Uncharted Territory: What do you do when these happen?

[whopper]

1) You run your own private practice. Your patient requests a refund for whatever reason (e.g. overpaid, insurance company didn't cover so they paid in the meantime but then the insurance company comes through).
So now on your tax records this patient's name is there smack in the face for non-HIPAA authorized person's to see and your accountant asks "who is this person and why did you write them a business check?"

What do you do?

2) Patient schedules an appointment, does all the required things (e.g. signs new patient forms, gives her insurance information, shows up for the first appointment), but it turns out she has a guardian, never told you she has a guardian and you find out after the fact that you've seen her a few times, wrote a few notes and never with the guardians permission?

What do you do?

3) Patient has a gun, frequently abuses alcohol, frequently is inebriated while on alcohol, known to play with his guns while drunk, and won't get rid of his guns. Also his desire to get sober is somewhere between non-existent to "I'm only doing this cause if I don't my wife is leaving me."

What do you do?

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[Old&InTheWay]

1) I think a lawyer or accountant counts as a "business associate" under HIPAA and they have to comply with HIPAA as if they were a Covered Entity.

2) Talk to the guardian, let them know, and see if they consent for you to continue seeing the patient.

3) This one is hard. Not sure you can do much more than document your assessment speaking to the degree to which the patient's drinking and his risky behavior while drinking are modifiable by psychiatric treatment. Continue to engage patient in MI and assess for SI at every visit.

 

[Sushirolls]

1) I write them a check and label it as refund. Happens. No big deal. I log it in my quick books as Negative income so its top line, and put it in the category of patient checks/cash. Not a big issue. If its to the insurance company, I put it down as top line item also as a Negative income but for that insurance company. Is it really so different as depositing the check for a copay a patient conversely writes?

2) Guardianship really depends on each state for how much power they have - or don't. State dependent, shapes response.

3) No different then say drinking and driving? Or drinking and boating? Or operating a saw in the garage while drinking. Document your concerns. See if they will grant permission to talk with other family members to assist in gun removal. If not you've done your part. If they are saying SI with guns, then do the usual admit pending on local state laws.

 

[calvnandhobbs68]

Yeah for 3)...can't predict everything and I'm sure we'd all be surprised how many people play with guns while drunk. Unless you're in some state where he might have some sort of firearm restriction "red flag law" due to his mental health concerns (in which case you might want to get familiar with if you have some duty to report this to law enforcement), I'd agree with the two above to just document this discussion every visit (firearm safety, requesting he have someone else hold onto the firearms, substance use risks and self harm, recommending abstaining from alcohol or engaging in substance use treatment). This is obviously assuming he's not giving off any persistent SI vibe and these are purely alcohol related episodes. If you're really concerned you could play the "I'm concerned about your safety with guns for now and I think we need to call a friend/family member today in the office to hold onto your guns for now or else I might have to send you involuntarily to the ER" but that tends to only play once and you risk killing all your rapport obviously.

I mean obviously if he shows up drunk to an appointment or something and talks about playing with his guns, I'm sending his butt to the ER to sober up but otherwise you can't be held responsible for everything that happens outside your office

 

[whopper]

I already dealt with all of the above. Just throwing it as food for thought.

FYI, California is the only state in the country that has a legal option of taking guns away from those who showed dangerous behavior related to mental illness but aren't yet crossing the line as an involuntary hold. No other state has it. So if a guy is drunk and playing around with his guns, you can only pretty much call the police and that's it and keep your fingers crossed.

 

[Sushirolls]

I already dealt with all of the above. Just throwing it as food for thought.

FYI, California is the only state in the country that has a legal option of taking guns away from those who showed dangerous behavior related to mental illness but aren't yet crossing the line as an involuntary hold. No other state has it. So if a guy is drunk and playing around with his guns, you can only pretty much call the police and that's it and keep your fingers crossed.

I get that you posted these to spice up learning potential, but if you are going to allude to already resolving these issues, please post up what you opted to do.

 

[Candidate2017]

1) I think a lawyer or accountant counts as a "business associate" under HIPAA and they have to comply with HIPAA as if they were a Covered Entity.

2) Talk to the guardian, let them know, and see if they consent for you to continue seeing the patient.

3) This one is hard. Not sure you can do much more than document your assessment speaking to the degree to which the patient's drinking and his risky behavior while drinking are modifiable by psychiatric treatment. Continue to engage patient in MI and assess for SI at every visit.

Agree with 1 and 2.

For 3, I'd DC the patient. Outpatient is not inpatient. I can't, and don't want to, form a long term relationship with people who don't want to work with me. He can continue to perpetuate the lie to his wife for much cheaper: refer to AA and LCSW therapist.

Also, a grown adult who continues to play with guns while drunk and knowingly puts others' lives at danger is morally reprehensible.

Or perhaps he is just narcissistic or histrionic, and this is his means of taking power back from you. "F you fancy psychiatrist, I'm bringing this up to show you have no agency over me, but I'm really displacing my feelings about my wife."

 

[Sushirolls]

Or its someone who enjoys their guns even when not inebriated, and their handling of guns isn't correlated to an intoxicated state and has no extra mental health weight to it. We didn't get enough from the excerpt to know enough about this patient and if there is significance of gun handling when intoxicated and mood state at the time.

What I'm trying to get at, people can be drunk and still take their pills just fine and they won't be at risk of overdosing.
People can be drunk and clean a gun, and won't be at risk of a self inflicted GSW with suicidal intent.
But yet, a person who is drunk may be more risk to drive their vehicle into something for expressed suicidal intent - because that is their default plan.

Although guns actuarially carry a higher risk of SI, *cultural competence* warrants a greater understanding of guns, of gun owners. There are plenty of people who own more guns they can feasibly count and attempting something like having their guns removed would be tantamount a full days worth of work for the local county sheriff to remove them all and laughable to even consider the feat - but the real threat to safety for that patient perhaps is a rope and the garage.

 

[KillCancer]

I already dealt with all of the above. Just throwing it as food for thought.

FYI, California is the only state in the country that has a legal option of taking guns away from those who showed dangerous behavior related to mental illness but aren't yet crossing the line as an involuntary hold. No other state has it. So if a guy is drunk and playing around with his guns, you can only pretty much call the police and that's it and keep your fingers crossed.

How would you implement "taking guns away?" Who would you call to do this?

 

[WisNeuro]

How would you implement "taking guns away?" Who would you call to do this?

Depends if your state has a red flag law, and how they set it up.

 

[clausewitz2]

How would you implement "taking guns away?" Who would you call to do this?

In my state you call the state police as they ostensibly maintain the database. This is...sometimes effective.