Can a doctor in a Medicaid-funded nursing home in California terminate a doctor-patient relationship?

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Can a doctor in a Medicaid-funded nursing home in California terminate a doctor-patient relationship?

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The doctor who services the nursing home where my brother has resided for 3yrs sent us a letter stating he is severing the doctor-patient relationship. Doctor refuses to return calls. I contacted the local ombudsman & we had a 3way call w/Dir of Nursing. They both said the doctor has a right to sever the relationship & that my brother can go to any doctor he chooses outside. If that were practical, he wouldn't be in the nursing home in the 1st place. My brother is on a number of life-saving medications; if he doesn't have these it could result in serious outcomes including heart attack, death, etc.

My research shows if a nursing home receives fed funding, they are req'd to provide medical care in the facility which I pointed out to them. The Nursing Dir then suggested I contact Med Rec to obtain the names of other doctors that visit the facility (I don't think there are any). We rec'd this ltr 10 days after I asked the facility & the doctor to explain discrepancies between what the doctor billed Medicare & what the facility's medical records show. Doctor billed Medicare for doctor/PA visits 2-3 times a week for an "extended complex consultation". This particular physician group specializes in nursing homes; they have 3 doctors & 3 PAs to service 13 other homes w/ almost 1,500 patients.

My brother doesn't recall seeing the doctor or his PA that often during the month in question. I have tried to get records from the record department for months now but I am being stone-walled. While my brother is not an easy patient, this feels vindictive - if not illegal. Has this happened to anyone else? If so, what did you do? We cannot afford a private attorney. Any help would be appreciated. Thanks.

Care Decisions Elder Law Skilled Nursing Facility

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"...my brother is not an easy patient..."

Please give specifics, as I feel like you're not telling us everything we need to know in order to give you our best recommendations.

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It could be OPs brother asks too many questions and is not easygoing to being demanding of the staff

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What does CA law say about this?

The doctor maybe right in this case, sadly.

As for the billing, there could be bills the doctor charges for doing work that doesn't require seeing the patient, such as paperwork, or calls to get medical information if you use an outside source.

Happened in my case. I got my COVID booster not from the facility, but from the pharmacy of my hospital. The facility NP sent a bill to insurance, for time getting this information to add to the medical record. I did not see the NP.

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Federal law states that a nursing home must provide physician care on site. It is part of their payment from his Medicaid insurance provider.

Regarding the billing from other entities, that is not the case in this situation. The doctor billed it as an 'extensive and complicated 45 minute' visit to the patient in the nursing home - a visit for which the nursing home has no documentation. Would you not question this?

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Of course, a doctor can terminate a doctor-patient relationship if there is probable cause. I have experience this firsthand when I worked in a gynecologist’s office in New Jersey many, many moons ago. The patient had come in for her appointment and she and the front-desk receptionist got into a confrontation over her co-payment. The patient then called the receptionist a derogatory and racist name, so the doctor told the patient to leave the building and that she was not going to be seen that day. The doctor then sent the patient a registered letter notifying her that he was severing ties with her because of her behavior and that she was not allowed to return to the building.

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Any doctor can refuse to treat any patient, yes.
Simply google "Can a doctor terminate a patient relationship".

You have no right to ask any doctor for patient's records unless you are POA for an incompetent patient.

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I do realize the doctor can terminate a relationship with a patient. But it should be a substantially better reason than no reason at all.

Maybe I didn't word it correctly. If this doctor has an exclusive contract with the nursing home to provide medical care onsite and he terminates that relationship, he is violating the contract with the nursing home. If the nursing home cannot provide another doctor to provide medical services on site, then the nursing home is not only breaking federal law, but they are violating their contract with my brother's insurance (the insurance plan pays for onsite physical services). Hope that clarifies it for you.

Because of his TBI, I have POA with the nursing home....so yes, I have every right to ask the nursing home and doctor for his records.

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According to your previous posts, your brother is bipolar and off his meds.

And in the past you've stated that he's a difficult patient.

Are you certain the doctor hasn't paid visits to him,? Are there records, outside of brothers recollections,?

