When a physician terminates supervision of a patient without notifying the patient in writing

Updated May 3, 2021

See related article Terminating patient relationships: How to dismiss without abandoning

When a physician decides to dismiss a patient, the patient should be notified in writing. The letter should be printed on office letterhead and sent by first-class mail and by certified mail with a return receipt requested.

The letters below are meant as general resources only. State requirements may dictate specific elements to include in termination letters and how letters should be sent. Consult your state medical board for guidance. A blank authorization to release medical records should be enclosed.

Termination letters should not be sent electronically, such as by email or through the patient portal. It is preferred to send notification more formally, with physically trackable evidence of delivery. Check your state guidelines for further definition on sending termination letters electronically.
 

Letter 1 — Termination of the physician/patient relationship

[Date]

To [patient name]

Please be advised that I will no longer be able to treat you as a patient. The termination of our physician/patient relationship will be effective in 30 days from the date of this letter. Your medical condition requires continuing physician supervision, and it is important that you select another physician as soon as possible.

Contact your health insurance company or the county medical society for the names of other physicians. Upon written authorization, a copy of your medical record will be sent to your new physician. A medical record release form is enclosed.

Sincerely,

[physician name]

Letter 2 — Confirmation of patient-terminated relationship

Date

To [patient name]

This letter is sent to confirm your decision to discontinue care with me. Your medical condition requires physician supervision, and it is important that you select another physi­cian as soon as possible. I will be available to you until [30 days from date of letter].

Please contact your health insurance plan or the county medical society for names of other physicians. Upon written authori­zation, I will provide a copy of your medical record to your new physician. A medical record release form is enclosed to expedite the process.

Sincerely,

[physician name]

Letter 3 — Non-payment notice

Date

To [patient name]

It has come to my attention that you have been sent several letters regarding your outstanding account with our practice. If there has been a problem or if you are unhappy with the care that you have received in this practice, please contact me to discuss the situation. You are important to us, and I hope we can resolve any issues you have.

My business manager is also available to discuss payment of your account or to set up payment arrangements if they are needed. Should we not hear from you within 30 days, it would be mutually beneficial to ter­minate the physician-patient relationship so that you may locate a new physician.

I hope that we will hear from you in the near future

Sincerely,

[physician name]

Letter 4 — Termination for non-payment

Date

To [patient name]

On [date], I sent you a letter requesting that you contact the business manager or me regarding any problems that may have occurred resulting in non-payment of your account. In the letter, I stated that it would be necessary to terminate our physician/patient relationship if we did not hear from you.

Since we have not heard from you, please be advised that I will no longer be able to treat you as a patient. The termina­tion of our relationship will be effective in 30 days from the date of this letter.

A release form for your medical records is enclosed. Please contact us with the name of your new physician so we may forward your records to his or her office. At that time, your account will be closed.

Sincerely,

[physician name]

Urgent message: Patients and communities rely on access to urgent care to augment primary care shortages and decant over-crowded Emergency Departments. A provider who quits without notice causes scheduling disruptions which could be considered “patient abandonment.”

Alan A. Ayers, MBA, MAcc is Chief Executive Officer of Velocity Urgent Care, LLC and is Practice Management Editor of The Journal of Urgent Care Medicine

Once a medical provider has accepted a patient into her practice, she is under an ethical and legal obligation to provide services to the patient as long as the patient requires them.1 However, it’s not uncommon for a physician at an urgent care center to seek a higher-paying job. How (if at all) does that affect the obligation to continue the care of a particular patient?

Take the case of a hypothetical physician who’s looking to increase her income, or perhaps has heard rumors that she might be cut from the schedule. To address this, she secures a similar position at a competing urgent care. Not wanting to forego income in the transition, she could submit her 2-week notice to her current employer and work right up to the start date at the new facility. Or, if she is under contract with her current employer, she may be required to provide a certain term of notice; leaving before the period has elapsed would be a violation of the employment contract. However, if she’s an at-will employee, the urgent care owner has the right to terminate her the minute she fulfills her obligation to give notice; thus, being forthright about her situation could cost her 2 weeks’ pay. As a result, she might choose to give no notice; doing so would protect her from immediate dismissal,2 but could be deemed “gross misconduct,” insubordination, and abandonment of the responsibility to care for her patients.2

This article will address the question of whether such a physician has any legal or ethical obligations to her patients when she quits without notice.

