SO I messed up........

[futuredo32]

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Long story short as possible. I have been trying to get paneled with Health insurance XYZ for eons. I thought it was coming and my contact from there said I could back bill and he would fast track me for approval. I prematurely started seeing patients with this insurance (bad move I KNOW NOW) The ball has been dropped for years, my biller said at one point it was all set then no, then I send all the stuff to Health Insurance XYZ and my contact doesn't receive it. SO............. current dilemma............. I would like to keep trying with XYZ insurance and I think scanning the documents to the contact for this insurer will be the only way he gets them, I have faxed mailed, priority mailed with tracking, and he never gets my stuff. but I don't want to keep seeing patients for free until that happens and truthfully I don't want 1 as a patient. She has a therapist and has a great rapport with her therapist she has bipolar disorder and severe borderline personality disorder. She is VERY demanding and sends me a text oh by the way I have had three serious cutting events over the past two weeks and I want to do a phone consult during my therapy appointment on this date at this time so we are all on the same page- I had another patient scheduled, couldn't accommodate and I tell ALL of my patients they can call ANY time if things are not going well and encourage them to do so.She is a patient in particular I really DO NOT want as a patient. I was thinking the best and most honest way to handle this was as follows-
Professional letter head, Dear Jane Doe,
I sincerely apologize but there was a miscommunication between your insurance carrier and myself and I believed I was able to accept XYZ insurance but that isn't the case due to a misunderstanding. I will not bill you for past visits because this was my error. I will provide psychiatric care to you for the next 30 days at no cost to you and following that you can either call the number on the back of your insurance card to find a psychiatrist who does accept xyz health or I can see you for a full fee cash visit. (And I pray to God she finds someone else). Please let me know which option you choose . It has been a pleasure having you as a patient.
. Sincerely,
I don't know how else to legally handle this. I will send it registered mail. I am not discharging her as a patient, just saying she will have to pay full fee . She will NEVER be stable. Lesson learned, I was stupid. No need to bash me, I get it. But moving on.................... The other two patients with this insurance don't have appointments for a few months and I should be able to get paneled by then, but I truly don't want to see her anymore except for the obligatory 30 days. She texts for an appointment, doesn't get back to me for weeks and then the appointment is gone despite several texts to her stating she needs to respond promptly because I cant hold the time spot for her. She says her phone doesn't work and she can only text..........
Its more that I want to discharge her as a patient than anything.

 

[Jules A]

If you don't want to see her discharge her by giving written notice, continue current meds 30 days and include a list of local providers. You don't need to include a novella size list of reasons. And unless you are a therapist maybe consider losing this from your repertoire:

"I tell ALL of my patients they can call ANY time if things are not going well and encourage them to do so"

 

[hamstergang]

I see 2 things that need to be done:

1) You should set boundaries and maintain them.

2) Look up the specifics for the licensing board in your state, and follow those for discharging this patient in order to avoid abandonment (typically sending it certified mail, providing refills and emergency coverage for 30 days, including referrals elsewhere, and explaining how to obtain medical records). Include in that the option to see you as a cash patient if you want.

 

[PikminOC]

I dont think op wants her even as a cash pt..

 

[thoffen]

You can't abandon her, but legally you certainly can terminate her care. In most cases it is sufficient to provide referral and maintain the treatment relationship for 30 days.

The better question is ethical. Are you potentially doing harm by this or by not providing the whole reason for the transition (you don't want to do the treatment she is requesting)?

 

[medicool]

You seem to have a conflict whether to continue to see her regardless of the Insurance issue. I personally don't think terminating her for insurance (or lack of it) might look ideal if she is not given the chance to choose to pay cash price. State your fee for a cash visit that will be charged henceforth for your visits and give her the option to find a new MD that will accept her insurance if she wants to. You may consider including in the content of the letter that if you don't hear from her in X days, you will have considered that she has decided to seek care elsewhere. Borderline patients thrive on attention and chaos. I know that you want to be there for your patients and it is a good quality. But sooner than later your texting will be a cause of concern due to patients have a sense of dependency for anything and everything without having a chance to employ skills they learn in therapy. It might also open you up to liability if a patient texts you at 2 am and does something while you are asleep. Just my thoughts.

