Limited English Proficiency (LEP) Patients: Frequently Asked Questions

Debra Kane Hill, MBA, RN, Senior Patient Safety Risk Manager, and Richard F. Cahill, JD, Vice President and Associate General Counsel, The Doctors Company

The Doctors Company frequently receives member inquiries about interpreter requirements for patients who are limited in their ability to speak or understand English, or “limited English proficiency (LEP)” patients. To help you understand LEP requirements, we have compiled a list of frequently asked questions with strategies to ensure compliance.


As defined by the United States government, LEP patients are individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English. These individuals may be entitled to language assistance with respect to a particular type of service, benefit, or encounter. Federal laws applicable to LEP individuals include Title VI of the Civil Rights Act of 1964 and Executive Order 13166.

The U.S. Census Bureau recently reported that more than 350 languages are spoken in the United States, with 67.8 million people (nearly one in five of the current population) speaking a language other than English at home. After English, the most common languages are Spanish, Chinese, Tagalog (Filipino), Vietnamese, and Arabic.

The country’s increasing linguistic diversity presents communication challenges for healthcare practitioners who encounter LEP patients. With nearly 20 percent of the population communicating primarily in a language other than English, it is likely that practitioners will encounter patients speaking at least one foreign language. When patients are unable to interact productively with their practitioners, it affects access to care, limits compliance with treatment plans, and prevents optimum outcomes.

Frequently Asked Questions

Yes. Practitioners who receive federal financial assistance from HHS are required to take reasonable steps to ensure that LEP patients have access to language services. The exception is if you receive only Medicare Part B payments. (Federal Register, August 8, 2003, 68[153], 47311–47323)

HHS provides the Revised Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons to assist practitioners in meeting LEP obligations. To determine the extent of your obligation, analyze the following four factors:

  1. The number or proportion of persons with LEP served or encountered by your practice. The greater the number, the more likely language services will be needed.
  2. The frequency with which persons with LEP come into contact with your practice. Even if that contact is unpredictable or infrequent, you must have a plan for obtaining interpretive services.
  3. The nature and importance of your services. The more important the services or greater the consequences, the more likely interpreter services will be needed. Also, determine if a delay in accessing your services could have serious or life-threatening implications.
  4. The resources available to you and the cost. As a solo practitioner, you are not expected to provide the same level of service as a large, multispecialty group, but you are still required to take reasonable steps to provide the service. Investigate technology services or sharing resources with other providers.

Failure to comply with the provision of meaningful access may result in the suspension or termination of the federal financial assistance.

Yes. The cost is considered a part of business operations. Failure to provide interpreter services may result in an investigation by the Office for Civil Rights (OCR). Depending on the OCR’s findings and conclusions, violations may result in fines, sanctions, and penalties.

No. LEP patients are entitled to language assistance free of charge. In some states, the cost of interpreter services is reimbursable under federally funded programs such as Medicaid and the Children’s Health Insurance Program. As noted in the Annals of Family Medicine, some state-funded programs provide free interpretation by telephone at no cost to the practitioner. In some jurisdictions, health plans may provide interpreters at no cost to either subscribers or clinicians in accordance with the terms of coverage as long as the healthcare practice furnishes adequate advance notice.

No. It is the responsibility of the practice to arrange interpretation services, with no obligation for patient-arranged services. The patient cannot transfer the expense to the practice.

No. Declining to give a patient an appointment on the basis of a linguistic barrier is considered noncompliance. All LEP patients are entitled to free access to language assistance. Violations for noncompliance may be enforced by the OCR under Title VI of the Civil Rights Act and by state and local authorities, depending on the jurisdiction. Fines, penalties, and sanctions may be imposed.

Yes, but it is permitted only in limited circumstances. When considering the use of adult family members or companions, it should be noted that lay personnel are rarely familiar with medical terminology and its nuances and may not provide an accurate interpretation. Additionally, the patient may not want a family member or companion to have access to confidential health information. The patient’s minor child should not be engaged for this purpose.

If a family member or companion must be used as an interpreter, that person should be an adult—unless an adult is unavailable and immediate care is necessary to prevent further harm or injury to the patient. Otherwise, it is recommended that you have a clinical staff member trained to provide interpretation or use certified interpreter services to ensure proper translation of medical information. The local hospital should have a list of qualified interpreters.

