PRACTICE FAQS

How much can I charge for copying a patient's records?

The Maryland Medical Records Act sets the maximum rate that physicians may charge for the copying medical records. This rate has two components, a base charge, and a per page charge. The Act provides that each July 1, the rates may be adjusted by the increase in the Consumer Price Index. Although the law does not delegate responsibility for the setting of the rates to any institution or agency, MedChi each year as a service to physicians calculates the permissible adjustment and requests endorsement by the Board of Physicians Quality Assurance. Below is a link to the updated law. Record copying fees
| top |

How long do I have to maintain records in my practice?

The following is a list of documents and storage period that should be in a practice.
[If system is automated, maintain back-up tapes/disks instead - this information is to the best of Montgomery County Medical Society's knowledge - you must check and update periodically.
| top |

Is there a proper way to terminate the doctor-patient relationship?

The physician/patient relationship is a consensual one, a contract. This contract, however, is usually not a written document setting forth the terms, rights, and responsibilities of the parties. Rather, the contract is implied: The patient requests medical care and the physician agrees to provide it. The contract thus created is one based on a fiduciary, not a financial, relationship.

Once the relationship is created, the physician is under an obligation to provide services as long as the patient requires them or until the relationship is properly terminated. (Failure to pay a bill does not end the relationship.) A physician cannot withdraw from a case or discontinue practicing without notifying the patient of the withdrawal. The physician must provide reasonable notice so that the patient may secure other medical attention if desired. In Maryland, the BPQA considers two to three weeks "sufficient notice."

To minimize liability exposure and to facilitate termination of the physician/patient relationship, a letter (preferably certified) should be sent to the patient with a copy kept in the doctor's files. The "view letters" button will display samples of these letters. View Letter Templates

| top |

What accommodations are required by law for patients with special needs?

Hearing-Impaired Patients
The medical society is contacted with great regularity about what is required of physicians when communicating with their hearing-impaired patients. The Americans With Disabilities Act (ADA) of 1990 requires medical professionals to communicate effectively with patients who are deaf or hearing impaired by providing auxiliary aids or services. This includes the provision of sign language interpreters if this is what is needed to communicate effectively.

Other means of communication may be acceptable, including lip reading, use of pen and paper or word processor, or communicating through a friend or family member of the patient. [Bear in mind that patients may not want a friend or family member to have knowledge about their medical condition, however.]

If the patient is willing to try lip reading, the following guidelines may make the interchange more successful and encourage the patient to continue using this mode of communication:

• Face the patient directly when speaking; speak clearly, directly, simply, and more slowly than usual.
• Use gestures, pantomime, and facial expression to facilitate the exchange of information; a sketch or chart may be helpful.
• Turn off any music or other background noise when communicating with a hearing-impaired patient.
• Even if an interpreter is present, speak to and maintain eye contact with the patient.
• Be sure you are understood; ask the patient to summarize your message.

Having said the above, if your patient insists that you provide a qualified interpreter at your expense, you should do so. We are aware of at least one case in which the Maryland Commission on Human Relations issued a "finding of probably cause" that a physician's office unlawfully discriminated against a deaf patient when it refused to provide an interpreter during that person's visits. The Montgomery County Medical Society has developed a relationship with two qualified sign-language interpreters who will discount their rates for Medical Society members. They are: Julie Rogers (301-754-2275) and Rebecca Davis (240-305-8171).

We also want to remind our members of the Disabled Access Tax Credit available to help defray the cost incurred for hiring interpreters. This credit is limited to businesses that had less than a million dollars in gross receipts or no more than 30 full-time employees during the preceding tax year. The IRS allows a credit of up to 50 percent of cumulative eligible expenditures made within the taxable year; the expenditures must be between $250 and $10,250. Physicians interested in taking this credit should consult with their tax professional or the IRS.

Other areas where accommodations may need to be provided are: wheelchair accessibility, visual impairment, and mentally Challenged patients.
| top |

What information can I disclose about a patient who is a minor?

Physicians frequently call the medical society with questions about the law governing the release of medical information on patients who have not reached the age of majority, which in Maryland is 18 years of age. This issue generates a healthy amount of angst, as physicians are trying to cope on the one hand with a more demanding patient population wanting access to information, and on the other, with governmental regulations safeguarding the privacy of patients. We want our members to be aware of the law, and to keep their staffs informed on the issue as well.

When is a minor considered to have the same capacity as an adult to consent to medical treatment?

Maryland Health General Article sections 20-102 and 104 identify the following circumstances in which minors may consent to medical treatment as adults:

• When the minor is married or the parent of a child.
• In an emergency situation if it is determined that the life or health of the minor would be affected adversely by delaying treatment to obtain consent.
• When the minor seeks treatment or advice about drug abuse, contraception other than sterilization, alcoholism, venereal disease, or pregnancy.
• When it is necessary for a physical examination to treat injuries or obtain evidence from an alleged rape or sexual offense.
• When a minor 16 years or older seeks consultation, diagnosis, and treatment of a mental or emotional disorder. In these cases, however, the custodian, guardian, or parent of the minor is not liable for the cost of this consultation, diagnosis, or treatment unless their consent has been obtained.

| top |

What may a physician disclose to a custodian, guardian, or parent?

a parent, spouse of a parent, guardian, or custodian of a minor, information about treatment needed by the minor or provided to the minor, except information about an abortion (which is addressed in Health General § 20-103). For situations not covered above, the parent, guardian, or custodian, as a person in interest to the minor, is entitled to be fully advised about treatment given to the minor or needed by the minor.

HG 20-103 requires that a physician may not perform an abortion on an unmarried minor without first giving notice to a parent or guardian, except under the following circumstances:

• When the minor does not live with a parent or guardian and a reasonable effort to give notice to a parent or guardian is unsuccessful.

