JOAN PORCARO: Welcome to the WTW Vital Signs podcast program. My name is Joan Porcaro, and I'm the senior vice president of risk services for WTW healthcare. I'm very excited as today's podcast continues our newest series designed for physicians, providers, and medical practices. This podcast series is dedicated to helping healthcare professionals navigate the complexity of medical practice with confidence and peace of mind. In each episode, we'll delve into practical strategies, expert insights, real-world studies to empower you with the knowledge and tools needed to minimize legal risk and enhance the patient experience.
In today's podcast, we will continue our focus on the topic of terminating the physician and patient relationship. A therapeutic, respectful provider-patient relationship, well, just like any relationship, requires ongoing time and attention to sustain it. Over time, that connection may also encounter periods of strain, disruption, or a challenge between the two parties. Sometimes the goal, of course, is to work through those rough patches and repair the relationship. However, there just are situations where differences become irreconcilable and trust is damaged and mutual respect, well, it's just not there. It's eroded. So despite sincere attempts to resolve the issue, we've reached a point that parties must go their separate ways. So in that moment, ending the relationship, however difficult, may be the most appropriate course.
So I want to first begin by introducing our guests today. I want to start with Anne Huben-Kearney. Anne is an independent risk and patient safety consultant after a career in multiple healthcare roles from staff nurse to nursing administration, quality improvement, risk management, and patient safety, as well as medical professional liability insurance with experience in diverse healthcare settings. She was elected to the American Society of Healthcare Risk Management advisory board for 2020/2022, and is serving on the 2025/2026 ASHRM Nominating Committee. She is faculty lead for the ASHRM patient safety certificate course and is co-author of the three-part American Hospital Association ASHRM white paper series on recognizing and managing bias in healthcare.
Anne is the current president of the Massachusetts Society of Healthcare Risk Management. She has a bachelor's degree in nursing and a master's degree in public administration from the University of New Haven. She is a distinguished fellow with ASHRM and is a Certified Professional Healthcare Risk Management, CPHRM professional. She also holds CPHQ and CPPS. Welcome, Anne.
ANNE HUBEN-KEARNEY: Thank you very much, Joan. And I just want to say thank you for this opportunity, but I also want to thank Claudine. I have been so impressed with her knowledge and insights, and I think you're going to all enjoy listening to her.
JOAN PORCARO: All right. Well, thank you, Anne. And without further ado, let me welcome Claudine Robinson. She is a risk management professional. She's a registered nurse with over 30 years of experience and more than 14 years in healthcare risk management and patient safety. Certified in risk management, patient safety, and operating room nursing, she works within a large hospital system in South Florida. She serves as a mentor and committee member for the Florida chapter of ASHRM and works with committees with ASHRM itself. Her passion lies in helping organizations and healthcare professionals navigate complex systems, reduce risk, and improve outcomes. Welcome, Claudine.
CLAUDINE ROBINSON: Thank you, Joan, and thank you, Anne. I'm delighted to be here. I'm looking forward to having a wonderful conversation with you guys. Thank you.
JOAN PORCARO: So I want to start off with a question for Anne. What are some of the internal operational challenges a practice may be faced when they're terming a patient?
ANNE HUBEN-KEARNEY: That's always a good place to start. Thanks, Joan. There has to be internal coordination for sure. Who's doing what? What are the defined roles? Is it the impact and import of the practice administrator, physician leader, the risk management professional? I think that's clear. We don't want to be impulsive. This should be a thought out, deliberate process.
And then when the internal operations that are practical, when the patient is being terminated is ensuring that the terminated patients are not scheduled for an appointment. Many times they'll just call and try to get something booked. And you need a flagging system. So that you're not inadvertently rebooking that patient except for emergencies. And we're going to talk about termination letters. So it should be clear if in an emergency the patient should go to the emergency department, or they are able to contact the physician or the provider. Basically, it's usually for 30 days after that termination letter.
