Progressive Focus©

Progressive Focus© Newsletter


Volume 6, Number 3 Fall, 2005
Helping You Manage the Expectations of Managed Vision Care

In This Issue:

No-shows: Manage This Pesky Annoyance Before it Can Cause Financial and Legal Problems For Your Practice

There are many telltale signs of administrative inefficiency in an ophthalmic practice. Some are easy to qualify and quantify while others are rather more difficult to get one's hands around. Whatever the case, it's essential that eye care providers (ECPs) do all they can to prevent small annoyances from turning into more significant, possibly costly problems.

No-shows are one of those pesky annoyances that plague virtually all practices. And the annoyance would seem to have a simple solution - double-booking to offset the no-shows.

But as simple a response as it is, double-booking does not get to the core of the problem and address it with a more effective, comprehensive "fix." More significantly, some ECPs simply are not aware of the collateral damage that can accrue to a practice as the result of a no show problem that goes unaddressed.

Liability risks - a hidden danger

In recent years a growing number of patients seem to have become increasingly irresponsible about keeping their appointments, or calling to cancel in a timely manner. They apparently believe, obviously mistakenly, that their insurance plans will cover the costs of any missed appointments.

But there is more than just the problem of lost revenue when a patient fails to show up for an appointment. No shows actually carry the possibility of liability risk for the practitioner since there could be injury to a patient who fails to present for a scheduled follow-up appointment, fails to go for a referral appointment, fails to take prescribed medications as directed, or otherwise fails to comply with the doctor's post-treatment instructions. These and other examples fall into a general category of non-compliance.


Although many practices believe it is the patient's responsibility to keep appointments, juries tend to have a different view. Juries look more favorably upon doctors who have documented a sincere effort to contact patients to find out why appointments were missed.

Paul Weber, JD, Risk Manager
Ophthalmic Mutual Insurance Co.

Many doctors find it hard to fathom that a jury would hold a practitioner liable for injury resulting to a non-compliant patient. After all, it was the patient, not the doctor, who failed to follow instructions. But in the sometimes-crazy world of malpractice awards, cases have gone against doctors who did not make what the jurors felt were adequate efforts to follow-up.

One of the basic problems for the practitioner is that a patient's non-compliance may be unintentional. For example, despite the doctor's attempts to be as clear and specific as possible, a patient may not fully appreciate the seriousness of their condition, or the importance of seeking follow-up treatment either with the original ECP or from a referral physician.

Therefore, accurate and complete chart documentation is essential, especially as protective defense in the event a suit is brought against the doctor. Plaintiff's counsel may be successful arguing that a missed appointment and subsequent injury were caused by unclear or inadequate instructions, or that the doctor did not adequately impress upon the patient the importance of follow-up care.

Ophthalmologists typically are cautioned that no-shows, and even cancellations, are not to be erased from the master schedule. And they are told that every practice should have in place a written protocol for contacting patients who no-show, and that those efforts should be documented in the patient chart.

Attorneys would probably caution optometrists similarly on taking these steps as a means of documenting both non-compliance and the practice's appropriate efforts to follow-up.

Why do patients no-show?

The answer is as simple as it is complex, and the excuses are seemingly unlimited: I forgot, or I had another appointment, or I didn't want to miss Oprah.

Many practices find that no-show rates fluctuate with the season. They're typically higher in the summer when it may seem as if some sort of "collective amnesia" overtakes whole families, and nobody remembers a doctors appointments. No-show rates may also spike in late November and throughout December as seasonal spending patterns shift toward holiday gift purchases and away from everything else.

Some groups of patients are notoriously unreliable about keeping their appointments. Medicaid beneficiaries may be among the worst offenders.

Medicaid families often are comprised of a single parent with several children. And when one family member can't show up (e.g., a child is sick) or doesn't show up (e.g., the mother can't get off work) that inevitably means the entire family no-shows. And this can mean significant holes suddenly appearing in the schedule when two, three, or even four appointment slots go to waste at the last minute. (More on this later.)

