Terminating a patient relationship — Part 2

In each episode, we will delve into the practical day-to-day strategies, expert insights, and real-world case studies to empower you with the knowledge and tools needed to minimize legal risks and enhance patient safety. In today's podcast, we will continue our focus on the topic of terminating the physician and patient relationship.

There is certainly a variety of different ways to cover on this topic. So today's session is but one within a series on this very topic. As we know, like any relationship, the effort to maintain a therapeutic and respectful connection between providers and patients takes effort and it takes time. And like any connection between two parties, the relationship can reach a point of disruption or challenge.

Ideally, we'd like to work through the rough patches, but circumstances may reach a point where differences are just too far apart, the bond is broken, and the mutual respect is lost. All efforts to resolve the matter have been exhausted. As the song goes, breaking up is hard to do.

In this series, we'll delve into ethical, legal, and practical aspects. And we trust that we will offer you an opportunity for some thoughtful conversation. So first, I want to welcome our guests today. Today, we are joined by Pamela Johnson. She serves as senior manager, practice quality and facilities at Copic, an insurance carrier. Welcome, Pam.

PAMELA JOHNSON: Well, thank you, Joan. I'm excited to be here today.

JOAN PORCARO: Thank you. Also with us today is Jeannette Domask. She serves as risk manager at the Ophthalmic Mutual Insurance Company, also known as OMIC. Welcome, Jeannette.

JEANNETTE DOMASK: Thanks, Joan. I appreciate you including me in your podcast.

JOAN PORCARO: All right. Well, let's go ahead and begin our conversation. So I want to throw out a little bit more about a specific topic when we're communicating the termination to the patient. And I know this is always a challenging situation. Do we do it in-person? Do we write it? But sometimes there are steps that need to be taken even before we get to that point. So let's start with Pam first. Pam, what are your thoughts about a physician practice having a written policy and procedure for termination?

PAMELA JOHNSON: Oh, I think that's critical. That is a component that your practice definitely needs because it will establish that you're not discriminating against any particular patient, but you're following your written policy about terminating a patient.

And in that policy, which you'll want to review annually, by the way, you're going to not have language that would be considered discriminatory. And your decisions to terminate a patient would not be based on protected classes, such as race, religion, sex, gender identity, disability, national origin, or age. And of course, it must align with the ADA regulations.

So I recommend that you work with your staff and your providers on the policy language that you want. Here's a tip. Include it in your new patient packet. And it's an opportunity when you're bringing in new patients to your practice to go over it. And also you can review it at the same time you're reviewing a patient's medication history for the year. It's just a quick reminder of this is how our practice works with patients and how you might be terminated from the practice if needed.

JOAN PORCARO: Yeah, thanks, Pam. Jeannette, your thoughts?

JEANNETTE DOMASK: Yeah, I agree, Pam. It is really important to have a policy and procedure. And often times when physicians or practices call, they struggle when they don't have a framework for how to deal with these types of things that come up. And there are different reasons for termination.

Typically, they fall in three buckets, whether it's noncompliance patient behavior or non-payment. So it's important to have a structured approach for how to manage those issues that then could potentially turn into termination. And again, we always say it's best to rehab the situation, the relationship before termination. But ultimately, you should have some procedure for how to handle termination in your practice.

JOAN PORCARO: Yeah, thanks, Jeannette. And I'm going to throw another question your way, Jeannette. What's been your experience as far as the best practices for actually communicating that decision to terminate the patient? Is it including verbal or written? What's been your experience?

JEANNETTE DOMASK: So definitely there should be a verbal discussion. And most of the time there should be a warning before the ultimate termination. It shouldn't be a surprise to a patient that they're terminated. I have had physicians call and they've just sent letters to patients. And then the patient gets this notification, has no idea why they were terminated, and that shouldn't happen.

They should have a discussion. Give them a chance to rehab the situation whether they're struggling with transportation or, are there issues going on at home that they need to deal with? Give them a chance. And then discuss with them what the expectations are. And if it happens again, then perhaps consider termination. But it shouldn't be a surprise. There should be some discussion either with a physician or the practice administrator about the termination before the letter is sent.

