Articles

Medical practices are often challenged with patients who either decline, cancel, or no-show recommended tests, imaging, referrals, and follow-up appointments. In these situations, communication is essential to promoting quality patient care and outcomes while reducing the likelihood of potential liability. When ordering a test or referral, it is important to have a conversation with the patient to explain the need for the recommended test or treatment, obtain informed consent if applicable, and consider having the patient sign an informed refusal form if the patient declines. All communication with the patient should be documented in the medical record.

Failure to obtain recommended testing or treatment could lead to a delay in diagnosis or treatment, progression of disease, or poor outcome, resulting in potential liability. Implementing risk-based follow-up and tracking helps to ensure continuity of care and better health outcomes. It is important for practices to track orders, referrals, and results. This includes patient no-shows, cancellations, and refusals of orders by the patient. Any results or actions taken should be communicated to the ordering provider, as well as any referring provider, and documented in the medical record.

Declined testing, missed appointments, and uncompleted referrals are not merely administrative issues but also represent potential clinical risks. Patients may decline recommended tests, imaging, or specialist consultations for a variety of reasons, including high-deductible health plans, limited understanding of the potential consequences of non-compliance, transportation barriers, low health literacy, and fear or anxiety related to testing. It is essential that the ordering provider clearly communicates the clinical necessity of the recommended test or treatment, along with the potential risks associated with failure to follow through.

The implementation of follow-up procedures and maintenance of sufficient documentation promote continuity of care for the patient and mitigate the risk of potential liability for the provider and practice. Generally, the efforts required to contact the patient are commensurate with the patient’s medical condition and potential consequences of missed treatment. Providers should contact patients directly for serious conditions or immediate action. Otherwise, clinical staff can be directed by the provider to communicate the action(s) to be taken. If the patient misses the initial consultation, send a letter to the referring provider notifying them of the patient’s missed appointment and whether the referral will remain open or will be closed.

There is no magic number for attempts to contact patients in need of follow-up care. Courts generally apply a reasonableness standard in these cases. Communication with patients who miss appointments or fail to complete recommended tests or referrals should be managed based on their clinical risk. Like any other patient communication, document all attempts to contact the patient (and any consulting provider).

Low risk of adverse consequences may require minimal follow-up, while high-risk patients require proactive outreach and rescheduling efforts to mitigate potential adverse outcomes. After appropriate discussion with the patient, and the patient refuses, it is recommended that you have the patient sign an Informed Refusal Form. SVMIC has a sample form on the Vantage website.

If a patient is at minimal risk, (e.g. a well checkup or referral for elective cosmetic procedure), a documented phone call evidencing patient contact or first-class letter outlining the consequences of failure to receive treatment in a timely manner may be adequate.

For patients at moderate risk, such as those who need ongoing monitoring or treatment (e.g. well-controlled chronic conditions), a more concerted effort may be required. Two documented phone call attempts and a first-class letter outlining the consequences of failure to receive needed treatment in a timely manner are recommended. If the letter is returned undeliverable, verify that the address on the letter corresponds with the address given by the patient and if a new address is provided by the post office, resend the letter to the new address and note this in the medical record. 

For patients at high risk, (e.g. patient with grave condition or serious diagnostic results requiring additional testing or treatment), two documented phone call attempts and a first-class letter along with a certified letter outlining the consequences of failure to receive needed treatment in a timely manner should be attempted. As previously noted, providers should contact patients directly for serious conditions or immediate action.  If the condition is emergent or potentially life-threatening, it may be reasonable to contact the patient’s emergency contact on file. In those instances, the practice may need to consider contacting local law enforcement for a wellness check if they are unable to reach the patient’s emergency contact. 

For moderate-risk and high-risk patient scenarios, the ordering provider should be notified when attempts to reach the patient have been unsuccessful. The decision whether to end attempts to contact a patient, particularly in high-risk situations, should be made by the provider based on their professional judgment.  

Letters should be in clear, reader-friendly language at a fourth grade reading level in order to be understandable and in compliance with Limited-English Proficiency Guidelines. Template letters are acceptable as a starting point but should be individualized to the patient’s condition, treatment plan, and potential consequences of failure to follow orders. Include or scan  a copy of any letter (and returned envelope if applicable) in the patient’s medical record.

If a patient repeatedly does not return to the office after appropriate contact attempts have been made, the treating provider may take steps to discharge the patient from the medical practice. Policyholders may login to SVMIC’s Vantage portal for additional resources or call 800-342-2239   to consult an SVMIC Risk or Claims attorney for assistance.