Patient Refuses To Be Discharged: What Should I Do?

A patient refuses to be discharged.  What should I do?  A reader asked me that question:

I wonder if you could do a post on when a patient refuses to leave the hospital. I just ran into this and I wonder how others handle it.

Ah. One of my most prized situations. I love having this talk. It used to be dreadful. Now I thrive for the opportunity. With science on my side, money will trump attitude just about every single time.

With the consumer driven "I am boss" attitude of all that is health care these days we as physicians will come upon many a patient that simply refuses to leave. Patients, for whatever reason, who feel they are "too sick", "too weak", "too lazy" to take care of themselves, either at their home or even at a skilled nursing facility for which they refuse to go to.

If the patient has Medicare, the answer is simple. You give them "The Letter". This new policy, in the interest of patient safety (or whatever) was instituted a year or so ago. It says that if a Medicare beneficiary refuses to accept the recommendation of discharge from the hospital, they can appeal their decision to some sort of Medicare board (reportedly a protected anonymous physician, but I'm certain it's hired nursing hands, based on my experience). The board has 24 hours to respond with Yeah or Nay. If the board agrees with the physician and discharge is appropriate, the patient is notified that Medicare will stop paying for their care as of now.

I have never had a patient decide they didn't want to leave if they knew their insurance coverage ended immediately.

The same goes for private insurance coverage. Most patients, if told that their insurance will stop paying after I submit their CPT 99238 or 99239 discharge codes and do their discharge summary, they  will leave without force.

Now, what do you do about the uninsured drug seekers? Those who claim to have chronic pain. Those without insurance? I don't do anything. If my medical decision makes a determination that discharge to the community is safe and and in-patient hospitalization is not necessary, I have science on my side to make my decision. The patient can throw the biggest tantrum they have ever thrown, my decision still stands. I will simply write discharge orders and stop seeing the patient.

Now, if the hospital wants to call the cops to escort the patient out, so be it. I have performed my duty as a physician. I am not an enforcer. I am not a cop. I am not a social worker or a Priest. Once I discharge a patient, I am done.

Don't let the moochers get you down. Let the patient's wallet make your decision for you.

Now, if a patient refuses to leave even knowing that their insurance will stop coverage, in all likelihood, the hospital will demand payment upfront for continued service of medically unnecessary charges at full price.