I think there's another concern internally is dealing with aggressive behaviors. Staff need to be trained on de-escalation in the office. If there's a problematic situation and the continuation of that relationship and the communication continues to be problematic, the staff need how to escalate that. When do they involve security? I think Claudine is going to talk about that later. Legal, human resources, marketing, and communications. And I Claudine is going to talk about not responding to social media. It's really super important.
The other thing, and I think it's important is the documentation. We'll talk about that as well. But the documentation in the medical record and in the practice file needs to include any letter sent to the patient. Any documentation or any phone calls, internal emails. All of that is really critical because there's a potential of the patient coming back with an allegation of abandonment. And always, always, always ensuring consistency and fairness. There should be no potential hint of discrimination. That means disability. Our language interpreters many times we get phone calls saying, I don't want to pay for an interpreter. It's one of those unfunded mandates. Well, you can't terminate a patient because they need a sign language or a language interpreter.
Age. They're more complex patients. Age is not a reason for terminating a relationship. And other non-discrimination concerns race, color, creed, gender identity, whatever it might be. So I think those are the top issues I see. When Claudine and I were talking about this regarding the internal operational challenges.
JOAN PORCARO: Thank you Anne. So the next question I want to pass over to Claudine. So what are some of the barriers that the practices might face when they're having terminations with patients? Claudine Robinson: And that's a great point, Joan. And overall termination is never easy. And of course, they will always encounter barriers. Some may include the rigor and the legal risk, making sure that everything is documented and mentioned, documentation, which is huge, and make sure it's documented, and it's defensible. So of course, you need to involve your legal team.
Secondly, we have regulatory compliance issues, especially around contracts or employment law. So we need to make sure that we are being compliant and we're also following our policies. The third thing is communication challenges. You have to deliver difficult news to the patients, but it should be clear and professional. And of course, you want to think about your staff as well. How does it impact the staff morale? You want to balance between protecting the practice, being fair, and keeping the team and the patient supported.
Another challenge as well is where you have patients who are complex patients. Their conditions, pregnancy. So the fear of retribution in terms of with the social media as well. You have a patient who has been with you forever, familial, whereby you took care of the mother, the parents, the grandfather. And now, because of whatever reason, you had to terminate that patient as a provider. And it's very hard as well. And of course, you worry about the social media. What impact does it have on-- will have on your practice? Because social media, everybody can-- they're posting on TikTok and on Facebook, so of course, the ramifications behind terminating your patients. So those are some of the things you have to consider and the challenges that we experience when we have to terminate that relationship. It's never easy.
ANNE HUBEN-KEARNEY: Can I add one thing to that. I think, Claudine, you had mentioned before about having the responses generic on social media.
CLAUDINE ROBINSON: Correct. And that's true, Anne. That's also true.
ANNE HUBEN-KEARNEY: So I think the point is that you can't respond. This was a patient. This was not a patient. You can't provide any of that personal health information, but just basically a standard statement saying we review these comments, we take them seriously. Please contact maybe the practice administrator giving the email address, but keeping it generic. You can never respond. This was not our patient. This was our patient. Patients can say anything, but the providers have to follow HIPAA.
CLAUDINE ROBINSON: And that's where also your marketing personnel comes in as well. You have to basically include them as well because as answer you can't respond. That's very, very key. You can't respond because you worry about HIPAA violation. So you want to make sure you keep it very generic and of course, involve your marketing team as well.
ANNE HUBEN-KEARNEY: That's a great idea. I didn't even think about marketing. Thank you.
JOAN PORCARO: Thank you both. I'm going to bring a question over to Anne. So when terminating the relationship, what are some of the factors that determine whether the patient is termed from that one provider, from the practice, or the system. Of course, barring EMTALA challenges, what are your thoughts?