Is 2 Weeks’ Notice a Law?

The requirement of employees to give notice of plans to quit is only a custom. There’s no legal obligation, and employees are not required to give 2-weeks’ notice.3 There are 49 states with at-will employment laws, which means that any employee can quit at any time, without notice—likewise, an employer can terminate an employee at any time.4 (The latter scenario was discussed in How Best to Manage an ‘At-Will’ Termination in the June issue of JUCM.)

Of course, without notice, an employee’s departure can be disruptive; giving notice generally allows an employee to leave a company on good terms.5

Legal Obligations

Malpractice for patient abandonment

Patient abandonment is a type of medical malpractice that happens when a physician ends the doctor-patient relationship without reasonable notice or a reasonable excuse, and doesn’t provide the patient with an opportunity to find a qualified replacement care provider.6-8 It’s also defined as “when a physician leaves the employment of a group practice, hospital, clinic or other healthcare facility, without the physician giving reasonable notice and under circumstances which seriously impair the delivery of medical care to patients.”9-13

According to the AMA’s Code of Medical Ethics, Opinion 8.115, a physician has the option of terminating the patient-physician relationship, but she must give sufficient notice of withdrawal to the patient, relatives, or responsible friends and guardians to allow another physician to be secured.

Patient abandonment in emergency rooms and urgent care situations

Urgent care owners should know that in some instances, emergency rooms and urgent care facilities are exempt from these notice requirements.

Ohio promulgated a regulation in 2013 stipulating that any physician leaving, selling, or retiring from a practice must comply with Administrative Code Rule 4731-27-03.14 Within 30 days of learning of a physician’s termination or resignation, a medical practice must send notice by mail or by HIPAA-compliant electronic means to all patients treated by the departing physician within the past 2 years.14 However, the notification requirements in that state do not apply to physicians who have provided treatment on an episodic basis, in an emergency department setting, or at an urgent care center.14

In addition, notice of termination isn’t necessary if the patient’s care has been formally transferred to another physician who’s not within the same medical practice, or when the patient is the person responsible for terminating the physician-patient relationship. This should be documented in the patient’s chart.15,16

Ethical Issues

Aside from the AMA Ethical Standards, an urgent care owner may consider some other standards of conduct that could give rise to a legal remedy for the physician’s departure:

• Availability of urgent care services in the community. The urgent care’s ability to be open and to deliver services hinges on its scheduling of a provider during all hours of operation. A sudden departure of a provider without notice may mean that the center is unable to staff its schedule and, thus, be required to reduce hours or even temporarily close—leaving patients to find care elsewhere. This translates into a loss of profits.

• Continuity of care. Established patients often return to urgent care to follow-up on lab tests, a reexamination of an injury, wound care (suture removal), when symptoms don’t improve, and for medication refills. A provider who quits without notice is unavailable for this follow-up with these patients. Further, urgent care providers are typically available to oversee referrals to medical specialties such as physical therapy or imaging, and if a provider leaves without notice, management of the patient’s ongoing care may suffer or not occur.

However, the standard practice of medicine involves physicians transferring patients, eg, from an emergency room to an in-patient ward. When physicians rely on other physicians to assist in caring for their patients, it’s not considered patient abandonment.17 A physician’s transfer agreement with another physician is a mechanism to ensure continuity of care. Continuity of care for a patient is often maintained even without formal measures like transfer agreements.17

A key aspect of the continuity of care is the documentation of charts by the departing physician. When a provider leaves without notice, she may have incomplete charts. This can create administrative and insurance billing issues. Further, that physician is unavailable to answer insurance questions or provide supporting documentation on claims, which can result in increased write-offs. The state may have regulations as to whether it constitutes patient abandonment for a provider to leave without documenting the transfer of care or by inappropriately terminating the patient/practitioner relationship.18 One solution, perhaps, is to withhold the physician’s final paycheck until all charts are updated.

• Supervisory responsibilities. If the departing physician had supervisory responsibility for PAs and NPs but leaves without transitioning those responsibilities, the ability of those medical professionals to continue to provide care may be jeopardized if the urgent care can’t find another physician to assume their supervision.19 Again, this may have an impact on the urgent care’s financial stability and bottom line.