Looking at the data: What is a no-show?

In trying to get one's hands around the problem it helps in the analysis if the practice has a clear, internal definition of no-show. Some practices count as a no-show only those patients who don't present for the appointment and who also do not call. Other practices consider it a no-show if a patient calls and cancels at the last minute, or calls and reschedules at the last minute. In either of these latter cases it's too late to fill the appointment slot that had been reserved, and so the anticipated revenue is lost just the same as if it had been a "traditional" no-show.

For tracking purposes in formulating a game plan, many experts opine that last minute cancellations with or without rescheduling should be counted the same as a no-show. Whatever method you use to track the problem, I think the practice should differentiate how it responds to various patients when they next try to schedule an appointment. Frankly, despite the fact that in all these examples revenue is lost, the patient who calls at the last minute to cancel or reschedule at least has tried to do the right thing. That patient deserves more consideration than the patient who gives you none.

Once the practice has quantified and qualified exactly what is a no-show it can begin the process of finding effective means to remind patients of their appointments, and follow up when patients are non-compliant.

Taking pro-active steps to reduce the number of no-shows

Successful practices have found that there are several components to a system that will reduce the number of no-shows. Two of those components stand out above the rest as absolutely necessary for all practices regardless of patient base demographics and circumstances.

One key component reduces opportunities for multiple no-shows in a morning or afternoon session by limiting the number of family members booked on the same day, or in consecutive time slots on the same day. The other key component is an effective reminder system. Let's look at both.

Controlling the schedule


I claim not to have controlled events, but confess plainly that events have controlled me.

Abraham Lincoln
Letter to A.G. Holmes, 1864

As much as we'd like to accommodate every appointment request, logistics and logic tell us that we cannot. There are only so many 9 a.m. appointment slots on Saturdays, and not everyone can be seen after school but before 5:30 on a weekday. And so we must be judicious in how appointment slots are created and filled.

Many practices have a policy that not more than two members of a family will be scheduled on the same day in consecutive appointment slots. Thus, if mom and dad and two kids need exams then the kids can be scheduled together. Or mom and one kid can get back-to-back appointments. Or mom and dad can get back-to-back appointments in the morning, and the two kids can get appointments after school.

But mom and/or dad and two kids cannot all get appointments, one after the other, say on Saturday morning. From experience we know that block-booking families can be a set up to a scheduling disaster.

In fact, burned once too often, some practices have implemented a policy that no more than two family members can be seen on the same day -- period. They know that if mom misses her appointment in the morning there's a pretty good chance that the kids will also miss their appointments after school, and so the policy is in place to minimize the possibility of multiple no-shows or late cancellations.

Whatever your practice may choose to set as policy, it should be applied consistently within categories of patients. But it might not necessarily be applied rigidly across categories of patients.

For example, office policy might be that for families made up of patients new to the practice, no more than two appointment slots are available per family per day. On the other hand, for a family made up of established patients who have no history of missed appointments the policy might be more liberal - a recognition that the established family is less likely to no-show or cancel at the last minute.

What about double-booking?

Many practices routinely double-book as an anticipatory means of offsetting the effects of no-shows. Typically they'll try to predict those days and times when it's most likely that patients will no-show, and to then load-up the schedule during those times on expectations that the predictions will hold true. Sometimes they win; sometimes they lose.

Clearly it's a gamble, and double-booking will backfire on the practice if too many of the expected no-shows do present for scheduled appointments along with the add-ons. The last thing your receptionist or tech needs at that point is two or three patients sitting in the reception area comparing notes and becoming increasingly angry upon discovering that they're all scheduled for the same time. And now you're late seeing all of them!

If you choose to double-book then do it cautiously, and certainly not across your entire schedule. Though it's unlikely that all of the double-booked appointment slots will actually result in double patients presenting to see you, it's too easy to think of double-booking as the cure when, in fact, it's only a Band-Aid.