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There were no records in the Nursing Home's records to substantiate the Medicare billings for the month in question. That's why I asked for a reconciliation.

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Your brother is an admittedly difficult patient who's bi-polar, on several different life saving medications, and you accuse his doctor of fraudulently billing Medicare for services not rendered because your brother can't recall if he saw the doctor that often? Now you're questiong why this doctor dropped your brother as a patient, and if it's legal to do so???? I'm thinking you weren't in a great position to do such a thing in the first place! My stepdaughter is bipolar and SO difficult that I had to sever my relationship with her entirely!

Forget about hiring an attorney to fight a hopeless cause. This doctor can drop ALL of his patients if he so desires. My suggestion to you is to find out which doctors do visit this nursing home regularly and nicely ask one of them to take your brother on as a patient. And don't do to THEM what you did to the last doctor who dropped your brother as a patient!

Good luck to you.

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- Nowhere did I say I accused the doctor of fraudulently billing Medicare for services not rendered. I only shared that suspicion here. I specifically asked the doctor for a reconciliation between the Medicare billings and the nursing home records which patients and family members have a right and a duty to do. I only later discovered how this particular doctor services many other facilities with limited staff. I have shared this info with others who are knowledgeable in such matters, and they agree, it should be looked at more closely especially, in light of receiving a termination letter, all of which looks like retaliation. This doctor group has been taking care of my brother at this facility for over a year without any communication he is unhappy with my brother. And then, suddenly, they can no longer take care of his medical needs?
- You seem to be overlooking the fact the nursing home must, by federal law, provide physician care on site and not force patients to go outside of the facility for basic care.
- I already stated I am pursuing a list of other doctors that service this facility. And, as has happened in the past, I am being stone-walled in getting this documentation.
- Even difficult or bipolar patients need and have a right to medical care - TBI, bipolar, or not. That's one reason I go every day to make sure things are running smoothly, to help out the staff where needed, but also to make sure he is receiving the care he needs.

When such patients don't get proper care - as often happens in our society - they end up on the street homeless. There's too much prejudice and lack of understanding on this subject in our society. It's heart-braking for the families and the patients. I am attempting to make sure my brother does not become a 'statistic'.

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A doctor cannot abandon a patient meaning as long as there are other doctors in the city who can treat your brother, then the doctor is legally allowed to terminate a relationship with a patient.

My husband is a doctor and in 26 years of private practice, he has only terminated a relationship with 1 patient. He also spoke with his lawyer before doing it to be assured there would be no blowback. He had a good bit of documentation to back him up.

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Yes, Right on and exactly. Cannot abandon, but can refuse to treat, and arrange other care. I have often seen doctors explain to non compliant patients that he cannot continue to treat them in their non compliance, and that the doctor would help them arrange outreach to another decision. It usually is a threat that works more or less well given the capacity of the patient to understand and comply. But usually also just a threat.

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Unless you've had experience at Medicaid-funded nursing homes or visit them daily as I do, it's difficult to see how the patients are treated and/or the interaction between staff and patients.

The staff at this facility are some of the most uncaring and antagonistic nurses and CNAs I have ever interacted with. Since I have been going there nearly every day for a long time, I have become acquainted with other patients and they have made the same observations. The company that owns this facility was even sued by the state for staffing shortages. This facility is overall rated a "1" on most internet sites - mostly because of the staff but also for poor food quality, lack of cleanliness, lack of maintenance, poor communication, lack of records, etc.

It is sad to see people commenting with such negativity toward what posted. Doctors may have the 'legal' right in a situation like the one I share, but it doesn't make it morally right to put patients in this position. Patients who have 'issues' deserve proper medical care as much as the rest of us.

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Carol, nobody is saying your brother isn't entitled to medical care. Why not look for another facility for him if this one is so awful??
"Morally" right doesn't mean much these days. When I had neck surgery in 2008 and contacted my insurance co about the $250K bill for 1 night at the hospital, they laughed at me, saying that was standard pricing. Meanwhile, the insurance co ASKED that we report what we felt to be outrageous charges.