ANNE HUBEN-KEARNEY: I think this is a difficult challenge, and it must be dealt with on a fairly individual circumstances and not a blanket policy. In many ways, the process is the same, but perhaps the, factors that you're talking about, Joan. And you mentioned that sometimes the relationship is not working. Not every patient is going to as a provider, and you are not going to like every patient. So you really have to take that personality conflict or some of the issues that Joan mentioned in the introduction into consideration.
So the first thing is the availability of another provider. Is there someone in the group who's not going to have that same personality clash, for example, able to and willing to accept that patient into their particular practice? What about the other providers in the community, particularly for specialists? And I think that's a concern that there is access to those particular knowledge-base specialists, for lack of a better term, and obviously, the vulnerable populations. So I think there has to be some type of discussion. Are they willing and able to accept a patient in the group to assume the care?
And I think it also depends on the reason for termination. If there's threats, if there's non-payment for one practitioner in the group, they're certainly not going to be paying the second practitioner, or non-adherence to the plan of care. And you're asking why is there non-adherence? Is it financial. Is it the fact that they don't believe in medications. They don't support what we're saying for westernized medicine. So I think that has to be taken into consideration.
And what's the impact on the group? If there's someone threatening an individual in the practice, you don't want that individual continuing with the practice. So I think that the system issue is a little bit more challenging because it's actually very rare because there are some of those potential legal and reputational impacts since Claudine mentioned some of that. So there really should be a very intense leadership, legal and risk review. I know it has happened periodically, and they've actually gotten involved-- in particular organization, made sure that they reached out to the department of health for their particular state to say, this is why we want to terminate the relationship. And related to the patients particularly being violent and threatening. And staff we are challenged to take care of that individual going into the room and afraid of what's going to happen to them.
There's also the need to comply with EMTALA. Now, you might be terminating the patient. You're a specialist. That patient comes into the ED, and you're on call. You have to see that patient. You are on call. You have a responsibility to evaluate, stabilize the patient under EMTALA. However, even if you're stabilizing the patient, you make it very clear to the patient and you follow up in written communication that is not re-establishing a patient-physician relationship. And that language has to be very clear.
Say for orthopedics, you're going to see that patient, you're ruling out a fracture or doing some type of care, putting a cast on. You may see that patient for a follow up visit, but again, reiterate that does not reestablish the relationship. And putting that in writing is extremely important. Claudine, do you have anything to add to that?
CLAUDINE ROBINSON: You've made some great points, and without a doubt, because one of the things that we worry about is EMTALA, and of course, we have to make sure that the patient is seen and of course, that there's no emergent medical condition. But of course, as you mentioned, we need to have clear guidelines that the patient doesn't think that OK. Because I saw Dr. Brown in the ED, that means I'm going to see him again as a patient. So that's really key. I'm glad you mentioned that. You highlighted that.
ANNE HUBEN-KEARNEY: Thanks,
JOAN PORCARO: Thank you both for your comments. I have to say, transparency and clear communication is going to be really essential in these particular situations and the timliness of the communication as well. So I'm going to come back to Claudine. Patients may want to appeal that termination. They may want to say, well I don't agree with it. I want to reestablish my care. Claudine, how should we address such incidents?
CLAUDINE ROBINSON: That's a great point, Joan. So when patients want to appeal the termination of their relationship, the key is to have a clear, consistent process in place. That's always key. It has to be clear and consistent. I also make sure that the policy is documented and communicated upfront. So of course, you want to also involve your legal team. You want to focus on safety, continuity of care, and fairness. So you want to make sure that it's not one size fits all. It's always good to reevaluate, but you also want to make sure that it's consistent. Even if the relationship is ending, patient should feel respected and know their next steps. So of course, outline your process. What next they need to do, and make sure that they're all aware of the next steps moving forward.
I'd also include the frontline staff because sometimes as well, one hand doesn't speak to the other. So you want to make sure that the frontline staff, they mean the person at the front desk, are also aware of what's going on. So include it in your documentation. And of course, make sure that your scheduling person always aware of what's going on, the front desk notes and the clinical staff are updated, so the re-established patient relationship is also clear. So as I mentioned earlier, communication is key in this aspect.