Still, if well thought out, double-booking can work to your advantage. For example, if you have chosen not to dismiss patients who chronically no-show, then appointment slots allocated to these chronic no-shows are good choices for adding another patient who is likely to present. Or, flipping the situation around, you could schedule all chronic no-shows only as the second name in double-booked appointment slots.

In either care, historic patterns are likely to repeat, and some/many of the chronic no-shows may do it again. But in these instances your time slots won't go begging for patients. And your daily revenue flow won't be shot full of holes.

When do you contact patients to remind them of appointments?

Virtually all practices call patients to remind them of appointments. In today's world where so many people fail to take personal responsibility, practices must be proactive and remind patients, especially when their appointments might have been made a few months or perhaps many months earlier. Still, the timing of the reminder call is critical in any effort to head off no-shows or last minute reschedules.

I would suggest that it's not a waste of effort, but it is low benefit, to call patients the night before an appointment. At that point it's often too late to remind the patient of something she may have forgotten, and to hope that the patient will still present if she did forget.

For example, if a patient only realizes when reminded by your staff's call that she has an appointment at your office tomorrow, then it's quite likely that she has other plans for that time you had reserved. And it's more likely than not that she'll want to reschedule with you rather than cancel this newer commitment that she does remember. That's not fair to you as the one who had first reserved the time for her, but it's also a reflection of human nature.

Much better, I think, to place the reminder calls two days in advance. This allows the patient sufficient time to get her schedule in order if there are any conflicts as a result of forgetfulness. And it gives the patient less "wiggle room" to ask for a last-minute rescheduling.

If you choose to issue reminders by postcard then I suggest sending them out to arrive no less than one week prior to the appointment. With that minimum amount of notice you'll still have reasonable opportunity to fill slots if patients call back to request a reschedule.

Do you send written reminders, particularly to no-shows?

Some practices have a policy of "call, call, send" when following-up on no-show patients. The staff will make two attempts to reach the patient by phone, and will then follow-up with a postcard or letter. All efforts to reach a no-show patient are documented in the chart.

Each practice must decide how aggressively it will undertake contact efforts with no-show patients. Certainly the practice must be more aggressive with at-risk patients - for example, those with identified glaucoma or retinal problems.

Practices may be concerned about postcards and HIPAA. Does it violate HIPAA to contact patients by postcard, or is it better to use a letter?

It is always appropriate to err on the side of caution, so a sealed letter is better than a postcard. But that does not mean that a postcard is automatically problematic. Assuming the postcard contains nothing that could be considered protected healthcare information (PHI), then you need not be overly concerned about a HIPAA violation. A simple, appropriately worded appointment reminder should not be a problem.

However, there is another, better reason why I would recommend sending a letter over a postcard -- particularly with patients who repeatedly fail to follow instructions or show up for appointments -- and that reason relates to documenting your efforts. If you send a postcard you can't put a copy of that contact effort in the patient chart. And in the event of litigation you're left in a weaker position to prove your actions. On the other hand, if you send a letter it is easy to document your efforts by placing a copy in the patient record.

Sometimes you simply have to play "hard ball" with non-compliant patients


You can't make an omelet without breaking eggs.


What do you do if patients repeatedly no-show in your practice, or fail to go for referral care, or otherwise demonstrate chronic non-compliance? The simple answer is get rid of that patient - get rid of the problem. But, obviously, it has to be done properly so as to avoid questions of patient abandonment. Again, proper documentation is essential.

Some practices set a "three strikes and you're out" policy. The doctor will warn chronic no-show patients that the next time they no-show will be their last. This warning is documented in the chart.

Upon the third incidence the patient is sent a letter dismissing them from the practice. The letter is generic and simply references "...failure to follow medical advice." It states that the doctor will continue to see the patient on an emergency basis for the next 30 days, and will provide assistance to the patient in finding a new doctor. Strict enforcement of this policy should result in fewer no-shows as problem patients are weeded out and removed from the practice. (Be certain to get your attorney's guidance before dismissing any patient.)

If the patient is a Medicaid beneficiary then a copy of the letter should go to the Medicaid agency responsible for the patient.