 

[futuredo32]

I dont think op wants her even as a cash pt..

I don't want her as a cash patient. I don't want her as a patient period.
I will give her the option to pay cash so it isn't abandonment. NOT many locally take her insurance, my psychiatrists office nixed a ton of insurances this year and my shrink/therapist said that he just tells them to call the number on the back of their insurance card to find someone else. I will do the same.
I use my cell for work. I have a SMALL private practice and because it's a cell phone, they know they can text.
.A lot of my patients are moving out of state for grad school or jobs (college town) and I am NOT looking to replace them currently. For a few reasons I don't want to work many hours this summer. I am not taking new patients and cramming the rest of the patients I have into two days a week for the summer. I have a locums job for two weekends a month that pays amazingly and a decent once a week job for med management and new evals.

I started private practice sharing a suite with one of my former attendings and one other psychiatrist. There was no receptionist there. I don't know if they had answering services for themselves. They did their own scheduling, just like I am doing now. I don't know how to get them to call instead of text? It's actually more convenient for me if they text if they are just rescheduling or need refills.
I have one rather new patient and he was calling or texting daily, sometimes multiple times a day. With him I DID explain when it was appropriate to call or text, the rest understand and don't need it spelled out for them. I have prevented a lot of needless hospitalizations by letting them call me. During residency there was an answering service that would call the residents if one of the patients called and we HAD to call the patients back in 10 min or we could have been terminated from the program.......... I guess this is kinda where I got this. We had to have our cell phones on us all the time unless we were on vacation and then another resident would take calls from patients.
For those that have private practices, do you just say call 911 if you have a problem?

 

[futuredo32]

You can't abandon her, but legally you certainly can terminate her care. In most cases it is sufficient to provide referral and maintain the treatment relationship for 30 days.

The better question is ethical. Are you potentially doing harm by this or by not providing the whole reason for the transition (you don't want to do the treatment she is requesting)?

It IS true that I am not a provider of her insurance and my full fees are high I cant imagine her paying cash.. I think it's less harmful than saying I don't want to see you because you are demanding, imagine tons of side effects to most medications, had serious issues for weeks and didn't say a word to me, and you are definitely a pain to have as a patient and a potential liability. 🙂. I haven't seen her for long, she DOES have a therapist she has seen for years which is good. I could say it nicer but she has severe borderline personality disorder so I think it would harm her to even say these things nicely. I know in Michigan you cant terminate care if the patient is unstable, I truly don't see her EVER being stable. I am technically not terminating the treatment relationship, I am saying she has to pay cash if she wants to continue care with me beyond 30 days because I truly am not paneled on her insurance (Thank God)

 

[futuredo32]

If you don't want to see her discharge her by giving written notice, continue current meds 30 days and include a list of local providers. You don't need to include a novella size list of reasons. And unless you are a therapist maybe consider losing this from your repertoire:

"I tell ALL of my patients they can call ANY time if things are not going well and encourage them to do so"

Most of my patients are therapy patients.

 

[futuredo32]

You seem to have a conflict whether to continue to see her regardless of the Insurance issue. I personally don't think terminating her for insurance (or lack of it) might look ideal if she is not given the chance to choose to pay cash price. State your fee for a cash visit that will be charged henceforth for your visits and give her the option to find a new MD that will accept her insurance if she wants to. You may consider including in the content of the letter that if you don't hear from her in X days, you will have considered that she has decided to seek care elsewhere. Borderline patients thrive on attention and chaos. I know that you want to be there for your patients and it is a good quality. But sooner than later your texting will be a cause of concern due to patients have a sense of dependency for anything and everything without having a chance to employ skills they learn in therapy. It might also open you up to liability if a patient texts you at 2 am and does something while you are asleep. Just my thoughts.

I totally agree about the texts. It IS more convenient for me if they text to ask for meds but otherwise I would prefer a call but it's a cell phone. They text even many elderly patients text.

 

[clausewitz2]

I totally agree about the texts. It IS more convenient for me if they text to ask for meds but otherwise I would prefer a call but it's a cell phone. They text even many elderly patients text.

