Fam Pract Manag. 1999 Sep;06(8):57-58.

Patient-discharge letter


One of our patients is abusing her medication and calling in her own prescriptions. What information should we include in a letter discharging this patient from our practice?


The letter should first explain why the care is being withdrawn and then should recommend that the patient find another medical practice. The recommendation should be accompanied by phone numbers or addresses of other practices. The letter should state that for a defined period of time — two weeks to one month to avoid the charge of “abandonment” — the current physician will attend to the patient's medical problems. The letter should also explain that the practice will forward the patient's medical records once a new physician is selected.

If your practice has nonphysician practitioners or many physicians, it is best to have all providers sign the letter. This leaves no doubt that the patient is being discharged from the entire practice and not just from the care of one particular physician.

As you prepare this letter, you should also check with the patient's health plan and any applicable state laws to find out whether there are specific procedures that you should follow.

Assignment agreements


Can an insurance plan legally refuse to send payment to a nonparticipating physician when that physician has an assignment-of-benefits agreement on file?


Laws about assignment of health insurance benefits differ from state to state, and policies about internal assignment of benefits differ among insurance companies. While most payers will pay the nonparticipating physician if the patient signs an assignment-of-benefits agreement, some payers always pay the patient.

In the absence of a participation agreement with a physician or an applicable state law, the insurance company has a contract with the patient, not with the physician, and it may simply choose to honor the terms of that agreement.

Your practice should have a detailed, financial policy statement that makes it clear to all parties that the patient is responsible for payment in full at the time of service unless the physician participates in the patient's health insurance plan. All of your patients should read and sign this statement. If you don't participate with a patient's plan and that plan will not pay you directly, his or her understanding of and compliance with this policy is doubly important.

You should be aware of the laws in your state that cover assignment of health-insurance benefits. If you believe there's a violation of state law in your situation, you should contact your state insurance commission. Keep in mind, however, that some insurance companies are designated as nonprofit entities and do not answer to state insurance commissions.

Stark regulations


I would like to set up Ultrasound in my rural office, but I'm uncertain that I could fully support my radiology technician with the amount of work I have. Therefore, I would like to share my expenses with a local surgeon who is also interested. We're both independent physicians. Would we run into problems with Stark regulations in this endeavor?


I'm afraid you would. Ultrasound is listed as one of the “designated health services” in the Stark regulations. The proposed regulations, which are the only guides the courts have at this time, reflect HCFA's interpretation that Stark encompasses any entity that provides designated health services, without qualifications or limits. Individual physicians or groups of physicians are considered “entities” when they refer patients to themselves or among themselves. The only allowable exceptions apply to group practices, but your financial arrangement described above clearly would not meet the criteria for this.

The regulations also state that designated health services must be billed by the physician performing or supervising the services, by the group practice, or by an entity wholly owned by the physician or group practice. Therefore, there would be no allowable Medicare, Medicaid, CHAMPUS or Veterans Affairs reimbursement possible under the arrangement you propose.

Perhaps it would be better to seek half-time employment for your radiology technician in some other office, and employ the tech under a job-share arrangement.

* Denotes member of FP Assist, the AAFP's online clearinghouse for consultants and attorneys.


Copyright © 1999 by the American Academy of Family Physicians.
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