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There's a good chance, the doctor's NP (Nurse Practitioner) saw him more then the NH doctor.

From personal experience that has been the case at the facility. The last time I saw one of the NH Drs and the one that is assigned to me, was on Father's Day. His NP handles most of the medical issues, and yes he charged insurance for this visit even though it was short.

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You are correct when you say the NP saw my brother more than the NH doctor. However, the doctor billed for an extended visit once a week and the NP billed for two extensive visits a week - total of three extensive visits a week. It's really stretching it to believe this actually happened. I think this is one reason the NH has been refusing to provide copies of his records.

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The better path might be to report suspicion of fraud to CMS, so that your brother remains anonymous. And CMS has much better resources to investigate fraud.

Our doctor has a terrific service that employs two nurses who call us once a month. They chat about our health, falls, med changes, upcoming medical needs. This is billed to Medicare as some sort of visit under the doctor's name, although we haven't "seen" the doctor. This is not fraud.

It's kept us healthier, especially my husband. The nurses know better than he does when he needs a new script.

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The Doctor's NPs?

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Carol, I had a similar situation with the medical provider that serviced my dad's board and care home.

When I questioned why they were seeing him 3 or 4 times a week they went straight out defense. I know that is because they would be at the facility daily, wound care patient, literally pop my dad's door open, ask, "How are you today?" My dad would answer fine and you? Then Medicare would be billed for an extensive visit. Fraud!! No two ways about it. I know this because I was in the room multiple times this happened and I handled all the paperwork.

I filed complaints with every governing agencies and Medicare, this is taxpayers money being stolen. The end result in my dad's situation, he moved, the facility was closed by the state and the "medical group" disappeared completely from the city. I have no doubt they think they can run and hide but, Medicare is federal and they will be found, if they haven't been already.

Being a jerk, hard to deal with or mentally ill is no justification for robbing the tax payers as sooooo many believe nowadays is acceptable.

Good luck finding a doctor to treat your brother.

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To answer recent questions:
- To 'IsThisReallyReal'. I agree. Too many people just accept what these organizations are doing. Someone needs to stand up and stop the fraud - IF that's what is truly going on.
- To 'Cover9339'. I have taken my brother to see outside specialists when it was necessary but that's not usually the type of care this doctor has provided. He (mostly his PAs) address every-day, non-critical issues, i.e., writing orders for weekly labs, ordering tests, and renews prescriptions every two weeks. It's really not that difficult nor do I believe it is asking too much even if my brother asks too many questions, which, BTW, is pretty difficult to do when the doctor rarely goes into his room to see him. I personally think he is going off the deep end and his male ego is hurt because I asked for a reconciliation.....OR there really is fraud taking place.
- I have contacted multiple facilities in this area. NONE have open LT Medicaid beds and none would take my name on a waitlist. The system is currently overwhelmed.
- The current nursing home is still stone-walling me and has not provided a list of any other doctors that could attend to his care at this facility.

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CarolPeaches

Thanks again! This is a large NH? I ask, usually the person assigned to the facility have their own office there, so they can go to resident's rooms if necessary. I hope fraud is not happening in your brother's case, and that this whole situation can be worked out.

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Carol, there are two issues here. One is finding a doctor for your brother, and the other is what to do about the fraud. I’d suggest that you document the fraud and then put it on the back burner for a month or two. It certainly sounds like fraud to me, a cute little scam on the taxpayer. They didn’t cut relations with your brother because he was too difficult, they cut it because they are protecting their fraud system. The NH may well be in on it too, because the NH has to know what is going on- which may be why they don't want other doctors involved in the facility. Focus on brother for now, but don’t forget to get back to the fraud when it’s not the top priority.

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Thank you for your helpful response. I pretty much came to same conclusion. I have spent practically the entire day trying to find an open LT Medicaid bed but no luck so far.

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Carol, when you have the energy for the fraud issues, I think the Ombudsman would be a good place to start. It should also cover refusing to provide records and the difficulties in getting services for your brother. The Ombudsman issues include failure to provide services in a government funded facility and fraud against government funding, as well as your brother's problems. It's free to approach.

