The Provider's Report

How to "FIRE" a patient

• Rebecca Deyo

Share episode

Send us a text

As healthcare providers, we strive to build strong relationships with our patients, but sometimes, ending that relationship is necessary. Whether due to non-compliance, boundary violations, or missed payments, discharging a patient can be uncomfortable—but it’s crucial for maintaining professionalism and protecting your practice.

In this episode, we’ll cover:
✅ The most common reasons for patient discharge
✅ How to maintain professionalism and empathy while setting boundaries
✅ Legal and ethical considerations for patient discharge
✅ Best practices for handling outstanding balances and missed appointments

💡 Whether you’re a solo provider, clinic director, or practice owner, this episode will help you navigate this challenging but necessary part of patient management.

🎧 Listen now on Spotify, Apple Podcasts, or your favorite podcast platform!

💬 Have you ever had to discharge a patient? How did you handle it? 

Share your thoughts with us on Instagram @theprovidersreport!

Follow us on social media!

Scarlett Solo USB:

Hello. Have you guys ever had to fire a patient before? I know that question and that concept doesn't really come up enough. What are some of the reasons why we might have to stop seeing or treating a patient? The list is kind of endless and I feel like we're not educating our students and our young providers well enough on this topic. So in today's episode, we're going to talk about the importance of establishing that patient provider relationship. the goal of achieving positive outcomes and what to do when we're not quite getting there. We're going to talk about what patient discharge even means and then why it can be such a challenging topic, but a big time necessity in some cases. And then the key question of this episode is how can providers discharge a patient while maintaining professionalism and being friendly? So first let's talk about some of the most common reasons why we might need to discharge a patient. So number one is pretty obvious. non adherence or non compliance, a. k. a. a patient's not following your recommendations, whether you are prescribing a certain medication, they're not taking it, or maybe you've recommended a certain number of visits, they're not following that, and there's just a clear disconnect. Number two would be behavioral issues. You have your classic physical abuse, sexual abuse, verbal abuse, even. these are also very, very common in healthcare. Next up is going to be any kind of boundary violation. So let's say there are very clear rules in your practice maybe inappropriate demands have been made from that patient onto the practice, and they are requesting Some kind of preferential treatment or maybe there's actually been a substance misuse if you are a prescribing physician of some kind. Boundary violations are a very real thing and you have to have some systems in place that your team is aware of too on how to address these as they occur. Next up would be provider limitations. Let's just say that you're taking care of a patient and it's very obvious they just need somebody else. Maybe that's somebody with a different skillset, or maybe the connection is just not there. I know a really common area where this occurs would be in the world of mental health. Sometimes a therapist can just tell after a few sessions that it's just not a good fit, and maybe you can decide that sooner than the patient can, and out of the goodness of your heart. Out of your expertise as a healthcare provider, we should know how to sit down and have that kind of uncomfortable conversation, but ultimately for the betterment of that patient. And lastly, missed appointments or non payments. What if you have a patient that just flat out doesn't pay their bill, starts racking up a balance, or maybe they don't pay a bill and don't come back for an appointment. Kind of the two fer there. And then just in general, missed appointments. Missed appointments. What happens if you have someone that routinely no shows and takes advantage of your time, but then still expects to be placed on your schedule at their convenience so those are a lot of reasons, which is why this conversation is important. What I've been seeing, especially when I'm meeting with offices and chatting with providers, They tend to let a lot of things go because in today's world, we live in suing culture. We obviously know that the customer is always right if you've ever worked in retail or anything like that. But when you own your own practice, or you're a manager, or you're a clinical director, or anyone for that matter, it's really important to make sure we're setting boundaries. This is something I have stood by from day one, but If you start to allow patients to walk all over you in practice, they will continue to do that. And that does impact their care. I'm not saying that the patient is never right. That is not true. when you work in a professional setting, there are rules, there are standards, there are regulations, there deserves to be a sense of professionalism from both parties involved. So I want to talk about what we would do in the event of a discharge. Let's say somebody has racked up a bill, and this is something that happens all of the time. And not all of our small practices have a billing department with specific people whose sole job it is to worry about collections. This could just be your number one front desk person. Sometimes this could be the provider themselves if they don't have a team. So there's two ways I like to go about this. you could also send an email, you can send a text message or you can have that conversation in person. I would make that determination based on one, if they have an appointment or not, if they're still coming for care and two, what that patient is like. Maybe their age demographic. behavior in general, if they tend to be combative, maybe, maybe don't meet with them in person to discuss this. If they're very, very cordial, maybe it's something that can be discussed in person and coming up with something that everyone can agree on. So here's what I recommend if you're going to go the email route. So when you're sending an email, obviously the subject is going to be something