Should patients be charged for no shows?

No shows.  It seems that no matter what we do, we always have them.

Despite the fact that we call every single person on the schedule to remind them of their appointment the day before (the staff personally makes the call. We don’t use an automated system) we found that in 2009, we had 389 no-shows.

Slicing the data

Is 389 a high number of no-shows? I guess it depends on the size of the practice, how many encounters a practice has in a year or how many days the practice is open.

Our practice is open about 310 days a year. If you do that math, that comes out to 1.25 no-shows a day. In 2009, our practice had 10,660 encounters. If you do the math again, you’ll find that the 389 no-shows represent 3.64%.

Further analysis shows:

  • 314 patients accounted for 389 no-shows. This suggests that there were few repeat offenders.
  • 1 no-show     = 261
  • 2 no-shows    = 38
  • 3 no-shows    = 12
  • 4 or more       = 3
  • On average, our patients’ no-show 1.23 times in a single year.

What kind of financial impact did the 389 no shows create?

If one averages, let’s say, $112 a visit, that would mean we lost $43,568. That is assuming none of those 389 no-shows ever came back to the office for their missed appointment. Which wasn’t the case. We often call parents that no-show and ask them to reschedule. The question then is, how many of those no-shows never came back to be seen? Then, we could figure out the loss of revenue. Do you agree?

How about charging a no-show fee? Charging, let’s say $25 for each no-show, we would have recouped $9725. But that assumes we can collect 100% of the no-show fee. Which I doubt we could collect 100% of the 389 no-shows.

What is the intent?

The no-show fee serves two purposes. The first purpose is to deter people from doing it the first place. And some would argue that the second purpose is to offset the revenue they would have otherwise received had they provided the services.

However, does the no-show fee really deter patients from no-showing? If so, by how much? How do we know that because of the no-show fee, people prefer not to schedule appointments in advance, which may result in delaying care even further because they never end up calling us back?

Does charging for no-shows create an expense because now we have to send out a statement, which some people say it cost upwards of $5 to send? Does the no-show fee really offset the loss?

To charge or not to charge

I consider charging patients for no-shows a hassle. It’s bad enough trying to hunt payments down from patients that actually received services in our office and don’t want to pay. I can only imagine having to hunt down payment from a parent for a service we didn’t actually provide. But I could be missing the boat.

Is the no-show really a loss?

No-shows are considered an opportunity cost. But, when a patient no-shows, does the staff and doctor sit in the practice doing nothing? Or does the unexpected free time give the staff an opportunity to do other important things?

I don’t see a no-show as a loss because there are equally productive task that we all do in the office when a patient missed their appointment. Again, I might be missing the boat here but in our experience, no-shows are almost a good thing because it allows the doctor to spend more time with the families during a visit, make a few extra phone calls to parents, check on labs or simply take a break.

I understand that this notion doesn’t work if a practice sees only 10 patients a day and 2 or 3 people no-show. But if you have a busy office, like I suspect many of you do, the no-shows shouldn’t affect the practice’s bottom line because there is always an equally productive task to be done.

Missing the boat?

I don’t know if I’m missing the boat here. Hence the questions and the analysis.

But it seems to me there is more value in learning to manage missed appointment, than to put so much effort in trying to eliminate them by collecting fees for them when in fact, we are always going to have no-shows.

Brandon Betancourt manages a pediatric practice and blogs at Pediatric Inc.

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  • docguy

    My problem is with complicated patient no shows. I have infertility tagged as a 40 minute visit in my office because typically they come with lots of records and lots of questions and lots of education. When One of those no shows I really don’t have something to fill 40-45 minutes of my time. Usually I end up on kevinmd, but I guess that’s somewhat a productive use of my time.

  • bladedoc

    There was an interesting study from a pre-school that was having problems with parents being late in picking up their children. They decided to institute a penalty fee if you were more than a few minutes late. They found however that the rate actually went up significantly. It seems people took the existence of the fee as “permission” to be late. Could the same thing be true of no-show fees? If you decide to go ahead with them it seems like you have the opportunity to find out.

  • http://twitter.com/jhemming JH

    I have long believed that co-pays should be paid in advance and if you don’t show for your appointment you forfeit the co-pay.

  • KP ob/gyn

    I want the patient to put some value to the time I set aside for them. That is the ‘no show’ fee.

    I want my doctors to put some value to the time I set aside for them. That is the “doctor is running late” fee.

    We overbook the earlier patients to balance out the late arrival patients. I wonder if a ‘no show’ or ‘late show’ fee would help.

    • http://www.andeanquipu.org Eduardo Alvarado

      Aboslutely agree
      I f we are thinking about charging patients for our lost time, we should consider paying them a fee when we present late to the appointment (which is, unfortunately, common, I waited yesterday 2 hours for a dentist!).