JOAN PORCARO: So it sounds like some limit setting would be in order to explain as we say, if not this, then that. So if you will continue with a certain behavior or issue, there will be situations where a change in our relationship will happen. So really good point. Pam?

PAMELA JOHNSON: Yes, I think that I agree with what both Joan and Jeannette have said. But I'd also like to add that the verbal conversation is great and important. But we need to follow it up and follow your termination of a patient policy and give the patient a written letter as well.

And I'm old-fashioned. I like to say we'll do the regular letter, the snail mail letter and also a certified copy. Because if practices rely solely on a certified letter, which many do when we receive calls on our hotline about they've terminated a patient and they followed their policies and guidelines and they sent out that certified letter, I'm going to ask everyone, when was the last time anybody that you know got great news in a certified letter?

And probably never, or maybe once, or twice. So many times those certified letters come back to you and I then counsel the practice. Well, the patient is still in limbo. You may have had the provider or the practice administrator may have had an in-person verbal conversation. But it might have been a tense, unpleasant scenario. And the patient wasn't listening or grasping everything that was being said to them.

And then of course, they never got the written letter that was sent certified mail. So again, I'm old-fashioned. But I say when you send out that written letter, which you need to do, send it two ways, the regular US Post Office and certified mail.

JOAN PORCARO: Yeah, and I want to add to that. I probably take it a little bit one step further, Pam. I think folks know that they have a busy schedule and sometimes they just don't have time to go to the post office. So I know this is more expensive. But in my work in the risk management world, we actually elected to send the letter via UPS with overnight mail.

It is a little more expensive. But the nice thing is it's registered. And you can keep track of it. And it will show up at their door. You can require a signature if you'd like. But most people are at work. So we don't want to be unreasonable. But we know that quite frankly no one wants to go to the post office and get in line. I mean, it's just a busy time.

PAMELA JOHNSON: I like that.

JOAN PORCARO: Yeah, it's a little bit more expensive, I realize. But most practices and health systems, they usually have some contract with FedEx or even the US Post Office has what is it overnight mail I think is the classification. So just something food for thought basically.

And I want to say, our work as consultants, most of us have worked on the operational side where we maybe manage a practice or been a director over a department and the concept and topic of documentation comes up. We're risk management people. It's always going to come up.

So I've had a couple cases where a patient physician situation has finally reached a point of being on the last nerve and then maybe there hasn't been the documentation we would like. So I'll start with Pam again. How important is it to document all the efforts to address patient noncompliance or behavioral issues before terminating?

PAMELA JOHNSON: Well, as difficult as that is and as you're right, Joan, sometimes when that particular patient that just tests your last nerve leaves, that's the last thing you want to do. And it's probably even harder to have a very objective statement about what just occurred with the patient.

But the documentation at this time needs to be objective, not subjective. I like to say tell the facts. And I said this. They said this. I recommended this. They said that, whatever. But just some documentation. It doesn't have to be four pages long. But that I would like to say, does it tell me the story of your relationship with the patient?

JOAN PORCARO: And Jeannette.

JEANNETTE DOMASK: Yeah, and it's important based on what the issue is. Say it is noncompliance, sometimes there is a patient that is no showing, canceling appointments, not following recommendations. So there are steps before the termination to document that noncompliance because that could create obviously liability issues for the physician. It can also create patient safety issues for the patient.

So sometimes we recommend having that noncompliance policy. And after maybe two or three no shows send a letter explaining this is what the expectation is. We really are concerned about your health. You need to follow our recommendations. If you don't follow, we might have to terminate you from the practice because it can really create liability exposures for the practice.

And similar patient behavior, if that's occurring and the patient is not following mutual respect in the practice, then that needs to be documented and then also potentially followed up with a letter saying if this happens again, we're going to have to terminate you from the practice. But I think it's really important to give them a warning before just going straight to termination because there are so many downstream effects that can occur from a patient not having that continuity of care.

JOAN PORCARO: Yeah, and I think it's important too that, you know we always say everyone is a risk manager. So when these bad experiences or problematic behaviors happen at the front desk or even with the billing, we need to make note of those too as well and work with those who document in the chart to make sure there's mention of it.

