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Nabbing no-shows: What can you do when patients are absent?

From charging to keeping same-day waiting lists, physicians are attempting to keep missed appointments -- and lost revenue -- to a minimum.

By — Posted Nov. 1, 2004

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Physicians never have the same day twice, but if there's one constant they can count on, it's that some patients miss appointments.

Sometimes that can seem like a blessing, especially during a busy clinical day where you're already half an hour behind by 11 a.m. But whether you're happy or not, an empty slot on the schedule still means missed revenue that can never be captured, kind of like an airline that flies cross-country with empty seats.

But in today's tight health care environment, few doctors take empty exam rooms and underpopulated waiting rooms sitting down. From charging for missed appointments to investing in elaborate automated systems to remind patients that they're on the doctor's schedule, physicians are trying hard to keep that revenue from floating out the door.

Missed appointments cost a practice in three different ways, said Bob Murphy, MD, a reconstructive surgeon with a three-physician practice in Allentown, Pa. First you take the lost revenue from the missed appointment itself, then you add the cost of employees who spend time scheduling the appointment and making follow-up calls with the patient, and then there's the empty time that otherwise could have been filled with other patients, he said.

"We allot 45 to 60 minutes for a new patient," Dr. Murphy said. "We could see anywhere from three to 10 people for follow-ups during that time."

Charge it

With lost revenue adding up, more practices are beginning to charge for missed appointments, trying to translate the issue into a language patients can understand: a financial one.

Other groups double-book at certain points of the day, though that can help perpetuate missed appointments because patients become irritated with waiting a long time to see the doctor.

"The root of it is the frustration that a practice understands patient access is a problem, yet every day, there's still 5% to 10% no-shows," said Elizabeth Woodcock, principal of Woodcock & Associates, a consulting firm in Atlanta. "Charging them or telling them you'll charge is the threat that gets them to come in."

It also can help a practice recoup some of its lost revenue, if the patient indeed pays the bill. Many practices simply hang the threat of a charge out there simply to get the patients through the door. Or, if a patient misses one appointment but shows up the next time, the practice issues a warning and waives the fee.

AMA policy states that a physician may charge a patient for a missed appointment, or for one not cancelled 24 hours in advance, if the patient is fully advised the physician will make such a charge.

Arash Tirandaz, MD, an internist in Plano, Texas, said his four-physician group recently instituted a policy to charge patients $20 for a missed appointment. While Dr. Tirandaz said he doesn't see the missed appointments being that detrimental to his busy schedule, one of his partners, an allergist, loses more when a patient skips an appointment.

"For an allergist or a surgeon, where you have high charges for a visit, it makes a big difference," said Dr. Tirandaz, the CEO of the group, Plano Internal Medicine. "For my practice, it's not going to make a huge dent one way or another. I really only intend to use it for people who really abuse the system."

With specialties such as psychiatry and ophthalmology, where large blocks of time are devoted to a single patient, the charges can't be idle threats. Priscilla Ray, MD, a psychiatrist in Houston, said she discusses her policy of charging for missed appointments with patients up front, and there are very few circumstances that would cause her to waive the fee.

"They're told, 'You're charged whether you come or not,' " Dr. Ray said. "I tell them they're leasing my time, and it's a lot of time. The point of my policy is it's spelled out in the beginning. It wouldn't be fair to do it if I didn't do this in the beginning."

While charging might work for some specialties, doctors also run the risk of alienating patients with the charges, consultants said. Woodcock described one primary care practice that studied the effect charging its no-show patients had on its revenue and patient population.

While the no-show rate was down slightly after six months, many of the missed appointment charges went unpaid, and the list of patients who transferred to another doctor were the same ones who had been charged for not showing up, she said.

"The issue in the patient's mind is [physicians] tell the patient they can't be seen for 4½ months, then they have the audacity to charge when they don't show up 4½ months later," Woodcock said.

Charging patients adds paperwork and costs for the office, and even if the group is vigilant in sending out its bills, many of the charges go unpaid, she said. Also, the targets of missed appointment charges most often are the busy professionals who are well-insured -- the type of patient a practice generally doesn't want to lose, Woodcock said.

Instead, there are proactive alternatives to addressing no-shows, Woodcock said, including tracking them to learn who are the chronic cases and scheduling them near the lunch hour or the end of the day.

