Non-paying patient?

[CarabinerSD]

Strange circumstance but I have a patient seen at my clinic for the past few months due to widespread body pain with fibromyalgia (in hindsight also psych overlay such as h/o trauma, gastric bypass), maintained on low-dose Buprenorphine by another physician whom she's no longer seeing due to insurance changes. She was reasonable for the first few visits with continuation of Buprenorphine. However at the last visit, she requested for increase to Oxycodone 15mg for pain....and I obviously did not agree for fibro, said I would only continue Buprenorphine. She refused other non-opioid adjuncts. I offered her a referral for second opinion since she didn't want to follow-up with us again.

So it has been a month since her last visit. She calls today to say that she wasn't able to find a new pain provider. She wants our office to call in Buprenorphine to her pharmacy...only hiccup is that she didn't pay for the last office visit co-pay. Apparently her money is frozen and she can't access it (but can afford Buprenorphine???) So my dilemma here is a non-paying patient (who is also unlikely to pay for future visits) and she's requesting medication refill. Obviously the simple answer is no payment no service, but I don't want a complaint of patient abandonment. What's the best way to handle this situation? My staff is instructed to collect copay upfront at time of service, but not sure how this one slipped through...

---

Members don't see this ad.

 

[Agast]

Tell her she would need to make another office appointment in order for you to prescribe the buprenorphine, because you don’t call in narcotics. Then on day of office appointment collect the balance owed. If she refuses to make the appointment to get the prescription, the lack of pain medication is on her not you.

 

[chibadriver]

I always think a phone call with the patient addressing these issues (as you’ve laid out) is the best way to handle stuff like this. As a manner of personal practice, in my clinic opioids are contraindicated in FM. I inform new patients of my intent to wean them and lay it all out there before I write the first script. I also never fill the first visit and wait for UDS. Our opioid contract specifies payment of services as well as adherence to a comprehensive pain treatment program, including non-opioid treatments (engagement in trails of PT, counseling, etc) and regular UDS… makes it easy to weed out those patients who don’t want to commit to improving their wellness or otherwise don’t respect your professional opinion. I dunno.

 

[Orin]

I'd document the interaction well (alternatives offered, financial balance no paid, etc).

If you trust the patient, offer to provide a prescription of a lower dose of buprenorphine if feasible on a week to week basis for a wean as a gateway to allow you to exit graciously without an abrupt opioid cessation triggering an abandonment claim.

If you have a written policy to enforce, that's great, but with eRX and telehealth visits, the no calling in narcotics thing is a lot harder to hide behind. Policies and protocols do a good job of protecting a practice.

 

[painfree23]

Do you all UDS for t3, tramadol and bup?

 

[Gnarvin]

Do you all UDS for t3, tramadol and bup?

Yes

 

[Ducttape]

please don't do this over the phone. in fact, this is the appointment where I will purposefully walk in to the room while she is getting checked in so that there is another person to witness the interaction.

offer her follow up appointment since the last time you talked, she was seeking a different provider.

at that appointment, you do need to obtain a UDS, and let the patient know as she checks in that that will need to be done.


if she refuses to pay, then she cant be seen or prescribed. simple as that.

she will call the office and say she cant come in. your staff will replay and say that you are sorry, we cant treat her if she refuses to come in, and the doctor will consider prescribing a taper dose off the buprenorphine to reduce the risk of withdrawal. 1 patch at 1/2 strength, tell her she can wear it for a week. if it looks okay at the end of that week, if she wants to keep it on for 3 more days to ease withdrawal, she can...


if she does come in, since she is unhappy with her care, then decide if you want to continue to deal with this struggle. it will be a long term struggle. if you do, kudos to you, but good luck. if not, let her know that the fact she was going to seek someone else does show erosion in your relationship, and you will prescribe for 6 weeks but at the end, she is done and you will taper her off, unless she finds someone new. that will give her 6 weeks to find someone else....

 

[Ferrismonk]

Echo everything said above.

You are not abandoning her by telling her that prescriptions for controlled substances are only given at office visits. You are not abandoning her by allowing her to schedule an office visit at your first available opening. You are also not abandoning her by insisting on payment of her balance and any applicable copays before she is seen. It is not abandonment that even if she is seen in the office, you choose not to prescribe more narcotics. You are also not required to tell the patient your likely treatment plan before seeing the patient.

As I often say, "Your failure to plan is not my emergency".

By offering her the first available appointment to discuss her care is the only thing you need to do. I would also argue that the wean off of a long-acting buprenorphine patch is likely nil.

 

[NJPAIN]

Echo everything said above.

You are not abandoning her by telling her that prescriptions for controlled substances are only given at office visits. You are not abandoning her by allowing her to schedule an office visit at your first available opening. You are also not abandoning her by insisting on payment of her balance and any applicable copays before she is seen. It is not abandonment that even if she is seen in the office, you choose not to prescribe more narcotics. You are also not required to tell the patient your likely treatment plan before seeing the patient.

As I often say, "Your failure to plan is not my emergency".

By offering her the first available appointment to discuss her care is the only thing you need to do. I would also argue that the wean off of a long-acting buprenorphine patch is likely nil.

100% agree. However, you can do everything correctly and a jury of your “peers” will disagree. Classic tail wagging the dog.

 

[geauxg8rs]

100% agree. However, you can do everything correctly and a jury of your “peers” will disagree. Classic tail wagging the dog.

I used to worry about the “what if I do everything right and I get sued anyway?”

You can’t live that way. Do your job right and leave the worries and what if’s behind

 

[NJPAIN]

I used to worry about the “what if I do everything right and I get sued anyway?”

You can’t live that way. Do your job right and leave the worries and what if’s behind

Ideally, yes. Dealing with opioids in the current climate is an entirely different animal. The recent 7 mil verdict is a sign of what’s ahead. A “lives matter” movement.

 

[lobelsteve]

I used to worry about the “what if I do everything right and I get sued anyway?”

You can’t live that way. Do your job right and leave the worries and what if’s behind

That's why we have insurance.

 

[paindoc007]

That's why we have insurance.

Its sure nice to live in a state with a cap on pain and suffering..

 

[painfree23]

Its sure nice to live in a state with a cap on pain and suffering..

Texas?

 

[Status Sciaticus]

Its sure nice to live in a state with a cap on pain and suffering..

put everything in your children/spouses/parents name? Stash it in an overseas account and declare bankruptcy if you get screwed over?