If they text you about something that you would really rather have them call about, there is a very simple response that should address your problem:

"We should discuss this by phone. Would [ insert preferred time here] work for you?"

Just because they text for scheduling and refills does not mean you have to permit texting about literally everything. I would say this is especially true for therapy patients, because otherwise your therapeutic relationship is sort of built on the knowledge that you are at their beck and call. Also it risks turning you into a human safety blanket instead of a real person with real limitations.

 

[futuredo32]

[QUOTE="clausewitz2, post: 1

Just because they text for scheduling and refills does not mean you have to permit texting about l is especially true for therapy pa
[QUOTE, member: 2278

"We should discuss this by phone. Would [ insert preferred time here] work for you?"

Just because they text for scheduling and refills does not mean you have to permit texting about literally everything. I would say this is especially true for therapy patients, because otherwise your therapeutic relationship is sort of built on the knowledge that you are at their beck and call. Also it risks turning you into a human safety blanket instead of a real person with real limitations.[/QUOTE]
It's more the med management patients . i did my first 2 years of residency in this area and it's an affluent area. As residents we were to call patients within 10 minutes if they called the answering service and not doing so was reason for dismissal. Patients in this area are pretty demanding. But i think the reply to texts is a good suggestion but I will call them back rather than scheduling a time via text. So patient whose insurance i don't take wants a med appointment next week. Do I send her the letter now or wait a week tell her and then send? I thought she'd be in the partial program longer. I don't want to be cruel about it. She really doesn't seem to have any attachment to me . I have only seen her a few times.

 

[MedMan80]

I had a BPD patient during residency who would no-show multiple times and other times would show up, would always take the earliest appointments (causing me to get up at 6AM to be at work by then), for residency I just sucked it up, but as an attending or even a Fellow the kind of behavior is unacceptable. Address the texting issue, an emergency number to call at times of crisis is one thing but to book your appointments and request refills via text is ridiculous, set firm boundaries. Also you may want to address your own counter-transferances as to why you don't want her as a patient anymore, it seems its because she is high liability, difficult to work with, demanding, but so are so many of our patients. I do echo what others are saying, if you truly don't want to see her for the reasons i mentioned before, look up your state patient termination rules and follow them..

 

[futuredo32]

My full fee is $175. I highly doubt she can or will pay that. Problem solved. I HAVE started setting firmer boundaries and appreciated that input, not easy for me to do but I have done it. Having patients request refills via text IS much easier for me ,so that is fine otherwise it leads to a five minute plus conversation. I don't know her well enough to know how well she could handle me really further disclosing further details of why she isn't a great patient, but I don't currently take her insurance and I am not seeing her or any other patients gratis. She is REALLY guarded and has been from day one. I can usually form a really good rapport with patients easily but not her. She made it clear that I was for meds only and her therapist was the one who was the important one.....

 

[Ahamis]

"It is true that one can try too hard, and try to do too much, and even with the best of intentions, such good efforts can rebound to cause harm to the clinician. Clinicians need to learn to set limits not only on patients, but on themselves. These limits involve not only standard aspects of malpractice, such as not having sex with patients, but also involve accepting that one should put a limit to one's attempts to help a patient. For instance, in a non-emergency setting, a clinician is under no ethical, legal, or moral obligation to treat a particular patient. In the first interview, a clinician may have a feeling that the treatment with that patient will not go well, or that there is a problematic transference.

For these reasons, or for any other reason, it is perfectly legitimate for the clinician to decline to treat the patient. After the first appointment, if a patient's treatment has begun, there are limitations to what clinicians can do due to the legal inability to abandon patients. But before a patient-doctor relationship has been established, either via prescription of medications or a formal agreement to treat, a clinician can decide not to treat a patient. Further, even after treatment has begun, a clinician may decide to transfer the patient to the care of another treater after some failed treatment trials, or a clinician may ask a patient to agree to termination of treatment.

All these limitations are reasonable, based on a clinician taking into account not only the patient's interests, but the clinicians own interest in providing care to others in a way that will not lead to legal complaints. Some of these ideas can be referred to as "defensive medicine" in a pejorative manner, and it is true that one can practice over-defensively. The point here is that some level of attention to legal risks and to self-preservation is reasonable in clinical practice." N. Ghaemi