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How to Dismiss a Patient Without Committing Patient Abandonment

(Note: Sharalyn Fichtl is a dental office compliance guru and we are pleased to have her expertise and to make her services available to more dentists in our BEST for Dentistry alliance. —- MG)

Three years as a dental board investigator was an education I’ll never forget. So have the last ten years as a private dental compliance coach and educator. I have so many stories to share with you! For this article, I’m going to tell you about a dentist that committed patient abandonment just by omitting one of three elements of a formal letter to a patient that needed legitimate dismissal. It cost him a $5000 fine and several hours of mandatory continuing education plus the cost of his attorney. If only he’d avoided some bad information he got from a colleague.

I’ll refer to him as Dr. Me Knoitall.

Dr. Knoitall had been practicing for 20+ years. In that amount of time he’d had plenty of patients come through his practice. Most of them great patients but there were a few bad eggs in the basket. I’m sure most of you know exactly what type of patients those are! Year after year he had to “dismiss” a patient or two and never had any trouble with his methodology. Which, by the way, was a letter he got from a colleague that said it was what he always uses.

Then all of a sudden a letter comes from the State Board addressed to Dr. Knoitall stating he was being investigated for Patient Abandonment. He now had a date to appear in Austin at Settlement Conference. As the Dallas Field Investigator for the State Board, at that time, that case file ended up on my desk. His expensive attorney, who I’ll refer to as Mr. Smarty Pants, said “he’s used the same letter for over 20 years and never had a problem”. So, I asked, “ Then what you’re saying is that Dr. Knoitall, over these last 20 years, has routinely dismissed patients that had unfinished dental work… to where the procedure had to be finished by another dentist”? Then Mr. Smarty Pants said, “Oh no, he would never do that! He’s a good guy. He always finishes what he starts on a tooth then he dismisses them”.

The education I gave them is the same one I’ll give you. The dentist was dismissing patients that were not dismissible so the letter he was using was nothing more than a courtesy letter. You see, a dismissal is a formal action. Going to the efforts of formally dismissing a patient is reserved only if there is an unfinished dental procedure that you can’t (or won’t for reasonable cause) finish. Notice I said unfinished procedure; not an unfinished treatment plan. Big difference. So this dentist I’ve told you about had been “dismissing” patients that weren’t even dismissal material because he was dismissing them without the presence of unfinished procedures. No wonder his letter had worked for so many years. It gave him a false sense of security! Those patients didn’t need to be dismissed. It was a total waste of time. All he needed to do was not schedule the patient for the next appointment and be done with it.

Here’s a little insider tidbit. When you give dismissal letters to patients it will likely irritate them and fan the flames. Since this is the likely response you might as well save it for the ones that are required to get one and not the ones that aren’t. The state board rule lays out the requirements of formal dismissal. The language within the rule specifically says that once you have undertaken a course of treatment, you must finish the work unless you have reasonable cause not to. You better document the heck out of your reason for not finishing the work you have undertaken. Try everything within your power to finish the work. That kind of effort is what the state board will expect. They expect you to resort to dismissal very last; after you’ve fought hard to finish the work first.

What is “reasonable cause”? Well, that’s a different article that needs to be written by a clinician. As a former regulator of the licensing agency (non-clinician) I can come closer to telling you what “reasonable cause” isn’t. For the purpose of this article, I’ll tell you about the most popular one. You cannot terminate the dentist-patient relationship because the patient has refused to pay their bill. In that case, you would finish what you started on that tooth (remember we’re not talking about finishing the entire treatment plan) and then simply not schedule the patient for future appointments. If the patient is an orthodontic patient you can’t quit mid-stream just because they stop paying you. This is a sticky situation and there are many that would disagree with me here since orthodontic treatment could be viewed as reversible. However, there are clinical experts that will tell you that you cannot terminate and you must finish. The reason is because the standard of care is a separate relationship from the relationship of business owner and customer. The two are not intertwined.

Dr. Knoitall had a patient that was actual dismissal material (he started a procedure on one tooth that he had reasonable cause not to finish). However, his letter, which remember was nothing more than a courtesy letter really, did not meet all of the rule requirements and therefore he was stuck with sanctions for Patient Abandonment. Don’t let this happen to you.

Your letter should look like this:

Dear ____________________,
On __________ (date), I, Dr. ______________________________ , began your course of treatment for _____________________________________________. This letter is to inform you, with adequate notice to find another dentist, that I am discontinuing treatment that has begun on tooth/teeth ________________________________ but is not complete. During this process, I will exercise the level of care necessary to prevent jeopardizing your oral health. My intention to discontinue the undertaken treatment will be effective 30 days from your receipt of this letter. Important notes about your current dental situation are as follows:
a) Your current diagnosis and summary of current treatment plan is:
b) Your present and future needs are:
c) The consequences of non-treatment are:
My recommendation is that you continue care with another dentist. I will be available to you for the next 30 day period to provide any emergency treatment necessary to prevent harm.
Respectfully,
Dr. Itsoktoaskforhelp

Sharalyn Fichtl
Dental Quality Assurance, PLLC
[email protected]
469-343-7888

Reference: http://www.tsbde.state.tx.us/documents/Jan2014_Rules_and_Regs.pdf
(Rule 108.5 Patient Abandonment)