And I think, too, I think, both of you called out how important it is to be factual. You can be brief. Really your cataloging the history of that relationship. And any relationship, there's going to be bumpy parts. And again, making sure that there's good consistent, commentary in there that talks about the tone of the relationship and the direction that it's going. So great comments. So thank you.

So we're going to move back to Pam again. So what are the legal and practical steps the practice should take to ensure the termination process was really handled properly and we don't end up with a situation with the medical board that constitutes patient abandonment?

PAMELA JOHNSON: Oh, yes. You don't want to-- that's a rough one. That's a case that's hard to defend with the medical board. So a couple of things come to mind when I think of abandonment. You can't stop treating a patient in the middle of a post-op period. That's one of the first ones that comes to mind.

We receive a lot of calls from orthopedic doctors that there might be a long post-op recovery period. And as Joan likes to say, that patient is getting on the doctor's last nerve for a myriad of reasons. And we'll receive phone calls that that's it. We're done with Pam. And we're getting rid of Pam. And I don't like that word either.

And I'll start asking some questions. And one of the first things I'll say is, well, tell me, is this week two, week eight, week 14? Where is this in Pam's post-op period? And I really hate to hear when it's week one or two. And even I hate to hear week 12 as well. But we can't-- as a provider, you cannot terminate a patient in the middle of treatment.

And another example is an oncologist, they'll say a patient is undergoing chemotherapy and it's not going well. And they're not compliant. They're no shows. They're this. They're that. Well, stopping chemotherapy has, as Jeannette said previously, a huge downstream effect on the patient's potential outcome. So that's the time, even though you may not want to do it, is to have a conversation with the patient.

And I'm going to go out on a tree branch here and say sometimes if you have difficult patients, if you know their family dynamics at all, and if sometimes there's someone that you see that brings them a spouse, a son, or a daughter, family member is you might bring them back into the conversation before you just said, that's it, "I'm done with Pam. She's this. She's that.”

It's to engage maybe if the patient is having a hard time understanding all the ramifications of not coming or not being compliant. So abandonment is a very tough issue. And I think one more item that I'd like to say abandonment is if you live in a rural area and if you are the only provider in town, I'm not saying-- we're not saying that you have to keep the patient forever, but it does become trickier. And you want to make sure that the patient before they leave your practice has somewhere else to go.

Now, it may not be as convenient as five minutes from their house in this rural community. They might have to drive 20 minutes down the road. But you would never want to just charge a patient in the middle of a post-op. I'm giving you an example of a chemotherapy.

JEANNETTE DOMASK: I remember having that situation, Pam and I worked together before. And Pam trained me. And we did a risk assessment in a rural area. And there was maybe three obstetric providers in the area. And they wanted to terminate a patient. And two other providers in the area had already terminated this patient.

So she's pregnant, first trimester. And then to terminate her and not have any other providers, it just wasn't recommended. So there are some sticky situations that you can get into. So we really want to look at, yeah, your area that you're in, location, or you're super specialized that you might be the only physician that provides that care.

So it's really important to try to focus on rehabbing the situation before terminating. And also another issue is the managed care plans. Some of those have specific contracts that have procedures to follow before terminating a patient. So you want to make sure you look at those.

JOAN PORCARO: Yeah, and I want to just add in. I like the word you used in it about rehabbing the relationship. And it is true that sometimes if you can take a moment and really work through whatever the issues are. I've had situations where patients have been involved with the practice for maybe a decade. And they've come in and they have been having a negative response to something. And the call I would get is, can we terminate?

And I often say, well, from this perspective, have you ever had any issues before? Has something changed? And having worked in health care environment for a very long time, I also gently remind folks that sometimes how we behave, how our practices are maybe organized, and maybe some of our own policies can frustrate people. And we can necessarily maybe even be at the root cause.

So if you're able to take to pause, ideally you should. Now, I always and I'm sure my colleagues here today will also draw the line that there has been an act of violence. My rule of thumb is anytime a patient's leaving in handcuffs is a good opportunity to consider the relationship is not in good stead.