      I think the important here is to preach with the example and consider puntuality as priority

      • John Ryan

        Sorry, I don’t agree that punctuality is a priority. Patients come to doctors for a service, and it can’t always be squeezed into appointment blocks. The most common patient complaint isn’t waiting time, but that their doctor doesn’t give enough time to answer their concerns. I simply tell them that I try to stay on time, but that I give every patient the time they need. I owe it to them to keep them appraised on how appointments are running and try to budget time to account for delays, of course, which is simple courtesy and good customer service. But waiting to see a doctor is a good investment for the inevitable time when they will need more time or an overbook. Those who give the staff grief about delays are the same types that grouse over their bill and want all sorts of special things done, in my experience. They disrespect you and your motivations; let them move on to the 10 minute “pill mills”.

        • Eduardo Alvarado

          By suggesting punctuality should be a priority, I am not intending to say that it must be at top. As you say, most complains come about us not giving enough time for questions. This, and punctuality, are different faces of the same problem: respect.

          MIS Prof has a good comment down here: “I would agree with the no-show fee if it were balanced by the running-late fee for the patient. I’ll show respect for your time if you will show respect for mine. Don’t routinely overbook and set aside the appropriate amount of time for the type of visit so that you don’t run late very often”

          • John Ryan

            My optometrist recently kept me waiting for an hour, while he removed a foreign body from a fellow patient’s conjunctiva. I guess he didn’t budget his time correctly. I guess he should have paid me for keeping me waiting. I guess he should have chased the injured man off to the ER, so he could have seen everyone else on time. I complimented my eye doctor, and you can bet I want him around, even if I have to wait.

  • Muddy Waters

    As a specialist, I have found that approx 90% of my no-shows come from consults. Makes sense, though, because if a referral is made by a PCP, the patient might not have been properly informed of the appt or see the need for the consult. I would still appreciate the courtesy of cancelling the appt, but one can dream I guess.

  • Dr. J

    When you say “there is always an equally productive task to be done” do you mean that there is an alternative income generating task to be done?
    In most physician offices the only task that generates practice income is actually seeing patients. Certainly many offices function in such a way that the physician stays behind hours after the end of the day completing paper-work and phone calls. In these offices a no-show seems okay because it gets the doctor home a little sooner, but this is a non-ideal practice management strategy. In a properly scheduled and managed office, which leaves a minimum of left over paper-work patient no-shows are simply lost income.
    I am not a huge advocate of penalties for no shows. Most one time no shows are good customers/patients and probably feel badly about the situation. We want to keep this business, these are nice patients who had a momentary lapse of memory. Repeat no-shows (with the exception of the dramatically mentally ill and a few others) are people who place little value on our time, effort and opinion. Charging these patients a fee is counter productive, they are not good customers and we should terminate our relationship with them.
    Truly the real solution to the problem of no-shows (which will always be present) is to develop flexible alternative ways to generate income. A 40 minute no show turns into 40 minutes of income from medical-legal reviews, consulting, writing (if you are KevinMD), etc.
    I think the solution in Dr. Betancourt’s practice is:
    1) Find an enjoyable and flexible alternative income stream that will take about 40 minutes of your time per day.
    2) Don’t worry about the one time no shows.
    3) Write a short letter to the 2 time no-shows asking them to be on time in the future.
    4) Fire all the patients (only 15) who failed to show up 3 or more times (unless there is a very good explanation).

  • John Ryan

    In my mind, there is no downside to charging a “no-show” fee:
    - if you collect, it partially defrays the loss of income ( and you can still have another income producing task to turn to, as mentioned above).
    - if you can’t collect, you get an early indication that this is a patient who disrespects your time. In our office, no reschedule until we have your credit card number for the fee. If they don’t pay, they are terminated, and I avoid writing off a larger fee, after services are rendered.
    - if its actually excusable, you get “nice guy” points for waiving the charge, which the patient remembers the next time you run late or mess up their charges.

    Let’s be real, where else but a physician’s office can you get so many free services without coming in or paying for them(refills, referral calls, record keeping, etc.)? Showing up or canceling is the least one can do.

  • Primary Care Internist

    Mr.Betancourt,

    As a practice manager rather than a physician, I wonder if you’re income is tied to the number of patient encounters, as it is with the physicians. If currently it is not, then would YOUR being paid on a per-encounter basis change your seemingly neutral or even positive view of no-shows? I believe it would, but invite you to please correct me if i am wrong.