in the realm of outstanding balance and next steps. I would just be straight to the point and say, Hey Mary, I hope this email finds you well. We're just contacting you to reach out regarding your your current balance in our office. This has been due since February. We've made a few attempts to contact you and as of today We still just don't have a payment plan or a payment scheduled in order to continue care at our office We do require outstanding balances to be paid We offer flexible payment options and we would be happy to discuss this with you if that works for you If we don't receive a payment by this specific date we will not be able to schedule future appointments for you and we will attempt to run the card on file for X dollar amount. Please reach out to our office if you have any questions or reply to this email to discuss further options. We value your health and we hope that we can find a way forward together. That's it. Like very simple. You've given them multiple options, but at the same time you're letting them know like, Hey, if there's a card on file, it's going to be run for this amount. I'd say we're pretty flexible and sometimes we'll totally just break up that payment. We'll let them know, hey, we're going to run 100 this week, 100 the following week. but honestly, we keep AR so low that most of the time when we're reaching out for an outstanding balance, it's no more than 50 or 60. this is what I would recommend via email. It allows you to also take control, run that payment. And this is another reason why I do recommend that you have cards on file for everyone. Sometimes balances get missed or there are changes to their insurance and that's how this confusion can happen even with cards on file. But you can still send this email out even if there is no card on file. You would just simply let them know, hey, this is the payment plan structure that we can do for you. If you have any specifics, let us know. I was actually just talking to a provider about this, this morning. typically what we will do is if there's no card on file, we will literally send an electronic statement or a way to pay online once a month for like six to 12 months or so. and I know that sounds like a lot, but we typically won't write it off or do anything with it until that one year mark. Here's why. The economy is what it is. Times have just changed. And so we understand that somebody might have a negative relationship with money and finances, and maybe they're embarrassed to let us know that they can't make even a simple 50 payment. Do they still owe that money? Absolutely. Should we be holding them accountable? Absolutely. You provided a service and you deserve to get paid for that. However, I think having an ounce of grace really does go a long way. There have been countless times where we have sent that out once a month repeatedly and by the ninth month or 10th month, all of a sudden that balance is paid. At that moment, we don't need to know why. We don't need to know what struggles they're going through. But we take solace in the fact that we were able to provide them that cushion. I don't recommend doing that for everyone, but it is something to take into consideration with your systems. Again, at the end of the day, it's best to have a card on file at all times, but things happen. Let's say the card gets declined and that's your only option. That is how I would recommend going about that. So next I want to talk about legal and ethical considerations. Let's say you have decided to discharge someone for a variety of reasons. We have to remember that in many states there is this thing called patient abandonment. You can't just not see a patient. You can't not have that conversation and try to just stop seeing them or maybe switch practices and not let them know where you're going. And this is mostly state by state, but even the AMA has some ruling when it comes to this. It's really important to make sure we're doing our due diligence to make sure that we are being as professional as possible in the moment. So let's say you are leaving your practice or something's happening and you're taking a medical leave. You are technically required to quote unquote discharge, even if it's temporary, your patients or just let them know where they can go during that time. So try to give 30 days notice when you can, and make sure there's a reason for it. Put something in writing that says, you know, we were unable to meet treatment goals, or I'm going to be taking a, an extended medical leave, Offer that patient a referral list of alternative care options. So two or three is the magical number that I typically recommend. Make sure you're giving them a variety of providers. Maybe a few female, a few male providers, different parts of town, that kind of thing. That way they can choose who they want to go to based on your recommendations. So let's go through a couple scenarios. So let's talk about the patient that is just not following your recommendations. It could be visit number, it could be a specific medication, it could be anything. I'm going to go ahead and state the obvious. In this case, you're not going to want to say, hey, you're not following our plan, so I'm not going to be able to help you anymore. Believe it or not, providers are doing this. And I'm hearing about this from my patients that and some of the people I'm consulting with. This is actually a very real problem. So what we recommend is have that conversation at one of the appointments they do show up to and just say, Hey Mary, it really just seems like this treatment plan is not working for you. This is what we're recommending based on what you've told us that you're going through. And we're starting to think that maybe switching to a different provider just may be better suitable for your needs. Something as simple as that can go a long way and then sit back and let them talk. Most of the time they may say something like, oh, you know what? My, Father in law is in the hospital, and this just isn't a priority for me right now. It is a great way for you to get that information and allow them to feel comfortable and not feel like they're letting you down. Most of the time, there's probably a reason that you're probably just not even aware of. So it's really