And then also important is it might be that another provider in the practice can work through some of those issues or maybe that they were working with the M.D, but maybe working with another individual like the PA if you have one in your practice or if you have a nurse practitioner. So just try different personalities just to see if there's a way to get things on a more firm, positive footing.

JEANNETTE DOMASK: That's a good point. And other questions that we get involve, are you just dismissing from this one physician? Is it the whole practice? And then I worked with a health system where, is it the entire health system? So there are obviously larger ramifications of the entire health system is discharging a patient. So that just needs to be clarified.

JOAN PORCARO: Yeah, and obviously when we've had to do that in the past, an entire health system, obviously EMTALA is still implied, is applicable and must still be followed. So we want to do a good analysis. And the other thing I mentioned is it's really the ultimate decision of the physician or even the medical director.

And I've had situations where people in different roles like medical assistant or another person in the practice has terminated the individual. Really, again, it's ultimately the physician who holds the responsibility and accountability for the situation. Yeah, so I'm going to bounce back to Jeannette again. How much notice should be given to a patient when ending the relationship? And what resources do we want to provide them to help them as they move on into this next transition?

JEANNETTE DOMASK: So the standard nationally is 30 days. You certainly want to look at your state guidelines to see if there's any regulations that dictate longer time period. But as Pam had mentioned before, you also want to keep in mind if they have a 90-day post-op period that you're not terminating before the 90 days is up.

But 30 days is standard. And you give them 30 days for emergency care and provide that care. Make sure that they're aware that they can come to you for any emergencies. So there's not that issue. Obviously, if there is a threat of violence or an actual violence that occurs, you can terminate them immediately. But any criminal act, that can be an immediate termination. So that's important.

But if it was just a minor issue, you can't just terminate someone without giving them the 30 days. That does lead to patient abandonment, which also can lead to board complaints and negative online reviews because we get a lot of those calls as well where patients are blindsided.

They're not given the 30 days. They've got issues that are outstanding. And then they go online and post negative reviews or they report the physician to the board. So you want to be careful of those potential consequences.

JOAN PORCARO: Thanks, Jeannette. Pam, anything to add?

PAMELA JOHNSON: Well, the one topic that we haven't talked about and I think it's really important in today's environment is-- and Joan, you're the expert in this field-- can you terminate a suicidal patient? We get those calls sometimes. And what do you think, Joan?

JOAN PORCARO: Well, I think with any behavioral health relationship-- and that can be in a physician practice that solely is psychiatric practice in nature or any practice-- being able to make sure that you really have analyzed the situation well, you maybe have to bring in other individuals.

Possibly if you are a primary care doc, you might want to bring in psychologist or some type of social service in the community if it's available. But we do have to figure out that patient is indeed mentally stable before termination. Now, mentally stable is a rather vague, large way to approach this. But we really have to look at, is it indeed the behavior? Are there other ways that medication might support the patient being in a more comfortable place with interacting with others? So again, really a deeper dive.

And in these situations I often think, yes, it is ultimately the physician's decision. But it's actually a team event where we really need to case manage and look at different opportunities for just a safe care transition, being able to possibly shift care to another provider, or another physician in the community, or even another service if possible. I mean, again, obviously they're coming in for a medical situation. We have to take care of those particular aspects as well.

PAMELA JOHNSON: I also wanted to mention that I think maybe we talked about this, I'm not sure. And if this still happens, but back in the day, people sometimes left their prescription pads out and it has been known to happen on more than one occasion where that prescription pad left the office, so if your patients participated in any criminal or illegal activity while they were at the office, that is also grounds for immediate termination and of course, excellent documentation.

And then sexual harassment or inappropriate behavior towards your staff, I think we're going to talk about this in a little bit, but that also is grounds for immediate termination with very objective, factual documentation of who did what to whom. Sorry to say that those two things do still occur.

JEANNETTE DOMASK: Yeah, one thing to highlight and you touched on it earlier, Pam, is it should never be discriminatory. So I recall a practice calling and saying, it's really expensive to get a sign language interpreter for patients. Can we terminate them because it's costing us a lot of money?

Well, that would obviously be discriminatory. So no, you can't do that. So if they're protected class based on race, religion, gender, disability, they cannot be terminated because of those issues. That would be discriminatory.

