Fam Pract Manag. 2005 May;12(5):88.

Can no-pays get the heave-ho?


Can I discharge a patient for not paying his or her bills?


Physicians are not obligated to continue providing care to patients who do not pay their bills, with the exception of patients who are under close medical supervision. If you've documented your efforts to collect what the patient owes, you may discharge the patient.

Your contract with the patient's insurer may dictate the procedures you should follow, so be sure to consult it. Generally it is acceptable to send the patient a letter stating that you are withdrawing from the patient's care effective on a specific date (typically 30 days from the letter's date). The letter should inform the patient that you will provide only emergency care for him or her until that date and offer to forward the patient's medical record, or a summary, to the physician of his or her choice.

Send the letter via certified mail so that you will receive a receipt of delivery. File a copy of the letter, along with the postal service's receipt of delivery, in the patient's chart.

Releasing deceased patients' records


One of my patients died suddenly at age 66. His family did not request an autopsy but would like to schedule a meeting with me to review his records. What sort of authorization do I need to release this information?


You may release the information to the executor of the patient's estate if you have received a written request to do so. The Department of Health and Human Services Office of Civil Rights specifically recognizes that this release of information is appropriate under the privacy restrictions of the Health Insurance Portability and Accountability Act (HIPAA).

You may also release the information to the physician of the next of kin for treatment purposes if you have received a written request from that physician. The treating physician would then be bound by HIPAA's “minimum necessary” rule in his or her use of that information.

Because state laws differ and frequently vary from federal law, contact your local attorney and verify compliance prior to releasing information.

Open access in an academic setting


I would like advice about how groups of academic physicians with 30-percent to 40-percent clinical time have handled open access. We have had a same-day side in our clinic for three years and it has been a success in some ways, but we are concerned about the loss of continuity that has resulted.


I have seen some academic models where physicians are required to be present in the clinic 50 percent of every day, preferably in the afternoon. With the correct panel size, these groups have been extremely successful. In addition, I've seen some academic environments designed around continuity to a team of physicians. These groups, again assuming the correct panel size, also have been successful. Academic groups that use a carve-out model can be successful as well with a commitment to meticulous measurement and flexibility.

There are inherent difficulties with carve-out models that just have to be accepted. For one, a carve-out will lengthen the waiting time for non-same-day appointments. Reducing the backlog in that queue can mitigate some of this problem. A carve-out also requires an accurate prediction of same-day needs vs. non-same-day needs. If you overestimate same-day needs, then unused capacity results; if you underestimate same-day needs, then overflow results. The longer the waiting time for non-same-day appointments, the higher the likelihood of no-shows, and the higher the likelihood that some patients, who don't meet the criteria for same-day may try to “cut in line.” This creates an increased tension for another appointment line (same-week) and increased practice walk-ins.

Your practice, with a “same-day side” and “non-same-day side,” is just a carve-out in another form. I would recommend that you decide whether you want to value continuity to the individual or continuity to a team of providers. If you choose continuity to the individual, merge the same-day and non-same-day groups so that physicians see their own patients.


Copyright © 2005 by the American Academy of Family Physicians.
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