• With urgent care billing, a physician and any PAs or NPs working under her must be “credentialed” by insurance companies to be considered part of their “network” and enable “in-network” contract reimbursement—a process that can take months. If a credentialed provider suddenly quits and is replaced with an as-of-yet credentialed doctor, the urgent care may not be paid by insurance. This can result in increased write-offs or patients paying out-of-network deductibles, depending on their insurance plan. The upshot is lost business.

• Workplace efficiencies. The unexpected departure of an urgent care physician can have a significant impact on the rest of the staff and on patients. Remaining providers and staff—particularly at centers staffed with multiple providers during a shift—may have to work harder and extra hours, and wait times and patient dissatisfaction may increase. If a center has to close temporarily or downsize operations due to losing a provider, support staff may also lose hours or employment. This, again, causes an economic impact on the urgent care.

What Legal Remedy Does the Urgent Care Owner Have in this Situation? 

Although an urgent care physician quitting without notice can be upsetting and potentially create disarray, a claim of physician abandonment requires there to be some type of harm. When bringing a lawsuit, a plaintiff must prove that the physician ended the relationship at a critical stage of a patient’s treatment without good reason or sufficient notice to allow the patient to find another physician, and the patient was injured as a result.20-23 Again, some states exempt urgent care facilities from patient abandonment notice requirements. Still, there can be consequences for the provider who leaves her employer or patients in the lurch:

• Report to the medical board. A physician who abandons her patients may be reported to the state medical board. Affected patients may be the first to file a complaint. Typically, the medical board will hold a hearing during which a hearing officer may recommend that the Board suspend the physician’s privileges or issue a written reprimand for abandonment of patients.24,25

• Business interference. An owner could claim that the physician’s actions constituted tortious interference of the business’s reputation and goodwill.26 The elements of a cause of action for tortious interference with a business expectancy or relationship are: 1) a contract or valid business relationship or expectancy; 2) the defendant’s knowledge of the relationship or contract; 3) intentional interference by the defendant causing or inducing a breach of the contract or relationship; (4) the absence of justification; and (5) damages resulting from the conduct of the defendant.27 Courts require an element of malice or wrongdoing to sustain a claim of tortious interference with business relations.28 This claim may be a high threshold for an owner to prove.

• Breach of contract. If the physician signed an employment contract, depending on the terms of separation, she may be in breach, presenting a claim for damages.29 The urgent care must document the damage that it suffered, which may include loss of business, additional overtime paid to other providers, and other monetary expenses.

Similar to an action in tort, the urgent care owner must weigh its contract damages to determine if they are sufficient to expend the time and expense of legal action.

Takeaway

Except in Montana, employment is at-will, barring an employment contract. If urgent care owners execute contracts with their physicians, they should include language that specifically details the circumstances and responsibilities for termination.

For at-will physician employees, systems and procedures should be in place to ensure an efficient transfer of care and documentation.

While there are potential actions for an owner to consider against the quitting doctor, urgent cares may be best served to proactively guard against damage to the practice by protecting against issues of continuation of care and inadequate staffing.