Additionally, it is recommended that you have written consent forms—especially for invasive procedures—translated into the applicable non-English languages by a certified translator for proper interpretation.

Possibly. The key consideration is how proficient staff members are in the patient’s spoken language. If they have only a marginal ability to speak the language, hire a certified medical interpreter. Office staff should meet the same standards as professional interpreters.

Document in the patient record clearly that an interpreter is being used, and identify the language or dialect. Include the interpreter’s name in the progress notes in the event that an issue subsequently arises calling the content of the interpretation into question.

A qualified medical interpreter must be fluent in both languages and able to interpret all aspects of the clinical encounter accurately—including the patient’s history, symptoms, practitioner recommendations, diagnosis, treatment plan, options, and issues related to informed consent. The interpreter must maintain patient confidentiality in accordance with federal and state privacy laws. Strong interpersonal skills are also essential. For additional information, consult the National Council on Interpreting in Health Care for National Standards of Practice for Interpreters in Health Care and the National Code of Ethics for Interpreters in Health Care.

Under Privacy Rule 45 CFR §164.506(c), an individual’s authorization is not required to disclose PHI when the covered entity provides interpreter services under healthcare operations. The practice may either use a member of the workforce (i.e., a bilingual employee, contracted interpreter on staff, or a volunteer) or the services of a person or entity engaged as a business associate. For more information, see the HHS HIPAA for Professionals Frequently Asked Questions.

Yes, a business associate agreement is required if you have a contractual agreement with a language service that provides interpreters and translators. For more information, see the HHS HIPAA for Professionals Frequently Asked Questions.

According to, an interpreter conveys meaning orally, while a translator conveys meaning from written text to written text. An interpreter is used to provide effective oral communication between the practitioner and the patient. An interpreter may also be used to orally present documents to the patient that are not in the patient’s native language, such as forms for new patients, disclosure of PHI, informed consent, or treatment instructions.

Face the patient directly, maintain eye contact with the patient (not the interpreter), and speak as you normally would to a patient who is fluent in English.

Document the following information in the patient record: mode of interpretation (in-person or by telephone), language translated, and the name, contact information, and professional qualifications of the interpreter.

If using the patient’s family member or companion as an interpreter, note that permission was specifically obtained from the patient, and indicate that a professional interpreter was offered at no cost but was declined by the patient. Include the individual’s name, relationship to the patient, and contact information.

For contracted services, keep a list of resources in administrative files with information on when the resource was accessed and by whom. It may be useful to keep notes in the administrative document about the quality of the service or the specific interpreter.

Practices may consider a number of different options for assisting LEP individuals:

  • Professional contracted on-site interpretation.
  • Family members or companions in limited situations (such as simple messaging or emergencies).
  • Bilingual staff who are proficient in both languages.
  • Telephone or online services.
  • Written messaging/translation services.
  • Services provided to patients through health insurance coverage.

Additional Compliance Strategies

It is important for all healthcare practitioners to be familiar with their obligations in managing LEP patients and how they can assist non-English-speaking patients in the office setting. Ensure that all staff members are trained in handling phone calls and inquiries with LEP patients. Failure to provide interpreter services can create access-to-care barriers. Healthcare practitioners can be held accountable for noncompliance and any resulting patient harm.

The following strategies can help to prepare your practice:

  • Develop policies and procedures for managing LEP patients. Periodically evaluate staff compliance and review policies and procedures to conform to HHS standards. Audit policies periodically, and amend the content as evolving circumstances may warrant. See HHS: Example of a Policy and Procedure for Providing Meaningful Communication with Persons with Limited English Proficiency.
  • Orient new employees to the practice’s LEP policy and procedure. Provide ongoing education to all staff as a periodic refresher.
  • Use a “mystery caller” approach to assess staff response to LEP patients.
  • Review patient documents, including questionnaires, educational materials, and other forms for ease of understanding. Make written documents available in the most common languages spoken by patients in the practice. Translated materials may be available from healthcare systems, professional societies, or specialty associations upon request.
  • Create a list of preferred certified medical interpreters available in your community or online. Your local hospital may assist with finding and recommending reliable resources. The General Services Administration’s List of Language Service Providers may be helpful.

For related content, see our article “Americans with Disabilities Act: Frequently Asked Questions.” For additional assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email


Agency for Healthcare Research and Quality, Improving Patient Safety Systems for Patients with Limited English Proficiency.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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