JOAN PORCARO: Thank you Claudine. And how should physicians handle situations where, let's say I'm been seeing a doctor for a while, but voluntarily, I withdraw from care or I don't need those services any further. Should this be formalized?
ANNE HUBEN-KEARNEY: That is a fabulous point, because I think sometimes we don't acknowledge the fact that relationship has terminated, albeit voluntarily by the patient. So I think we have some of the same things that we talked about. A brief follow up letter. You're confirming the patient's decision to end care. You're documenting the last date of service, making sure they know how to get a copy of their records, follow up with urgent care. You're basically doing the same thing, but you're acknowledging formally in a letter, in a written communication. And it's really important because that's knowing what their plans are. Again, the transparency on both sides. The patient may just not show up. They may not make an appointment for a period of time. And you should be tracking those no shows or patients that are lost to follow up if is a terminology rather that we use. So please make sure that you are closing the loop.
You want to make sure there's no abandonment because patients will say, if they haven't formally communicated their termination with you, is that Dr., I think it was Burns, whoever you said, Claudine, is still my doctor. Three years from now, when you haven't seen that provider in three years, you've got to close the loop. And that is really, really important. So that tracking system is absolutely, absolutely critical. And I think these recommendations are consistent with podcast number two. You want to make sure that you're following your practice if you terminate or if the patient voluntarily terminates.
JOAN PORCARO: I think also with the portal situation, and if I'm no longer wanting to be a patient of that doctor or maybe that health system, we also want to let patients know that they need to let us know if they've updated their situation. The practice or the hospital may be sending reminders about prevention and different testing that need to take place. And they're talking in an echo chamber and they're not getting a response. And so making sure that maybe the practice or the health system sends a letter stating, are you going to continue with us?
ANNE HUBEN-KEARNEY: Excellent.
JOAN PORCARO: It could be that the patient may have passed away or they moved out of state. And so closing the loop would be really helpful. And I know that it is not uncommon that-- I've talked to providers, physicians that have sent letters to patients saying, we noticed that you haven't seen us in two to three years, has your circumstances changed? This way, there's no assumption on anyone's part. So again, formalizing those processes within your organization, maybe a help to encouraging the communication.
ANNE HUBEN-KEARNEY: Joan, you just made me think of something too when those letters are going out, which is an absolutely best practice. But there should be a time frame. If we don't hear from you within, and I'd make it like two weeks, I wouldn't make it contact me at your earliest convenience. Well, that earliest convenience could be another three years. So contact me within whatever x number of weeks, 2, 3 at the most because you got the letter, you get the response, you follow up. Then you can say in your letter that we are assuming that you are ending your relationship with us so that you give them a time frame to respond. And after that time frame, it's fair to assume that the relationship has been ended and then do that closing letter, that termination letter. So that's a good point with the portal and the transparency, and communication. Good point.
JOAN PORCARO: In most organizations, if you haven't seen that particular provider, it might be an employed specialist within a three-year window, they automatically conclude the relationship. But the patient doesn't know that. So on year 3 plus 1 day, they call for an appointment and they find out, oh, you're considered a new patient. So really outlining what the practices policies will be helpful. Great comments.
CLAUDINE ROBINSON: Just also to add as well and to your comment is that the letter should also be certified as well, so that's one of the things that we need to make sure that letter certified so it gets to them or they sign for it versus we don't know exactly what transpired with the letter. So that's also key.
JOAN PORCARO: What I've been doing later in my practice was not sending a certified US mail, but actually just spending the extra dollars for UPS or FedEx because it's trackable. If I got a certified letter in the mail, the likelihood of me having the time to go to the post office and get in line, it's going to be a tough call. So again, most practices and organizations have a relationship with UPS or FedEx or the post office for overnight mail. So just a thought.
