Triage by the front desk clerk is a common and legally dangerous form of implied delegation of authority, particularly in large group practices and clinics. In this situation, the physician implicitly authorizes the appointments clerk to determine whether a patient needs immediate or follow-up care. Certainly this is not the physician’s intent, but it happens when the office manager or clerk is permitted to deny appointments to patients who are behind in paying their bills or when there are no provisions for evaluating patients who may need to be seen more quickly than the physician’s appointment calendar allows.

If the front office tells patients that they will not be seen until they pay their bills, this is implicitly determining that the patient does not need the return appointment. If, as frequently happens, the patient does not return for care, the physician could be liable for any consequences that flow from the denial of care. This is also the case when the patient is made to wait more than the medically acceptable time for a follow-up appointment. If the obstetrician tells a patient to come back in three days for a preoperative visit because it is time to put a stitch in her incompetent cervix, the appointment clerk must not schedule her for an appointment in three weeks. The obstetrician would be liable if the patient lost the fetus during this delay. Physicians must ensure that a patient’s medical condition is considered when appointments are being scheduled. They should always be consulted before a patient is denied a timely appointment.

Triage is carried to an extreme in many MCOs. Patients cannot speak directly to a physician, or even to the office staff, but must go through a triage nurse system. These nurses, operating under some sort of protocols, call an ambulance for the patient, direct the patient to go to the emergency room, send the patient to an MCO- run urgent care center, or schedule the patient for an office visit. In some systems, these nurses are pressured to keep patients out of the emergency room. The result has been several deaths when patients with heart attacks or other emergency conditions were sent to poorly staffed and poorly equipped urgent care centers. As plaintiffs’ attorneys litigate these cases, they will seek to tie the nurses back to both the MCO that employed them and to the physician who approved their protocols and carried out the oversight of their actions.