"Don't start charging patients until you have a call plan in place," Woodcock said. "Appointment reminders are tangible. You also can ask them if something comes open earlier, do you want us to call?"

Phone first

Though it's tedious work, many practices use some form of a telephone reminder system to confirm upcoming appointments with patients. Though it may seem like the simplest idea, consultants say it's the most effective way to keep no-shows to a minimum.

It's also the only way to deal with new patients, who typically require longer blocks of time. New patients also are the hardest ones to gauge, since the office does not have a history with that person.

Christine Schon, who serves as director of cardiac services for Deaconess Billings Clinic in Billings, Mont., studied no-show rates several years ago while at her former organization, Bassett Healthcare in Cooperstown, N.Y.

Looking at just one primary care clinic in the system, Schon found that new patients who had to wait more than three weeks for an appointment had a greater chance of not showing up, and the lost revenue per missed appointment averaged out to be more than $100 per visit.

System officials decided to address the issue by calling patients to remind them of their appointments, which, when they reached people, cut the no-shows in half, Schon said.

The problem with some call systems, though, is that employees spend valuable time making calls during business hours, only to get answering machines and voice mail boxes, where the messages that are left might never reach the intended person. It's not until the time of the appointment, when the patient either shows up or doesn't, that the practice knows if the staff member's time was spent wisely or wasted.

"You're paying people to remind people," Dr. Murphy said. "Then, if they don't show up, it wastes people's time on the front end."

To get around this problem, some practices request a confirmation call from the patient, with enough lead time to fill the slot with someone else if the person doesn't respond or cancels the appointment. Some offices keep waiting lists of patients who have an appointment several weeks out but would like to get in to see the doctor sooner.

Waiting lists can help fill more slots at the last minute, especially if a practice takes careful notes and knows what patients are willing to do anything to get an earlier appointment.

"We call everybody the night before, and we have a waiting list of people who would take same-day appointments," Dr. Tirandaz said. "If [patients] tell me in the morning that they won't be there, we can try to fill it. Otherwise, it's a wasted slot someone else could have used."

To avoid the staff hours involved in making calls, groups have started to invest in automated calling systems, which also can interface with practice management software to conduct the entire appointment confirmation process with very little, if any, human input.

"Many physicians like to have their staff make these calls, since they believe their staff should be able to do one more thing," said Gary Pritts, president of Eagle Consulting Partners, a consulting firm in Cleveland. "However, the staff often is not able to make the calls consistently when other matters come up."

Automated systems also can make calls later in the evenings, when the chances of reaching a live voice are better, and they allow for an immediate confirmation, consultants said.

Schon said Bassett Healthcare in New York eventually settled on an automated system to call patients, and when she arrived at Deaconess Billings Clinic, she found a system already in place.

The Montana clinic did struggle with the voice patients would hear, however, because it was unsure how patients would react to being called by a computer. Instead, the system uses a human voice, which adds a more personal touch to the calls, she said.

"I'm a strong advocate for using technology in a way that benefits patients and the practice," Schon said. "Systems have advanced so much over the years. Given the economic realities of health care, this is a critical part of the practice."

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ADDITIONAL INFORMATION

Keeping no-shows to a minimum

Charge for missed appointments

Advantages: You can at least collect something for the lost time; the threat exists to convince patients to come in for the appointment.

Disadvantages: You could alienate some of your most desired patients; valuable staff time and money is spent sending out bills, many of which go uncollected.

Double-book

Advantages: You can be assured of filling virtually every slot, regardless of the no-show rate; more patients means more revenue.

Disadvantages: If all of your patients show up, you're bound to fall pretty far behind your schedule; it doesn't fix the problem of missed appointments.

Reminder calls and waiting lists

Advantages: You can get in touch with patients shortly before the appointment, and if they can't make it, you can refer to your waiting list to quickly fill the slot; it's a personal touch that patients will respond to.

Disadvantages: A lot of staff time is spent leaving messages during business hours; you can never be sure if the patient got the message.

Automated phone system

Advantages: You can make calls at night, when patients are more likely to be home; the system can interface with your practice management software and operate with very little human input.

Disadvantages: Could be expensive to implement and confusing for staff; patients might not like the automated aspect of it.

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