Combating Patient No-Shows at Your Medical Practice

Like many physicians, chiropractor Jeff Robichaud experiences as many as 12 no-show patients per week. But when new patients don't show up, that's 60 minutes and up to $200 down the drain.

That's why Robichaud, and the other providers at his integrative medicine practice, Concord Clinical Health Center in Concord, Mass., charge fees for those patients who miss - $50 for a new patient appointment and $20 for an existing patient appointment. The practice also has an established 24-hour cancellation policy.

"We have a waiting list of patients who are looking to come into the practice," says Robichaud, who has charged the missed appointment fee for 10 years. "No-shows are a big deal for us. We used to be gracious with patients we'd see for a long time, but found that repeat offenders would be the patients that we didn't charge. Generally what we find is that when they get the first bill, they're very embarrassed."

Charging for missed visits is just one of the tactics Robichaud and other physicians have used to reduce patient no-shows, which are more than just a mere nuisance.

Missed appointments cost your practice money and waste providers' time. They may also invoke legal issues if your practice doesn't have an appropriate strategy in place to address them.

The no-show effect

Patient no-shows plague every medical practice and may be increasing in some parts of the country as the cost of care rises, says Elizabeth Woodcock, an Atlanta-based healthcare consultant, trainer, and author of "Mastering Patient Flow to Improve Efficiency and Earnings."

While some practices experience a small number of patient no-shows, and others see higher rates, the average hovers somewhere between 5 percent to 10 percent, says Woodcock.

"They've certainly risen after the recession," she says. "It varies by specialties, and the bigger factor is payers. We see higher no-show rates if you have a larger self-pay or Medicaid population."

Certain specialists, such as reproductive endocrinologists, tend to have a higher rate of patient no-shows because they aren't patients' regular physicians or they aren't covered by insurance, says Woodcock.

"We've seen a lot more no-shows with the self-pay patients," says Woodcock. "Ten years ago, it was sort of like, 'Well, gosh, our self-pay patients didn't show. It's not that big of a deal.' But today practices really have to pursue payment from everyone."

As Robichaud's experience shows, new patients are some of the biggest offenders at non-primary-care practices (like Woodcock, he suggests that it is due to a lack of a pre-existing physician-patient relationship). Other common no-shows are patients who schedule appointments between routine visits and forget to cancel.

Regardless of why a patient doesn't show up, it always costs practices money - especially if the practice doesn't charge for the entire missed appointment, says Woodcock.

"Some specialists take credit card numbers over the phone because they charge so much and it's not covered by insurance," she adds.

However, such an approach may not be right for your practice, particularly if your patients can't afford it. There are also some payers (such as a state Medicaid plan) that don't allow providers to charge for missed appointments.

"We're well over 30 percent Medicaid [patients], so we can't charge them," says Leann DiDomenico McAllister, administrator for Plymouth, Mass.-based Performance Pediatrics. "We had [another patient], one woman of means, who really liked our practice, and just said, 'Can I just pay if I miss?' because she didn't want to leave the practice, and I couldn't do that. I couldn't have one set of rules for one person, and another set of rules for another."

Effective tactics and technology

At McAllister's practice, the rate of patient no-shows for the last two years is just under 2 percent. But because the practice is small - with one physician and one nurse practitioner - the effects of just one missed appointment have a big impact.

"If they cancel [without adequate] notice, it's too late to fill them; that's revenue we never make back," says McAllister. "When you go for a well exam, it's 45 minutes for the doctor. He has set aside that 45 minutes for you. If you don't show for it, the chances of us filling it with an acute-need [patient] is not high. We work very hard to set aside acute time."

While the practice used to have a 48-hour cancellation policy in place, that wasn't a cure-all solution, as it would be difficult to fill an appointment for a Monday that was cancelled on a Saturday.

The practice, therefore, recently revised its scheduled appointment policy to better explain to patients that no-shows and cancellations with little notice are problematic. For a copy of this policy to customize for your own practice, go to http://bit.ly/ptnoshowpolicy.

"We send a copy of the policy with a letter to the family the first two times they violate the policy, letting them know it's a problem," says McAllister. "[With] the third violation, they get a letter putting them on probation, stating that one more violation will lead to dismissal from the practice. The fourth violation - the patient is dismissed by certified mail, with a copy by first-class mail in case they refuse the certified mail, and with a copy to the insurance provider if the patient is in managed care and needs to have the primary-care physician reassigned."

After most patients see that first letter and appointment policy, the problem does not persist.

"For well more than half [of no-shows], they don't realize it's a problem" says McAllister. "Our patients for the most part appreciate us, and once they realize it's a problem they don't do it again. For another small grouping, there are true emergencies that come up. We've had patients who've gotten in car accidents or their house caught on fire. And we do make exceptions for that. And then there is that very small subset of patients that, for whatever reason, don't believe it's their responsibility to show up on time, to be here when they say they're going to be here."

While Robichaud's practice, which doesn't accept Medicaid, has recently started charging a portion of a visit cost to patients who miss visits, that's not the only tactic the practice uses to make sure patients step through its front door, he says.

Over the last year, Concord Clinical Health Center, in an effort to further decrease missed appointments, has been using eligibility- and benefit-verification software from its EHR and patient portal vendor, Emdeon, to collect copays, insurance information, and patient information in advance. Patients simply click a link on the practice's website that takes them to a questionnaire where they can fill out their demographic and insurance information.