JOAN PORCARO: Yeah, and both of those comments about sexual harassment of the staff by the patient or what you just mentioned with regard to any type of protected situation, I want to go back and ask another question. When we're thinking about staff training, how much and how deep do we go?

How much does comprehensive staff training contribute to actually working through those challenging patient interactions and how to make better informed decisions, which let's go to Pam, what's your experience been with working with practices?

PAMELA JOHNSON: Oh, I think that is probably one of the most important things, is that your staff need to be trained on all of your policies, including terminating a patient because when in my decades of doing risk management assessments, the first person that I see at a practice or a facility is the front office person.

And I feel sorry for them many times because I think they take the brunt of unhappiness, or dissatisfaction, or inappropriate behavior. And so if they're not adequately trained, the first response, of course, is to become very defensive. And then during communication workshops that just escalates. So now we have two very defensive people going at it.

So I can't highlight that enough that is the onus of the practice to train all of their staff on de-escalation and good communication because sooner or later somebody's going to have an unpleasant conversation with either a fellow staff member or a patient and they need to know how to handle it.

JEANNETTE DOMASK: I would definitely agree because it gives them-- you want to give them the autonomy to be able to handle these situations. Also staff should be trained that it's not their job to be abused in health care because I oftentimes will get calls and it's been the third time that a patient has been verbally abusive to a staff member and the staff members never reported this to either practice administrator or physician.

So it's important that if something does happen that they do report it so that the issue can be nipped in the bud and it can be addressed. Because the problem is when it escalates and it happened multiple times and then nothing's done, that creates just more issues within the practice. So it's really important that they're trained how to address the issues with patients and then report it if something does happen with a patient.

JOAN PORCARO: Yeah, and I'd like to add be able how to escalate and who to escalate to. Sometimes there's one particular person in a practice or in a hospital department that just is a little more comfortable with diffusing a situation. And it doesn't necessarily mean it might be the manager. It might be that somebody knows that patient and really has a way to get to the root of that patient's anxiety, which is maybe causing some of that acting out behavior.

So we mentioned a couple of things. We talked about the sexual harassment. I've had situations where patients have actually put hands on doctors or staff in the practice in the hospital setting. So how can a practice-- and we'll start with Pam again. How can the practice balance their obligations to the individual patient with the safety and well-being of staff, but other patients too that are in the area?

PAMELA JOHNSON: Well, I think one of the primary things is to identify, what is acceptable behavior and what isn't. Verbal abuse is equally as damaging as physical abuse. And so I went to a presentation and it was like, when is enough? And so I think that that is up to the practice to determine. I mean, there's lots of resources out there to help you.

But to have very clear expectations, write them down. Communicate them to both sides, so the staff and the people at the practice and as the patients as well. We all want to get along. We want to have a harmonious experience here. We want to promote patient well-being and patient safety.

But we also-- and I think this is sometimes where practices fall short. And it makes me really, really sad is that sometimes we are quick to blame like the staff like we shouldn't have engaged. You shouldn't have done this. We know that Pam is a hothead. She has red hair or whatever. And I've seen this conversation in break rooms or whatever. It's like, oh my God, here comes Mr. Smith. Well, we all about Mr. Smith.

But for me, as someone working at the practice, I feel like the practice is endorsing Mr. Smith's behavior because we're just accepting of it. We know here comes Mr. Smith. So I Jeannette has seen that as well.

JOAN PORCARO: As have I.

JEANNETTE DOMASK: Yeah, I remember seeing the signage in hospitals now where they have the patient expectations. And that not only reinforces to patients that we don't accept this behavior from patients, but it's also reinforcing the staff. This isn't part of your job to be abused. And we have your back. We're on your side and don't expect-- you want to provide a safe working environment for your staff. And part of that is letting them know that you're going to do something if they're being mistreated by a patient and you'll address it.

JOAN PORCARO: Yeah, when you were both talking, it just brings a memory back as a former ER trauma nurse that it was considered part of the job. And it was considered to be the norm. And there are times when patients situations of injury and such where their ability to control their behavior is a challenge. And that's where we want staff how to protect themselves as best they can.