ANNE HUBEN-KEARNEY: I'm going to add something else to that is also recommends sending it by regular mail because people do not want certified mail. It's always bad news. So sending it regular, keeping a copy of both. And I think we're going to talk a little bit about that. But you got to do what you need to do to protect yourselves, that you have indeed made every effort. And the patient doesn't have to sign it, but you keep a copy of that receipt to show that you sent it. It was delivered. The patient refused acceptance because you need to have that paper trail for-- as Claudine had mentioned, there's regulatory requirements, board of medicine complaints, board of nursing for nurse practitioner complaints. So you really need to go to that x degree. And I think the $1.50 whatever for FedEx is money well spent.
CLAUDINE ROBINSON: Definitely.
JOAN PORCARO: Absolutely. And I was actually going to ask that question to Claudine. Are there specific risks or the liabilities or any type of regulatory issues that practices face, whether they're independent or hospital owned, if the termination process, well, it's just not handled right?
CLAUDINE ROBINSON: Oh, yes there is. So if the terminations are not handled correctly, practices can face CMS scrutiny around patient abandonment, continuity of care, and proper notice. So not following the rules or skipping steps can lead to liability or complaints. So of course, they can file with the board of medicine or of course, under CMS and EMTALA rules, the practice must ensure continuity of care and emergency services. And it is important to document everything and ensure patients still have access to care during the transition.
We also need to review the situation carefully and respond professionally and under, and of course, involve the legal team. As skipping steps, of course, as we can create liability or complaints. So you got to document everything and keep your patients supported during the transition because that is key. So you want to make sure we're dotting all our eyes. And of course, if not we can come under scrutiny from the board from different payers. And also it's important that we're making sure to make sure that we are documenting and following the proper process.
JOAN PORCARO: Excellent point. So back to Anne. So let's talk a little bit about patient rights during that and after that termination process, especially with access to records and ongoing care. We've touched upon it, but I wanted to spend a little time emphasizing it. Anne?
ANNE HUBEN-KEARNEY: Thanks, Joan. I think this is very, very important. A couple of points that we definitely want to make. Patients are entitled to timely access to their medical records. And I want to emphasize, you cannot hold a patient's medical records, sending them a copy or sending a copy to whomever they're going to be having as their next primary, next caregiver for nonpayment of bills. You have to send it. You may not ever see that money from that patient. And it's important then, as you've heard in prior podcasts, to make sure that you're monitoring that nonpayment. So you don't end up with a patient owing you thousands of dollars, but you cannot hold it for that.
You need to have the ability for them to have their records sent to their new provider. And you have to make sure, as Claudine had mentioned earlier, the patient's clinical status during this termination process, the OB patients-- you're not going to transfer care in the midst of a depending on the gestational age of the baby, immediate post op patients, those that are acutely ill. That is potential abandonment for sure. Say active chemotherapy. You have to really, really look at the exclusionary criteria, and you're going to have that care for that period of time. And you can be working for a transition, again, a personality issue or whatever that might be. But I think you have to be very cautious.
I think you need to have options for coverage. And I think we underestimate telehealth. If there's someone who has a personality clash with your staff and is nasty to your staff and belittling, they don't need to be in the office. You can see them via telehealth. I think, again, limiting the scope of services for immediate post-op. I will care for you to the end of your recovery period, whatever that might be, follow up visits, but then we're going to terminate the relationship. The key is, and I think, Claudine, you talked about this. That should not be a surprise, unless, of course, there is verbal or physical violence, but you want to be able to make sure that you're communicating that there is a process.
One thing I want to mention is about medications. Many times patients are terminated and then they usually have 30 days, maybe longer than that. If it's a particularly difficult and referrals needed, specialist is needed in the geographic area is limited in that availability of those specialists. The patient will call to have their meds renewed. Now, think about that when you're terminating, yet you're giving them appropriate unless it's an issue regarding their medications and they're not taking them appropriately, but say it's 30 days, maybe even 60 days. If you renew the patient's medications, you are reestablishing your relationship. So think about what resources are there.