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Actually, I think the Ombudsman can no longer be helpful (see my comments above). Unfortunately, this is the 4th or 5th person to fill this position in our area-probably because 80% of them are volunteers. There's very little continuity. Not sure how this can ever be effective.

We used to have a Nurse Representative from his Medicaid insurance provider. But after she quit, no one replaced her. I've requested a replacement several times and got - crickets!

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Carol, I recommend getting certified return receipt requests in the mail to both NH and medical group. Give them a deadline of like 10 days to forward the records, provide an email address, a portal if you have one, a mailing address and phone number. Be sure it has any identifying information for your brother, no excuses then. Keep copies and attach these to your receipt and signed for certified mail slip.

Asking verbally can be blown off, your word against theirs type of bs. In writing, sent via a Federal agency with proof of receipt is a different story all together and will get people's attention, either the Doctor and NH or the governing agencies when you file complaints.

Make the requested information very clear, explain that you are concerned about the bills and require the records for an audit but, DO NOT make any allegations of wrong doing.

My bet is they are up to no good, whether it's fraudulent billings or abominable record keeping or....something is amiss, otherwise they could have and would have printed the records for you.

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I have plenty of documentation, both email and letters. However, when I have sent out certified letters to the facility and this doctor, the receiving party convenient does not sign for the letters so the sender never receives proof of delivery. This is an old legal trick that's been around forever.

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Isn't there Nursing Home laws covering all 50 states that says a resident has the right to ask for and look at all their medical records if they want? Some can charge a fee for copying this if they want?

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Yes, it is a federal law that they receive records within (I believe 48 hr); the facility is allowed to charge $0.25/page for paper records. I have paid these fees whenever requested but have been stone-walled since last August on receiving copies. The first time I called in the Ombudsman on this issue, she and I met with the Director of Records who agreed I should receive copies once a month; that happened for a month or so - then crickets. Now that I think about it, this particular doctor started just prior to my having problems getting copies. Wow! What a coincidence - not!

I've engaged the local Ombudsman several times on this one issue and she's not been able to accomplish anything. Just recently I was informed that all Ombudsmans are volunteers with no enforcement capability. Guess it's time to file a complaint - at least on this issue!

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Where I live Moms LTC had 3 doctors I could chose from. All from the outside. None had offices at the facility. Just like when a patient is in the hospital, they do their rounds. I would think on these rounds they look in on every patient. So that is charged. My PCP alots so much time to a visit. If I go over that time, I am charged for it. So, I have learned to keep my visits for just what I am there for. He bills Medicare for this and they pay what they feel is reasonable.

Maybe this doctor feels that your brother is out of his realm of expertise. I really find it weird that the NH only has one doctor with privileges overseeing the patients. And the DON should know who these drs are. Drs who except Medicaid are not prevalent. Medicaid is a lousy payer. I also don't think just any doctor can enter a facility to see a resident. The doctors must be given privileges. So a doctor has a right to say that you must come to him if u want to continue with him.

All I can say is keep trying to get brother into another facility. Unless you have a lot of money and a good lawyer you are not going to win this one. If you have not called Medicare, do it and talk to their fraud dept. Let them figure it out.

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I received further clarification on this issue. The facility has a contract with this particular doctor to provide on-site visits for any patient that does not have an existing doctor-patient relationship - which turns out to be the majority of patients. Yesterday, I received a list of potential doctors that accept Medicaid that could possibly visit him at the nursing home. No doctor has an office at the facility on a full-time basis. I also spent two days calling other nursing homes in the area. So far, not a single one has a LT Medicaid bed available and no one maintains a WL.

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Carol, It might be good to ask for the rules about what and why the ombudsman can look at. Where I am the role of the Ombudsman is to look at denials of justice by the government system to individuals outside the government system. That may not be the case where you are, but it may be along the same lines. If so, the challenge is to put your personal problem within rules that fall within the ombudsman’s brief. I tried to do that in a previous post, but if you don’t understand the rules, it may be worth finding them and looking at again.

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Can a doctor in a Medicaid-funded nursing home in California terminate a doctor-patient relationship?

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