But it's those other times, that nobody gets up every morning, we always say no one gets up every morning and goes to work with the intention of hurting a patient. But they also don't have the expectation to come home after being hurt by the patient. So we want to walk gingerly. Yeah, good points.

I would say I've been seeing more signage posted in health systems and I have seen it in a few physician practices. And the messages are essentially with the same intent. But the messages might be softened in different ways that make sense for that particular practice. So it is something to consider for sure to look at that as well.

And I think I working with my clients, one of the popular requests I get is, can you come and talk to us about complaint and grievance management? Because sometimes patient termination, what's been at the root cause is possibly an unresolved complaint or grievance that has happened.

Again, not saying the patient's right in doing so. But sometimes patients can get on their last nerve. They can have their own last nerve too if they feel like they're not having the kind of engagement. So we want to keep a balance with that. I want to go back to just one other question here, the topic of, how do we ensure continuity of care during that 30-day transition period? Jeannette, do you want to speak about that a bit?

JEANNETTE DOMASK: Yeah, so it's really important in your policy and procedure to have a form letter that you send to the patient like here's how you can get your records. Here's how you can find a new provider. We do stress not to give them actual provider names, but you can go to the medical society. You can go to your health carrier. Here's your options. We will provide refills for the next 30 days. Or if you're in your post-op period, we'll continue to treat you during your post-op period.

But you want to make sure that all of this is outlined so that they don't slip through the cracks and that they aren't sure what to do next, but to give them the framework to follow, to get their records, to get them transferred, and then have a smooth continuity of care.

JOAN PORCARO: Yeah, as smooth as possible. Pam, other thoughts?

PAMELA JOHNSON: No, I think that just be mindful depending on what contracts you have with your insurance companies is to just review those before you send them all out. And one of the biggest beefs used to be I can't get my medical records. Well, now with the Cures Act, everybody can look at everything all the time, but it's still

so important to promote patient safety, is I agree, I would not give someone particular names of people because then it looks like you can be considered that you're endorsing them or whatever. It's just a generic list like here's a list of ENTs, or orthopedist, or dermatologist in Dallas County, for example.

JEANNETTE DOMASK: Or passing off a bad patient to another provider, then I've had calls where someone said, well, I don't really like this doctor, so I'm going to give this doctor this patient. That's not it, no. You don't need to get into that. Give them their options, the patient choice where they want to go next.

JOAN PORCARO: Again, that whole aspect of trying to help facilitate finding a new provider, I know that there's a lot of different options out there. And obviously their health plans should be able to help them with it. So any thoughts about that?

PAMELA JOHNSON: No, just offer that as a resource because sometimes I think we don't think about that when either having the verbal conversation and/or in the termination letter. I think the termination letter just spells out everything you'll get. We'll provide medications for the 30 days.

And I'm a stickler in our practices. We actually put in the 30-day period like January 1 to January 31. I think that's just a nice thing and then it cuts out the calls like, well, I didn't when the 30-day started. Was that when--

JOAN PORCARO: Yeah.

JEANNETTE DOMASK: When you sent the letter or received the letter?

PAMELA JOHNSON: Yes, yes. Oh, yes. I'm sure you've all heard those. I've heard those. So I think that's why we just strenuously recommend to practices is tighten that down. Put it right there. Underline it. Put it in bold, however you want.

JOAN PORCARO: Yeah, so unless there's an urgent reason for termination like we've said with violence obviously. But I always like to give them a little bit of wiggle room. So maybe I'm mailing the letter on the first of the month and it's going to take some time or the patient's coming in for an appointment and I want to at least have that conversation, I'll try to buffer it a little bit.

But there's one topic we hadn't really touched on and I know a lot of times I would get calls and have continued to get calls where folks have said, the patient's not necessarily violent, but they're just disagreeable. And how can they make sure they're protecting themselves and their staff when they're having this conversation?

This is a topic for an entirely different podcast of, what is your emergency preparedness plan for your office? You might have a good fire safety plan, or you have a water main break, or power goes out. But making sure that you have a good conversation about how you are going to address maybe the unwelcome intruder, but also the unwanted concerning kind of upset that puts people on edge. What's the plan if there's a concern that anxiety of the patient is now actually moved towards acting out behavior?