    Most people don’t understand how doctors are paid, hence the endless posts and responses and how doctors “should” do endless tasks that aren’t otherwise billable eg. email, callbacks with lab results, referral auths for patients not seen recently, rx refills for same, etc. The list goes on and on.

    • http://pediatricinc.wordpress.com/ Brandon

      Mr. Primary Care Internist,

      My wife, who is a pediatrician, owns our private pediatric practice. I manage it.

      I’m well aware of the challenges doctors have to go through to get paid and all the work that goes into being a physician these days.

      So even though I’m not a doc, our household income is tied to her production and how well I manage the practice. In other words, I don’t get paid if she doesn’t get paid.

  • solo dr

    Good article and comments. I average one no show a day, despite having the patients reminded 1-2 days by live person about the appointment time/date and despite giving reminder cards at the previous visit. One is frustrating is having a patient not show up for a visit and then the next day getting a refill request for diabetic or other medication refills. I have tried to coordinate refills to be done at office visits. A patient realizes that when the bottle states no refills and the the meds are almost a gone, a visit is likely coming up soon.
    I tried the no show fee but found that patients complain to the variuos insurance companies. I called each of my plans, and half of them refused to allow a no show fee. Medicare considers it an extra fee and forbids billing it.
    The solution to frequent no shows is to either double book them or fire the patients. Frequently not showing up to a visit may mean that the patient is not concerned about staying healthy.

  • MIS Prof

    I would agree with the no-show fee if it were balanced by the running-late fee for the patient. I’ll show respect for your time if you will show respect for mine. Don’t routinely overbook and set aside the appropriate amount of time for the type of visit so that you don’t run late very often.

    My consulting fees are as high or higher than your office visit fee. I lose money if I spend unplanned time in a physician’s office. I’ve often thought of billing the offending physician if I wait more than an hour. Since such billing is a hassle and unlikely to result in payment by the physician, I usually just cancel that visit and find another physician. I make an exception if running that late is unusual and the office staff calls me so I can either re-schedule or delay going to the office until 10 minutes or so before ‘my turn’ comes up. I really appreciate that phone call!

    • John Ryan

      As above, hard to anticipate whether medical issues will be complex or trivial. Some doctors do need better time management, but when I run behind, its because of serving the patient, not my bottom line. I don’t get that feeling in my accountants office.

  • solo dr

    Another option would be to have the no show patient return sooner. For example, if a T2DM/HTN patient who normally comes in q 3 months no shows, make the patient come back in a month for a BP/T2DM checkup.

  • http://www.cosmeticsurgerytruth.com Dr D

    I tend to discharge patients who make no shows a common occurrence and restrict the times in which I will see them. No shows tend to be new patients. It is easier to fire them before they are “hired.”

  • http://freelancemd.com Freelance MD

    Interesting that almost all of the comments are around revenue that’s lost, not opportunity cost, and no mention of the astronomically huge cost that waiting rooms and overbooking for appointments cost the general population… not a great way to run any business.

  • steve weaver

    The best ideas I have found for repeat no-shows are:
    1) giving them the last appt of the day. If they show up, great; if not, go home early
    2) give them a day and not a time. If they show up, work them in.

  • http://www.talktoyourunconscious.wordpress.com BobBapaso

    The reason to send a bill to a no show is to motivate them not to make another appointment.

  • Brian G

    As a patient, I terminated my relationship with a dentist over this once. I had been seeing this dentist for about 5 years. Never got a reminder call about my 6 month cleaning, so didn’t show up, and he charged me a no-show fee. Paid my fee and found another dentist.

  • MeMyselfAndI

    I’ve been with my neurologist for over 20 years. I’ve never even been less than 5 min earlier than the 15 min early they ask me for (in other words, I always allow for at LEAST 20 min early). Recently, my appointment card was wrong .. someone had written the wrong time, but they charged me a $50 fee because I’d been reminded by phone call. I find that absurd given my history.
    I’ve been with my PCP for 15 years … 3 years ago, during snow and ice, I called to say there was a car accident in front of me and I’d be 5 min late. They refused to see me AND charged me a $50 fee … refusing to reschedule until it was paid. (their no call no show is not cancelling 24 hours in advance …not sure how to do that with car accident on the way to the appt)

    I protested that one (witht he PCP’s support) and got it over turned, but it took me 2 months to do so. (also, the PCP informed her staff to NEVER do that to a patient calling again!)

    Flip side was a family member who frequently was late or blew off appointments and just chose to sleep one day. They got charged full amount and I was FULLY supportive of that .. and I refuse to refer that person to any more of my doctors! they mess with my reputation when they do so.

    Late fees have a place … a good place. And as long as there is a ‘grace’ for unforseeable problems or misunderstandings in patients who never do this … it’s ok.