Risk Management

When Patients Won’t Pay for Care

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, Winter 2013

Some patients who opt for high-deductible health insurance plans or go without insurance altogether decide to postpone or refuse recommended care. Some of these patients are perfectly willing to receive the care, but not to pay for it. When patients base their healthcare decisions primarily on financial considerations, they put their physicians in a difficult position. OMIC’s risk management team has received a number of calls from policyholders trying to balance their professional liability risk with their practice’s financial well-being. The following discussion assumes that the patient has some financial resources and provides general principles for dealing with this situation. In the case of indigent patients who have no financial resources, ophthalmologists may decide to provide care at little or no cost and/or help the patient find alternative sources of care. OMIC believes this is not only compassionate but also helps minimize the risk of a claim. Please call our confidential risk management hotline at 800.562.6642, option 4, for specific advice.

Q. My patient presented with a macula-on retinal detachment. I recommended that surgical repair take place within several days. When my surgery scheduler informed the patient of the price, the patient said he was not willing to pay and refused to sign a financial agreement form. Do I have to provide the surgery free-of-charge now that I have established a physician-patient relationship?

A. No. OMIC is not aware of any law or regulation related to outpatient, non-emergent care that requires a physician to provide free care. To our knowledge, the only situation in which patients have the legal right to obtain care without payment being an issue is in an emergency room. The law governing this care is the Emergency Medical Treatment and Active Labor Act, or EMTALA, and applies only to care provided in the ER, and only until a physician determines that the patient does not have an emergency medical condition (EMC), or that the emergency medical condition has been stabilized. If no EMC exists, or it has been stabilized, the hospital may then ask about the patient’s insurance status, and may then either provide further care with payment provided by insurance or on a fee-for-service basis. Hospitals provide patients who choose not to pay for non-emergent care information on where such care may be obtained outside the hospital. Ophthalmologists may also choose to refer patients who are not willing to pay for care to other possible sources of care.

Q. If I refuse to provide the care I am recommending unless the patient pays, am I “abandoning” the patient?

A. If you offer to treat the patient, you have not abandoned him. Clarify to the patient that you are available to provide the treatment, but that you expect to be paid for your care. Explain when the care is needed, what the consequences of not getting the care are, and where else the patient may go for care. Document the conversation, and provide the patient with a list of resources as well as a written discussion of the consequences of not getting treatment. Consider discharging the patient (see http://www.omic.com/terminating-the-physician-patient-relationship/ for a sample form).

Q. Should I provide emergent care even if my patient won’t sign a financial agreement?

A. While we are not aware of a law or regulation that requires physicians to provide any care for free except as discussed above in the context of EMTALA, we feel that the risk to the patient and physician alike is too great to refuse to provide emergent care when you have established a physician-patient relationship. Our risk management recommendation, therefore, is to provide the emergent care, and then address the patient’s financial obligations. If the patient continues to refuse to pay for care after the emergent condition has been treated, consider terminating the relationship.

Q. My patient showed up for an appointment for a non-emergent condition, but won’t pay her copay or deductible. May I reschedule the appointment?

A. Yes. As long as you are confident in the screening process your staff use to determine the appointment category, you may ask patients to come back when they are prepared to meet their financial obligations. See “Telephone Screening of Ophthalmic Problems”.

Ophthalmologists should consider developing a “Patient Financial Responsibility” policy and statement that clarifies what options are available for payment, and what consequences the patient might face if he does not meet his financial responsibility. Many sample statements are available on the internet.

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