Patient Dismissals: Why, When and How

Just as the doo-wop song proclaims, breaking up is hard to do.

When you must sever the patient-provider relationship, however, you must first thoughtfully consider potential risk and act in accordance with ethical standards of treatment. In addition to state laws and any Dental Practice Act requirements, ADA’s Code of Ethics can guide your decision. Your local dental association should offer guidance on the laws regarding treatment within your state.

The Dentists Insurance Company policyholders also have access to specialized expertise through TDIC’s Risk Management Advice Line.

Recent calls to the Advice Line showcase the unique complexities of dismissing patients prior to completion of treatment.

Case Study: A Noncompliant Orthodontic Patient

Advice Line analysts received a call from an orthodontist regarding a minor patient who was noncompliant with treatment recommendations. The patient was breaking brackets by eating hard foods, failing multiple appointments and otherwise showing up late. The patient’s noncompliance had already caused significant treatment delays.

The orthodontist felt the best approach would be to call the patient’s parents into the office to discuss these concerns and determine if the case could get back on track or if treatment should be discontinued. Upon her arrival at the next appointment, the patient’s mother was asked to wear a mask while in the office in alignment with COVID-19 protocols.

The mother became confrontational and refused to comply, stating she would never wear a mask while in the office. The orthodontist attempted to explain the rationale for the requirement, but the mother’s position remained unchanged. Rather than press the matter further, the orthodontist advised the mother she would need to leave if she refused to comply with the mask mandate but agreed to contact her to discuss the matter later that day by phone. She reluctantly agreed to this compromise, but when the phone call took place that evening, the mother was less than pleasant.

Despite the communication challenges, the treating orthodontist explained that when the patient was inconsistent with appointments and noncompliant, treatment could be delayed.

The mother refused to accept responsibility for the delay in her son’s case and instead attributed the delay to the office closure during the pandemic. The orthodontist realized that he was at risk of losing his composure, so he ended the call and simply requested that they please keep all future appointments and be on time. He also provided a reminder about the acceptable foods to eat to avoid bracket breakage.

During their phone conversation, the orthodontist avoided revisiting the mother’s failure to comply with the state mandate for wearing a mask during office visits. The patient was on time when he presented to the next appointment, however, the mother again refused to wear a mask. The office manager informed her that wearing a mask was not optional and asked the parent to wait outside during her son’s appointment. The mother hesitantly left and waited in her car. However, on her way out, she became more combative by slamming the door and shouting profanities directed at the dentist and staff.

After reviewing the case, the Risk Management analyst advised the orthodontist that he should consider patient dismissal. Even though the patient was still receiving treatment, there were adequate grounds for dismissal due to the patient’s noncompliance and the parent’s escalating abrasive treatment of the orthodontist and staff members. The analyst reminded the orthodontist to fully document the interactions with the mother in the patient file. They also guided the orthodontist in composing a letter to the patient providing a 30-day notice of dismissal, which allowed reasonable time for the patient’s parents to find a new orthodontist.

Case Study: A Demand for Refund or Refinement

Another call received by TDIC’s Advice Line involved an adult patient nearing the completion of Invisalign treatment. The orthodontist felt the treatment was going well up to that point, but when the orthodontist was ready to deliver the retainer, the patient complained about the case outcome.

Growing increasingly hostile and rude when communicating with staff, the patient demanded additional refinements and, if her demands weren’t met, a full refund of the treatment fee of $7,000. After the orthodontist reviewed the patient’s account with the front office, it became apparent that payment had not been made to the account in more than a year.

When the orthodontist informed the patient of the past-due balance on the account and lack of recent payments, the patient argued that she had previously paid the balance of her account in full. There had been some changes to the front office staff during the patient’s treatment, and she claimed she had given a large cash payment to a staff member who was no longer employed there. The staff inquired if she had a receipt documenting this large payment, and the patient stated that she would try to locate it.

The patient argued that the office’s failure to ask her for payment over the past year or mentioning a balance due on her account was further proof that her account had been paid in full. The orthodontist and office staff did not have a satisfactory answer as to why the patient was allowed to go for an extended amount of time without being asked for a payment.

When asked by the Risk Management analyst if a collections protocol was in place, the orthodontist explained that their office typically set the patients up with payment plans.

The analyst explained that if the patient was unable to present a receipt and the orthodontist was unable to prove without a doubt that a cash payment had not been paid, then it would be best to consider the patient’s request for refinement. He was advised to focus on treatment completion in the meantime until the patient was able to provide a receipt for the cash payment, as refunding the $7,000 without proof it had ever been paid to the office appeared to be an unreasonable expectation

To Dismiss or Not To Dismiss?

Unsure whether to pursue dismissal? Some common and acceptable indicators that a dentist may need to consider dismissing a patient from care are:

• The patient is noncompliant with treatment recommendations or attempts to dictate treatment.
• The patient tries to take dental care into their own hands through actions such as attempting to make adjustments to a prosthesis or orthodontic appliance.
• The patient has not been in for an extended amount of time. Consider dismissal if the patient has not been seen in 24 months.
• The patient demonstrates abrasive behavior or makes inappropriate comments to the dental team or other patients.

Patients may not be dismissed or discriminated against based on limited English proficiency or status within a protected category under federal or state legislation, including race, color, national origin, sex, disability and age.

When dismissing a patient, provide a formal written notice stating that you are withdrawing care and requiring the patient to find another provider. Mail the confidential written notice to the patient by both first-class and certified mail with a return receipt requested. Risk Management analysts can provide guidance on the dismissal process and letters along with resources to protect dentists before finalizing the separation.

Patients in Midtreatment

In situations where orthodontic patients elect to discontinue treatment and establish care elsewhere or there is a behavioral problem with a patient midtreatment, automatic dismissal is not recommended. Allowing the patient to remain in appliances without ensuring the patient will be monitored could expose you to liability risks, such as patient abandonment. Furthermore, there is potential for the patient to increase the likelihood of relapse, broken brackets, loose wires, decay, decalcification, etc.

If the patient dismisses themselves or if the dismissal is a last resort due to nonpayment, then the treating orthodontist should offer to remove the appliances and provide a retainer to maintain existing tooth positions and any orthodontic tooth movement achieved if appropriate.

If you have questions or concerns about a possible dismissal, seek guidance before moving forward. Policyholders benefit from access to TDIC’s Risk Management Advice Line. Remember that careful patient case selection, thorough or complete documentation and clear communication are essential to minimizing your risks.

TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 1.877.269.8844.