References

1. Merritt M. Ethics on ending the patient-physician relationship. Physicians Practice. Available at: https://www.physicianspractice.com/compliance/ethics-ending-patient-physician-relationship. Accessed June 12, 2019.
2. Chandler v. CHS-Park View, Inc., 1:12 cv 223-HJW, 2013 U.S. Dist. LEXIS 66271, at *16 (S.D. Ohio May 9, 2013)
3. Graham J, Hatlen J. 2-week notice to quit job only a custom. Seattle Times. February 5, 1990. Available at: http://community.seattletimes.nwsource.com/archive/?date=19900205&slug=1054420. Accessed June 12, 2019.
4. Stiegler Law Firm. Should I give two weeks’ notice? April 21, 2017. Available at: http://stieglerlawfirm.com/2017/04/21/two-weeks-notice-employment/. Accessed June 12, 2019.
5. Huppke R. Taking a look at 2 weeks’ notice. Chicago Tribune. September 22, 2014. Available at: https://www.chicagotribune.com/business/careers/ct-biz-0922-work-advice-huppke-20140919-column.html. Accessed June 12, 2019.
6. Chowdri P. What is patient abandonment? Nolo (2019). Available at: https://www.nolo.com/legal-encyclopedia/what-patient-abandonment.html. Accessed June 12, 2019.
7. McCauley v. Danainostrat, Civil Division Code 007, GD 14-006833, 2015 Pa. Dist. & Cnty. Dec. LEXIS 17104, at *21 (Penn. C.P. Nov. 26, 2015).
8. Cole v. Marshall Medical Center, 2007 Cal. App. Unpub. LEXIS 4490 (Cal. App. 2007).
9. 49 Pa. Code § 16.61(a)(17).
10. Cygan v. Kaleida Health, 51D.3d 1373, 1375 (2008).
11. Cappellino A. Patient abandonment cases: what you need to know. The Expert Institute. , May 3, 2018. Available at: https://www.theexpertinstitute.com/patient-abandonment-cases-what-you-need-to-know/. Accessed June 12, 2019.
12. Physician’s Weekly. Avoid patient abandonment: 8 tips for termination. June 7, 2016. , Available at: https://www.physiciansweekly.com/avoiding-patient-abandonment-proper-termination/. Accessed June 12, 2019.
13. Irvine MS. You’re fired: dismissing a patient. AAPC. May 11, 2010. Available at: https://www.aapc.com/blog/6069-youre-fired-dismissing-a-patient/. Accessed June 12, 2019.
14. Ohio Admin. Code § 4731-27-03(D)(1). Notice of termination of physician employment or physician leaving a practice, selling a practice, or retiring from the practice of medicine. (Effective December 31, 2013.) Available at: http://codes.ohio.gov/oac/4731-27. Accessed June 12, 2019.
15. Zinsmaster New rules regarding termination of doctor-patient relationships and proper notice to patients upon physician termination. Lexology. January 2, 2014. Available at: https://www.lexology.com/library/detail.aspx?g=a1325049-b6cc-4243-aee9-00826c3ab3c6. Accessed June 12, 2019.
16. State Medical Board of Ohio. FAQs: terminating the physician-patient relationship and notifying patients when a physician leaves a practice approved. December 12, 2013. Available at: https://www.ohioafp.org/wp-content/uploads/2018/01/FAQs_Medical_Board_Rules_Effective_12-31-13.pdf. Accessed June 12, 2019.
17. June Med. Servs. LLC v. Kliebert, 250 F. Supp. 3d 27, 65 (M.D. La. 2017).
18. Admin. Code tit.46 § LIV.345 (B)(1)(h).
19. Rev. Stat. § 32-2533; Cal. Code. Reg. § 3516; 3 Col. Code Reg. § 713-7.
20. State ex rel. W. Va. Bd. of Exam’rs for Speech-Language Pathology & Audiology v. Lindsay, 17-0555, 2018 W. Va. LEXIS 541, at *13. June 15, 2018.
21. Gables at Sterling Vill. Homeowners Ass’n v. Castlewood-Sterling Vill. I, LLC, 2018 UT 4, 417 P.3d 95, 111 (Utah February 9, 2018.
22. LeCroy v. Byrd Reg’l Hosp., 56 So. 3d 1167, 1172 (La. App. 2011).
23. Casperson v. N.E. Wis. Ctr. for Surgery & Rehab of the Hand, Ltd., 2007 WI App 138, 302 Wis. 2d 261, 732 N.W.2d 863 (Wisc. App. 2007).
24. Whitehead A. Avoid allegations of patient abandonment. Cooperative of American Physicians. April 1, 2009. Available at: https://www.capphysicians.com/articles/avoid-allegations-patient-abandonment. Accessed June 12, 2019.
25. Reed v. Franklin Par. Hosp. Serv. Dist., 04-1481, 2006 U.S. Dist. LEXIS 89272, at *5-6 (W.D. La. Dec. 11, 2006).
26. Medi-Weightloss Franchising USA, LLC v. Las Colinas Medi Weightloss Clinics, LLC, 8:13-cv-990-T-23TBM, 2013 U.S. Dist. LEXIS 143874, at *13 (M.D. Fla. Sep. 4, 2013).
27. Hertz Corp. v. RAKS Hosp., Inc., 196 S.W.3d 536, 549 (Mo. App. 2006).
28. Island Rehab. Servs. Corp. v. Maimonides Med. Ctr., 2008 NY Slip Op 50597(U), ¶ 11, 19 Misc. 3d 1108(A), 1108A, 859 N.Y.S.2d 903, 903 (N.Y. Sup. Ct. 2008).
29. Clinica Sierra Vista v. Subramaniam, No. F072467, 2017 Cal. App. Unpub. LEXIS 4212, at *1 (June 20, 2017).

President of Experity Networks and is Practice Management Editor of The Journal of Urgent Care Medicine

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