Or, when in the professional judgment of the physician:

• such notification may lead to physical or emotional abuse of the minor.
• the minor is mature and capable of giving informed consent.
• notification would not be in the best interest of the minor.

Obviously, these situations should be considered and documented with the utmost care.

What is a physician's liability when treating a minor?

A physician, or an individual under the direction of a physician, who treats a minor is not liable for civil damages or subject to any criminal or disciplinary penalty solely because the minor did not have capacity to consent.

Will HIPAA affect any of these issues?

Most physician offices will have to be in compliance with Federal HIPAA regulations by April 2003. The general rule of HIPAA is that state laws that provide stronger privacy protections will not be superceded by HIPAA privacy protections; however, access of parents to protected health information of minors continues to be the topic of debate and could be the topic of clarifying regulations to be issued later. MedChi is monitoring the HIPAA issue closely and will keep members informed if changes occur.
| top |

How should I handle medical testimony and depositions?

Proposed guidelines by the Montgomery County Medical Society/Montgomery County Bar Association Interprofessional Committee

Most of the complaints forwarded to the Montgomery County Medical Society/Bar Association of Montgomery County Interprofessional Committee center around fees and miscommunication. In an effort to resolve these issues, the physicians and attorneys that serve on the committee propose the following guidelines:

Depositions:

• There should be a written agreement signed by the physician and the deposing attorney, specifying the time and place of the deposition and the fee as an hourly rate or fraction thereof to be paid at the time of the deposition.
• The fee should include preparation time and should reflect the rate the physician normally charges per hour of office time.
• For video depositions, "the clock should start running" as soon as the physician is present.
• The physician and attorney should communicate personally if there are problems, not through office staff members.

THE ABOVE APPLIES WHETHER THE ATTORNEY REPRESENTS THE PLAINTIFF OR THE DEFENDANT WHEN THE PHYSICIAN IS AN EXPERT WITNESS (i.e., the physician is being asked his or her opinion, rather than just presenting facts).

Court Appearances:

• The above written agreement applies.
• The court appearance fee, assuming the physician is missing office hours, should be in one-half day increments, again representing a typical half day income for that physician in his/her office.
• The guidelines in the Interprofessional Code of Cooperation regarding payment of fees when court appearances are canceled should be included in the written agreement, unless an alternative agreement is reached.

Medical Records:

• 1. Attorneys and physicians are encouraged to use the standard Authorization and Assignment adopted by the Montgomery County Medical Society and the Bar Association of Montgomery County.
• By law, the physician is required to release all records in the files unless specifically prohibited by another health care provider or health care facility.
• Maryland law allows for charges to be made when providing medical records.(see FAQ about charges for medical records)

| top |

What Recourse Do Patients Have When an Insurance Company Refuses To Pay?

In 1998, the Maryland General Assembly passed the "Appeals and Grievance Law" (Health General 19-705.2 and Commercial Law Articles 12-4A-04 and 13-4A-02) to assist patients in appealing adverse decisions made by their insurance companies. The law, which has been in effect since January, 1999, utilizes two different state agencies to assist patients when they feel they have been denied coverage for needed medical care. Most of the cases that are referred to these agencies are decided in favor of the patient.

The Appeals and Grievance Law was passed in response to concerns expressed by the physician community and the public, that necessary medical services were being denied. Under the law, carriers must provide their members with a written copy of an adverse decision within five days of its being made. The decision must clearly state the exact factual basis for the carrier's decision, including the specific criteria the company used in making its decision. Unless the complaint is deemed to be an emergency, the member (patient) must first go through the insurance company's internal grievance process. Patients may utilize the Health Education and Advocacy Unit of the Maryland Attorney General's Office to assist them in filing this grievance with the carrier. The number to call for this assistance is 1-877-261-8807.

If the insurance carrier still refuses to pay for the medical care, the patient may then file an appeal with the Maryland Insurance Administration (MIA). The MIA investigated 255 cases in 2000, resulting in only 69 (27 percent) decisions in favor of the insurance company. The number to call to file an appeal with the MIA is 1-800-492-6116.

| top |

How can I use the Maryland Insurance Administration and the legal system to get insurance carriers to make timely payments?

| top |

Where can I get the employment posters required by law for my office?

| top |

How do we comply with the new subpoena requirements?

As of July 1, 2005, Maryland law will require that the following notice (or a notice substantially similar) accompany any subpoena issued by a private party requiring disclosure of medical information. Subpoenas issued by governmental agencies, such as the Board of Physicians or a police department are not covered by this requirement.
The notice must be sent to the patient at least thirty days prior to the subpoena being sent to the physician

SAMPLE NOTICE
[Identification of court]
Plaintiffs [Name of Plaintiff(s)]
v.
Defendants [Name of Defendant(s)]
Case number: _____
[The text of the subpoena goes here]
(Newly required notice) Notice to [patient name]
In compliance with § 4-306 of the Health-General Article, Annotated Code of Maryland, take note that medical records regarding [patient name], have been subpoenaed from [name and address of health care provider] pursuant to the attached subpoena and § 4-306 of the Health-General Article, Annotated Code of Maryland. This subpoena _____does, _____does not [one should be marked] seek production of mental health records. Please examine these papers carefully. If you have any objection to the production of these documents, you must file a motion for a protective order or a motion to quash the subpoena issued for these documents under Maryland Rules 2-403 and 2-510 no later than thirty (30) days from the date this notice is mailed. For example, a protective order may be granted if the records are not relevant to the issues in this case, the request unduly invades your privacy, or causes you specific harm. Also attached to this form is a copy of the subpoena duces tecum issued for these records.

| top |