The physician-patient relationship works best in an atmosphere of mutual respect. Problematic interactions and adverse events may damage the relationship or interfere with the establishment of a productive therapeutic relationship.
Patients may be noncompliant with medical advice because of a lack of communication with the physician or a failure to understand or when unrealistic expectations for improvement are present. If attempts at communication do not resolve the compliance issues, a physician may determine that the injured worker (IW) may benefit from a relationship with another physician.
Although the failure to establish an effective relationship is an acceptable and reasonable basis to end the relationship, the physician has an obligation not to abandon the IW outright and to ensure continuity of care in a legal and ethical way.
The relationship may be terminated for causes that might include:
- Patient failure to comply with the recommended treatment plan or medical instructions
- A documented, ongoing pattern of failure to keep scheduled appointments
- The inability of a physician to provide the level of care necessary for the IW’s needs
- The physician moving or retiring from the practice
- Patient behavior that threatens office personnel with verbal abuse, physical harm or violent actions
There are no universally agreed-upon legal standards for when or why to dismiss an IW from care. Physicians can discharge IWs for many reasons. However, the termination of the relationship must not be discriminatory, violate the Emergency Medical Treatment and Labor Act (EMTLA), or put the IW’s safety, health or welfare at risk.
Guidelines for continuity of care
If a treating physician decides that a relationship with an IW needs to be terminated for nonmedical reasons and such a termination would not violate any of the above principles, he or she should follow these guidelines to ensure continuity of care for the IW:
- If the IW is in an acute phase of treatment, termination from the practice should be delayed until the acute phase has passed. It is not advisable to end the relationship when the IW is in the immediate postoperative stage or is in the process of medical workup for diagnosis.
- When the physician is the only source of specialized medical or dental care within a reasonable driving distance, he or she should continue this care until the IW can be safely transferred to another physician who is able to provide treatment and follow-up.
- The physician must notify Pinnacol Assurance in writing when discharging an IW following the process outlined by the Division.
- Terminating treatment for IWs with chronic pain can become complicated. IWs with chronic pain who have been taking opioids should be referred to a pain management specialist or treatment program, as discontinuing opioid treatment can lead to withdrawal or the use of street drugs and may precipitate suicide.
For cases of noncompliance with a treatment plan, it is important for the physician to document the treatment plan and the attempts made to counsel the IW about remedies for noncompliance. The record should document the IW’s continued nonadherence and inability to follow the treatment plan and advice as well as the anticipated unfavorable outcome as a result of noncompliance.
Discharge notices
The Division of Workers’ Compensation (DOWC) created Desk Aid 15 to help physicians implement the discharge procedure. The template letter may be modified as long as it meets the elements of the Colorado Revised Statutes, summarized below.
The notice to the IW and insurer must:
- Give the reason for the discharge or refusal to treat.
- Offer to transfer the IW’s medical records to a new physician.
- Provide the effective date of the termination.
- Be sent to the IW and the insurer or self-insured employer via certified mail, return receipt requested, within three business days of the decision to discharge.
- When notified of the new treating physician, transfer the IW’s records to the new physician within seven calendar days.
The insurer has 15 calendar days and the initial right to select a new authorized treating physician for the IW if the IW still requires medical treatment and no other authorized physician is willing to provide treatment. After that time, the right of selection passes to the IW.
Billing
According to Rule 18-7(G)(3) effective 1/1/2020, the physician may bill the insurer for completing the requirements of Desk Aid 15, the notice of non-medical discharge to the IW and the insurer.
DOWC Z0754 Form completion $50
IWs who fail to return for treatment
When a physician recommends a return visit and the IW does not return, the physician is not abandoning the IW. The IW may voluntarily terminate the relationship by ignoring the advice to receive further treatment and choosing not to return. The IW’s failure to return effectively terminates the physician-IW relationship and the physician may consider this to be noncompliance on the part of the IW.
The physician need not formally notify the IW or the insurer under this circumstance unless the physician independently decides to discharge the IW for nonmedical reasons. The physician must exercise independent judgment on whether and when to discharge an IW.
In the case that the physician decides to discharge an IW, Pinnacol or the employer will send the IW a letter asking whether the IW requires additional medical treatment or is claiming permanent impairment. The letter is sent after the second missed medical appointment and advises the IW that failure to respond to the letter within 30 days will result in a final admission being filed with the DOWC and that the claim will be closed per Rule 7.
Conclusion
Although there may be many nonmedical reasons to discharge IWs, discharge can be achieved in a manner that ensures continuity of care and minimal disruption to treatment.
If you have any questions or need additional information, please contact Provider Relations at provider_management@pinnacol.com or 303-361-4945.
