QUESTION:  Should I ever offer to refund fees or waive payments for a patient who says they are unsatisfied with my care?

ANSWER:  Your fees and services are a business transaction to which the patient has agreed.  Circumstances under which you might even consider reducing the bill and/or refunding payments already made should be rare, and should be addressed on a case by case basis.  Any actual action on your part to do so should only take place after you get the best professional and legal advice.  Your goal should be to respond to the patient without professional or ethical compromise and defuse the situation to the greatest possible degree.

Serious disputes with patients are generally quite rare and almost always center around payment concerns or objections to their bill.  Very often, patients either assume their insurance will cover all costs, or, they do not stop to calculate the ongoing costs of care.  As well, a patient's needs, circumstances, insurance status, marital or employment status can change quickly and unexpectedly.  Some patients will respond in unexpected or even hostile ways with respect to their status and obligations as a patient.  You should be prepared to patiently explore and respond appropriately to such situations.  They are a part of everyday practice.  The patient may ask or demand a refund.  The doctor should not, however, ever be the party to raise the prospect of a financial accommodation. 

In a few of these situations, however, a patient may adopt a very challenging, hostile and/or belligerent or accusatory tone, hoping to use any minor issue to bring their fee obligations into question.  Usually, some minor issue of no real significance is raised.  Even in these potentially heated circumstances, the issue of a refund will be quite rare.

If it does come up, your immediate need is to get to the truth of the situation. Do a detailed review of all of the facts of the case.  Talk directly to the patient and make a serious effort to fully understand the true nature of the dispute.  Ask them to get specific but never be confrontational or aggressive.  Any escalation of the intensity of the discussion on your part only serves to undermine your position. 

• Is this an issue of quality of care or clinical procedures?

• Do they claim any injury?  (Never ask them this question and risk planting the notion but look for them to make such a claim on their own.)

• Do they allege you violated any claim, promise or commitment?

• Is any other health professional influencing or advising the patient to contest your care or your bill?

• Have friends or family members intervened in the situation?

• Does the patient say they have sought legal counsel?  (This is another question you should never ask directly and perhaps prompt them to take such a step.)

If the patient presents any reasonable concern, it is in your best interest to accommodate in procedural, timing, or other clinical concerns.  If, however, there is an underlying or unspoken reason that appears to you to be different from what the patient is actually saying, try and work through the confusion until you are agreed on just what the problem really is. 

If the patient persists in demands for a refund or other financial accommodations, here are some important action steps. 

• Determine the exact amounts of payments made and identify whether insurance made those payments or whether the patient paid out of pocket.  A demand for a refund by a patient whose bill was paid by an insurance company raises obvious ethical and legal questions.

• Seek the counsel of one or two experienced colleagues (protecting patient confidentiality) to help you make sure you are on solid ground from a peer perspective in both clinical and business terms.

• Contact your malpractice carrier and ask for their advice.  They should be happy to help you in such an important risk management situation.  You may want to ask them about any mediation service or process that might be helpful.

• Contact your state, provincial, or national chiropractic regulatory body and obtain a copy of the rules and regulations that govern financial issues such as refunds, reductions or fee waivers in your jurisdiction. 

• Never be in haste to offer any financial accommodations or settlement.  Do not put anything in writing without checking with local authorities, your malpractice carrier and NEVER pay any refund without checking with your own attorney.

• Remember, in raw legal terms a refund may be interpreted as an admission by you that something actually was wrong, regardless of the real truth.

• Finally, a refund may be appropriate in some situations, but it will not beneficially affect your liability for malpractice.