And many times patients are referred back to urgent care or the ED. Not the most appropriate use of those high intense services, but you have to think about the patient's individual circumstances, what medications they need, if they are not abusing them or inappropriately taking them, and then making sure that you've got that medication coverage. But if you renew the medications, you're reestablishing the relationship. So I think that's really important. That comes up, I think, fairly frequently. And that whole time frame for when you're going to be able to offer that urgent and emergent care as you're making that transition. Again, it might be longer, depending on the clinical context, the local standards, the local availability. But you still start the process anyway. And have that discussion with the patient regarding the reasons for termination.
Claudine Robinson: Great point, Anne. Great point.
Joan M. Porcaro: So back to Claudine. So we would be remiss if we didn't discuss data collection when we're looking at terminations. Why is tracking and trending important?
CLAUDINE ROBINSON: So when looking at termination, it really helps to collect the right data. So we have to track and trend, and we need to know the reason for the termination. Were there any prior warnings or documentation? Patient interactions and whether your policies were followed. So it's key to always look to track and trying to see any data. Was there a particular doctor? Which practice? The location, and reasons for the termination? Also, you want to note any complaints or appeals.
Doing this helps a practice spot trends, stay compliant, and reduce the risk. So you want to make sure that you're tracking and trending your data. Is it a particular staff member whereby each time the patient has a problem with, what exactly is going on? And of course, when you track and trend your data, then you can implement measures based on what you have found. And of course, proceed accordingly when you're moving forward.
JOAN PORCARO: Anne, anything that you could add?
ANNE HUBEN-KEARNEY: No, I think that's really important. And I don't think we do that. I think we think it's a complaining patient, but you're not really looking. I think your point is well taken about the staff. I have been in situations personally where someone was particularly rude. And I'm thinking to myself, does the provider know that? Because that's a reflection of the providers office practice. So I have had, again, the opportunity to say, you may want to think about this. This is not helping your reputation. Is that a reason why someone is terminating or being terminated? So I thought that was great. You can look at, and again, obviously, my focus on bias, but is there a potential bias associated with why? I do think the interpreters are a major issue.
No one wants to pay, no physician practice because you're going to pay more in many situations for the interpreter, let's be honest, than you are for the actual receipt of Medicare or Medicaid. I know that's a fact, but it's an unfunded mandate. And you have to be able to make sure-- and it's actually a medical malpractice. You have to be able to make sure that your patients understand their care, their treatment, your education, et cetera. So it's one of those pay me now, pay me later. If you pay me now, I'm paying for the interpreter. Pay me later in a medical malpractice case, when you're in there for a week or two and your reputation is at risk because you're not meeting the needs of your patients, that's a little dramatic, but it's true.
CLAUDINE ROBINSON: But it's true. I agree. And I think once we have a better idea of what's happening, we can always, if we need to, revise our policy, look at the workflow design, or train the staff. We can basically implement measures once we have identified what the issues are. So it's always good to track and trend what's going on.
JOAN PORCARO: Well very good. Well we're coming to a close to this episode. So I first want to extend a thank you to Anne. Thank you for joining us today.
ANNE HUBEN-KEARNEY: It was delightful. I enjoy hearing the questions and then obviously, working with Claudine. So thank you.
JOAN PORCARO: Without further ado, I'd like to extend a thank you to Claudine. Thank you for joining us in our episode today.
CLAUDINE ROBINSON: Thank you as well, Joan and Anne, I appreciate being here. Thank you. It's a pleasure.
JOAN PORCARO: That's it for today's episode of WTW Vital Signs. Thank you for spending part of your day with me. If you found this helpful, please follow our episodes on YouTube, Apple, or Spotify, and share it with someone who might enjoy it and find the information helpful, too. I'm Joan Porcaro, and I look forward to being with you again next time on Vital Signs.
SPEAKER 2: 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.
