical judgment.”

Risks of treating a family member include:

• Personal feelings and fears might compromise a doctor’s professional objectivity and judgment leading him/ her to either over- or under-estimate the seriousness of the patient’s condition.
• Potential informality associated with treating family members may lead to inadequate history-taking, physical and diagnostic work-up and/or record-keeping.
• Personal connections may also complicate the way in which the patient/family members and doctor interact.
• Potentially sensitive, but clinically relevant questions may not be asked or examinations may not be performed.
• Family members may be less likely to disclose personal, but pertinent, facts.

However, there are instances when treating a family member may be necessary in limited circumstances, such as minor illnesses or emergency situations. Some states have regulations prohibiting doctors from prescribing medications to family members.

Termination of your relationship with a patient should always be carefully considered. However, there are many reasons that termination may be necessary. Examples include:

• Continued patient non-adherence.
• Patient demands treatment not considered to be within the standard of care.
• Patient is verbally abusive/threatening to you or your staff.
• Patient is abusing prescription drugs or controlled substances.
• Patient refuses to pay or make arrangements to pay bills.
• Any other reason the physician feels is eroding the physician-patient relationship.

You should not terminate a relationship based on the patient’s race, color, gender, religion, national origin or age.

The following steps can minimize liability exposure arising from termination of the physician-patient relationship:

1. Review the medical record for conditions that might require additional treatment or monitoring.
2. Check the provisions of any contract signed with the patient’s health plan to ensure compliance.
3. If at all possible, discuss the termination with the patient in person.
4. Send a written notice of termination to the patient by certified mail, return receipt requested, and by regular mail simultaneously. Keep a copy of the letter and the receipt in the patient’s medical record. If the patient refuses to sign for the letter, keep the copy of the undelivered receipt and the letter in the medical record.
5. The letter should state:
   • The reason for termination (e.g., “you have consistently failed to follow my advice and recommendations,” “you have not followed through with arrangements to pay the balance due on your account,” “there are important differences in our views of medical care and treatment,” “the present nature of our physician-patient relationship,” or “your continued inappropriate behavior in my office.”)
   • That you will continue to provide care to the patient for a reasonable period of time (usually 30 days) while he/she finds alternate care.
   • If the patient has a condition that requires continued medical treatment or follow-up, include that it is important for him/her to continue with treatment because of his/her current medical condition and that you encourage him/her to select another physician promptly for ongoing care.
   • That a copy of the patient’s medical record will be sent to the new provider at the patient’s request.
6. Avoid referring the patient to another specific physician. Instead, refer the patient to a provider referral source(s) in the community.

Prior to terminating your relationship with a patient, you are encouraged to contact PICA’s Risk Management Department for direction.

A sample "Termination of Physician-Patient Relationship" is available on PICA’s website.

The amount of involvement with the patient in the 30-day period depends upon the situation. The main concern is to prevent or to be able to defend against allegations of patient abandonment. If the patient has a problem requiring continued observation or treatment and would normally be followed during the 30-day period, it would be prudent for you to continue to see the patient during the 30-day period if the patient chooses to return to see you. 

However, if the patient does not have a condition requiring continuing observation or treatment and would not normally require an office visit during the 30-day period, then you can tell the patient you will be available for emergency situations. Regardless, if a patient calls for an appointment in the 30-day period, it would be prudent to make an appointment and perform a proper examination and necessary treatment. However, you do not have to perform any elective treatment or procedures.

Yes, the termination is still effective. Make sure to place the receipts from the certified letter that show that patient refused to sign for letter in the patient’s medical record.

In this situation the patient terminated the physician-patient relationship so you do not need to send a termination letter. However, you should send the patient a letter confirming the patient’s termination of the relationship. The letter should be sent certified mail and standard mail and a copy of the letter along with the certified receipts should be placed in the medical record.

A sample “Letter Confirming Patient’s Termination of Physician-Patient Relationship” can be found on PICA’s website.

First, find out why the patient continues to call. Does he/she have a legitimate question that needs to be addressed? Is it a billing issue? Does he/she want a copy of his/her medical records? Try to resolve the issue if possible.

If the patient continues with harassing behavior, you could send the patient another certified letter confirming the date the relationship was terminated and that you and your staff will not be able to take any more calls. If the patient still continues to call, you can make a formal complaint with the local police department.