important to have that conversation. The next one's a little bit tougher. So you've probably listened to a few of our old episodes about sexual harassment in the workplace. That's fine. This can happen. It could be aggression. It could be harassment. And we need to talk about how to address these patients. this could be the lead doc that does this, you as the provider if you're comfortable, a manager, anyone can really take this role, but it's important to know in your clinic who should be doing this. The obvious of what not to say is flat out yelling at them saying, Hey, what you're doing is inappropriate. I refuse to treat you or, Ugh, that was nasty. Sorry. I don't feel comfortable. there's no need to add fuel to the fire, right? So typically what I recommend is you let them finish, you know, whatever nonsense that they're spewing at you. Once you get that awkward silence, you say, Hey, Mary, maintaining a respectful and safe environment in our practice is actually really important for us, for everyone. And because of today's interactions, I just think it's best that you find care elsewhere and I'll help you do that. It could be as simple as that. and even in an aggressive type of setting. As long as there's dialogue that can happen, that type of sentence structure actually works well. It's a form of de escalating the situation instead of responding by being just as combative. Obviously, in the event of an actual, physical, hands on situation, you wouldn't do this until after the fact. But nine times out of ten, thankfully, A conversation can be had here and that is how we recommend going about it. Next up would be someone who cannot pay their bill. We talked about how to send them an email or send them a message outside of the office, but what if they're in person with you? So one patient kind of jumps to mind, we don't really have a lot of patients with balances in our practice, thankfully, because we have a lot of systems in place, but I am seeing patients from former practices where there were less. strict rules, I think, on payment structures. So we do have someone that used to rack up like a bill of 200, 300, 400, and so we did have to have a sit down. And with this patient, since they were well known, very cordial, it made sense to do this in person. So at the time, my lead admin just sat them down and instead of saying something rude like, Hey, if you can't pay your bill, you can't be seen. That's too direct. You have no idea what's going on with them. So here's what we did. And here's what we recommend. Sit that person down or greet them when they walk in. As long as there's no one in the waiting room, obviously don't embarrass them, but let's say there were, you can feel free to take them into another room. Flat out say, Hey Mary, we just wanted to remind you that we do have an outstanding balance and per our office policy, we don't really like that to get higher than 200. Can I help you today set up a payment structure? Are you able to do 50 today? Something as simple as that come up with a solution. Let them know what that solution is, but also do so in a friendly manner. Most of the time they're going to be like, oh, I completely forgot. Yeah, let's take care of the whole thing today. Or they'll say, yes, 50 sounds great. Thank you for understanding. And then you're not addressing that in a embarrassing way for them, but you'll still get your collections. So both parties end up satisfied. You can tell we're trying to deescalate. That is the key word here, deescalation, deescalation. Try to remember to always use the word I, I, I here instead of you, you, you in reference to the patient. So making it about you instead of them or about your practice. For example, like saying, Hey, this is our office. policy. Instead of you personally demanding something or saying that, hey, you as the patient are failing to comply with this, deescalating is really important here. And saying things like, I think it's a great idea that maybe we transfer your care to someone else. I would just like to bring this up. And always maintaining compassion. passionate and professional words when you're having these conversations. Staying calm is also really important as well in making sure that you've gone through these scenarios with your team so that when you're busy treating patients, your team is able to de escalate these situations as well. And I want to close with one final tip. So as you can see, these things happen, and we've gone over multiple ways today on how to squash them and effectively bounce back from these. But ultimately, if you don't set up these systems in practice early and set these boundaries, it's going to keep happening. So what I recommend is constantly check in with your patients every single visit, figure out how they're doing. Are they better? Are they worse? What other things do they need? Are they being compliant? Check in with recommendations, remind them, Hey, yeah, I do need to see you once a week for four weeks, or, you know, it is important that you get these regular CT scans every six months and reminding them in person. Even though they receive that information on the MyChart, it's going to help them be more compliant. It's going to make sure that there is no lapse in communication and that everybody is on the same page. Setting up these systems in your practice can help prevent outstanding balances, disgruntled patients. I speak with a lot of practices, especially those who buy practices from older providers who are retired. MyChart. A lot of times it was just the wild, wild west in some of these practices. So if you were listening to this and you are a new provider and you are just constantly going through this battle daily with patients who don't pay bills, this is your sign to put your foot down. There's no need to be rude or angry, but establish some practice systems. Put them on your website. Put them in your consent forms. Put them on your booking email confirmation. It's 2025. We can totally do this. if nail techs and hair salons and all these other places have impeccable systems and they get paid on time, why can't we as healthcare providers? So I hope this information was helpful. I look forward to hearing how this has made a difference in your practice. Thanks for listening.