This not only helps the practice figure out coverage and patient copays in advance, but because patients are spending time prior to the appointment filling out information (and subsequently receive both an e-mail appointment confirmation and a text-based reminder), they're more invested in the practice.

"Because the patient has seen we've made an investment in time in them, they see more professionalism and more value in what the practice is," says Robichaud. "So there's a certain level of respect that comes with going the extra mile with patients."

The text-based reminders, which are part of the Emdeon system, only require a patient to confirm "yes" or "no" to a scheduled appointment a few days in advance.

"We're seeing the trend of no-shows significantly reduced with text," he says.

For more on what Robichaud does, please see http://bit.ly/noshow_patientsto come.

Not following up: legal issues

No-show patients don't just have a financial effect on your practice. They can also present legal issues.

Julie Loomis, a registered nurse and attorney for Tennessee-based State Volunteer Mutual Insurance Company's risk-management department, says patients who miss appointments can create serious problems for practices that don't follow up.

"The most common allegations we see would be negligence, delay in diagnosis, or failure to diagnose," says Loomis.

This could put a practice at risk for negligence, for example, if a patient booked an appointment for examination of a skin lesion that turned out to be a melanoma. In such a case, if a practice didn't follow up with the patient who missed her appointment, the patient's health is at risk.

"The courts would look at, 'How much did you know about this patient?' [and] 'Was it a referral from another physician?' Those are all levels that could [be considered]," says Loomis.

Ericka L. Adler, a partner at the law firm Kamensky Rubinstein Hochman & Delott, LLP, and contributor to Practice Notes, Physicians Practice's blog, says a practice should always follow up with a patient who does not show, and document the reason - Are they sick? Was there a work issue? Does the patient not think a visit was needed? - and try to see the patient again, and document those efforts.

"Clearly where it is a true medical issue, if a patient does not get required care it can come back to hurt the physician," says Adler. "This is not entirely fair since the patient was the one that chose not to come to the appointment, but there are many reasons that a patient may miss a meeting, and it is best to follow up no matter the reason. How do we know if the patient is following the doctor's directions? Maybe they did not understand the importance of the follow-up visit? These types of issues … can create a liability for the doctor."

Adler recommends that practices institute pre-visit reminders and follow-up calls to patients.

"They do not need to chase the patient down unless it's a serious issue, just make a reasonable effort," she adds.

Improving patient relationships

Practices that have the best relationships with their patients tend to also be the ones that experience the fewest patient no-shows. But when you have hundreds or even thousands of patients to manage, how can your practice establish a better relationship with patients? Woodcock offers the following suggestions below (see http://bit.ly/late-patients for more tips on dealing with late patients).

1. Give plenty of reminders. Often times, patient appointments are scheduled weeks or months in advance, so patients are inclined to forget about them. Or, even if they're scheduled just days in advance, not every patient remembers to add an appointment to her calendar. To make sure patients show up, Woodcock is a fan of multiple reminders, such as automated phone calls, or personal confirmation calls 24 hours to 48 hours in advance. She also recommends practices use text-messaging reminders. "I generally recommend texting two hours before an appointment," says Woodcock. "It's not the only reminder that you should do but it's a great supplemental tool."

2. Engage patients. "The way we emotionally engage the patient while they're here is important," says Woodcock. "Helping patients understand why they're coming back is very important for the emotional engagement." Woodcock suggests allowing patients to be part of the appointment-scheduling process. "If you call in for an appointment, you [usually] hear, 'You want Thursday at 9:30?'" says Woodcock. "But you really need to start off with, 'What time and date work best for you?' I see good practices and they are capturing the fact that, for example, a Tuesday morning works well for a particular patient, and [the scheduler] says 'I see Tuesdays work well for you.'"

3. Give fair warnings. "I am not a believer in charging [patients] the first time for a missed appointment," says Woodcock. "But I do think charging the second time [is fair]." After the first missed appointment, Woodcock recommends sending patients a warning letter. It should say something to the effect of, "You missed your appointment, and that's a problem, and we want you to know, if you do it again, it's going to be [a certain amount of] money," she says.

4. Dig deeper. Don't just call a patient when they miss an appointment to ask them when they want to reschedule. "Call the patient and say, 'Are you okay? Are you alright?'" says Woodcock. "What you're doing is you are saying, 'We missed you. We are so concerned about you that we're taking the time to call you and make sure you are alright.'"

Most importantly, let patients know that when they miss their visit, it is not just about keeping a one-time appointment, it's about a long-term relationship.

"In order to really take our no-shows up a level, I think we've got to make our patients realize this is a relationship between you and the physician," says Woodcock. "You are not showing up for the doctor and the doctor cares about you."

In Summary

Want to reduce patient no-shows at your medical practice? Consider the following solutions:

• Give plenty of reminders, from automated telephone calls to text-based messages.

• Consider sending patients a warning letter for missed visits; if they miss a third time you may need to dismiss them from your practice.

• Encourage patients to fill out demographic and insurance information in advance.

• Check all your payers' policies to make sure they allow you to charge for missed visits.

• If your patient misses an appointment, always follow up; find out why they missed the appointment.

Marisa Torrieri is an associate editor at Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the October 2013 issue of Physicians Practice.