And so again, that we can do a whole webinar on and I am available to do that. But again, it's to give a little wiggle room. I mean, if you know it's going to take a couple of days for you to talk to the patient and then to follow with the letter, yes, 30 days. But it doesn't necessarily hurt if it's 35.

PAMELA JOHNSON: Oh, no, no, no.

JOAN PORCARO: You build it into the letter. We're letting you that effective of if this was the 24th of the month or 25th, that effective of such and such, the 1st of the month, this is when it goes into play. Yeah, and that leads to for some patients this becomes very emotional. And are there any other tips we want to

offer about providing any practical solutions for their potential stress response, Pam?

PAMELA JOHNSON: I think everything we've said so far, but just reinforce it. We're here for you. If you have an emergency, you give us a call. We're not just literally kicking you to the curb tonight at 5:00 PM. We're still going to be here for the next 30 days if this is a non-urgent termination.

And that we'll do everything we can to help you get your records to where they need to go in a very timely manner. And I don't know if some people like to do this. I have some practice managers that are really friendly and very helpful. And they'll say, if you have any additional concerns, here's my office number and you could give me a call. I don't know if people do that anymore. That was the old days.

But I think, most importantly, recognize that this is a stressful time for all parties involved, not just the patient and not just the provider because it is difficult. If you talk to providers that have to terminate patients, even those that got on their very last nerve, maybe six months later when I'm back at the office and I'm talking to them and they're saying, oh, I had to terminate red haired Mr. Smith, I don't think-- it's not like they're callous and they don't feel bad. They do feel bad. But they have to look out for everybody and the best interest for everyone concerned.

JOAN PORCARO: Jeannette.

JEANNETTE DOMASK: Yeah. And I think it goes back to what we've talked about, that it's really important. This should be, as a last resort, that this shouldn't be a surprise to patients, that there should have been a warning, a discussion about behavior, or noncompliance so that they are well aware of consequences if it continues.

I know I worked at a health system. And they always said stress, like giving the warning and said the majority of the time, like almost 90% of the time. Once they spoke to a patient about their behavior or noncompliance, they turned around and it didn't happen again. So it's really important to stress that because oftentimes we'll get calls where they just want to terminate automatically instead of addressing the issue and trying to work with the patient. So again, yeah, it's going to be stressful for the patient if it comes to that.

JOAN PORCARO: Having those difficult conversations, you want to have the right mindset and you want to make sure the right people are delivering that message too. Pam?

PAMELA JOHNSON: I'm just sorry that it has to happen.

JOAN PORCARO: I think the other thing I just want to remind our listeners is when you are writing your policies, think ahead how you're going to handle the request to have that termination appealed. A lot of times we will get the call or the patient's asking for an appeal, can they be reinstated? And obviously there's no blanket response to that. It's each case is very, very specific and has to be treated as such. So just something to consider.

All right. Well, we are at the close of our conversation. I have to thank you and first, both for joining in to this call. We have all had the opportunity for many, many years to work in these settings and also in the supportive role of consultants. So I want to first thank Pam for joining us today. Thank you, Pam.

PAMELA JOHNSON: My fun. I was reuniting with my fellow risk managers.

JOAN PORCARO: Yes, indeed. What's the old saying? The band is back together.

PAMELA JOHNSON: Yes, the band is back together.

JOAN PORCARO: And Jeannette, thank you. It's really been a pleasure to connect again. And I appreciate your time with us. So thank you.

JEANNETTE DOMASK: Thank you. I appreciate it, Joan.

JOAN PORCARO: Well, in closing, I want to thank our listening audience. And those who have tuned in to our discussion, I hope you'll be joining us for future discussions and our webinar series that will continue in 2026. So again, thank you for listening to our podcast, WTW Vital Signs.

SPEAKER: Thank you for joining us for this WTW podcast featuring the latest thinking on the intersection of people, capital, and risk. WTW hopes you found the general information provided in this podcast informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors.

In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, WTW offers insurance products through licensed entities, including Willis Towers Watson Northeast, Incorporated in the United States, and Willis Canada Incorporated in Canada.