Sometimes third party payers are willing to help, especially if you can present documentation of an unacceptable no-show rate or non-compliance. For example, you might ask a payer to send a letter to its insureds with children under "X" years old stating that no-shows are an increasing concern, and that the doctor's office has the right to bill for the visit (and be paid by the parent) if the parent doesn't show up with the child, or cancel per the practice's published cancellation policy.

Charging for missed appointments?

Opinions certainly vary on whether it's worth the time and effort to bill patients for missed appointments. Certainly every practice will need to decide on a policy.

Some practices write-off the first time as a courtesy, but dismiss the patient if it becomes a chronic issue. Most practices that charge for no-shows feel it has reduced the problem. A few patients pay; many complain. Those who refuse to pay are likely not to return to the practice because they realize there is a no-show fee sitting on the books.

And so what if they don't return? Let those chronic no-shows, especially the ones who refuse to pay for missed appointments, become someone else's financial and legal headache. You don't need patients who would repeatedly fail to show you even a modicum of respect.

Giving your patients proper notice

If you decide to charge for missed appointments or cancellations without minimum notice then you'll want to post a notification so that all patients can be properly informed. At a minimum, the notice should be posted at the reception window. Some ECPs also include the notice on the patient bill. If you publish a newsletter or have a website then the notice certainly should go there.

The notice need not be long or involved. Something simple will suffice -- for example: There will be a $"X" charge for all missed appointments not cancelled or rescheduled "Y" days prior to the day of the appointment. (You fill in the values for "X" and "Y.")

Making sure everyone is pulling in the same direction

Savvy practice owners know that the methods and efforts put into confirming appointments by one staff person can be quite different from those of other staffers. Leaving a message on an answering machine or with a child is not the same as speaking directly to the patient and confirming that the time is reserved specifically for them. And so I recommended that staff training emphasize a uniform methodology for confirming appointments and, perhaps, even developing a standardized script from which the callers work their schedules. Zero percent no-shows a majority of days is not impossible.

But in setting that goal as an objective the practice owner must recognize that no-shows actually make the day easier for staff - fewer charts, fewer visit slips, and fewer insurance forms all result in less work and a less "frantic" day. Thus it's essential that practitioners monitor staff efforts so as to be certain that everyone is putting in the requisite effort to reach every patient and confirm every appointment.

If a staffer "cruises" and makes the workday easier by not aggressively confirming appointments then holes in your schedule will reflect that lack of effort and concern. You can't afford that, and it's a pure dollars and cents issue.

Staff should understand that continued employment is dependent upon the practice generating certain revenues and profit margins, both of which are made all the more difficult if there are holes in the schedule as a result of (preventable) no-shows.

Does this mean you need to offer incentive pay - perhaps a bonus to the appointment staff for every day with zero no-shows? While I do think that zero no-show days could be established as one performance measurement for annual review evaluations, I don't know that it's necessary to pay a daily bonus for each day without no-shows. In my opinion zero no-shows should be a part of the job expectations for those who confirm appointments, and any performance bonus should be paid for continuous excellence, not just for an excellent day here and an excellent day there.

Quick Quiz

1) If a practice decides to charge for no-shows or appointments cancelled without minimum notice it should:

  1. post an announcement of the charge at the reception desk, on its website, in the practice newsletter, etc.,
  2. refuse to see any non-emergency patient who doesn't pay the charge,
  3. specify the amount to be charged,
  4. both a and c,
  5. a, b, and c.

2) Sending patients a postcard to remind them of an appointment is:

  1. always appropriate if sent at least a week in advance,
  2. appropriate if no PHI is disclosed,
  3. never appropriate due to HIPAA concerns,
  4. both a and b,
  5. none of the above.

3) Patients who miss appointments:

  1. should have their medical records documented,
  2. should be called to determine the reason,
  3. should be considered candidates for dismissal from the practice if the problem becomes chronic,
  4. both a and b
  5. a, b, and c

Answers to Quick Quiz

1 d

2 b

3 e

Education is what you get when you read the fine print.

Experience is what you get when you don't.

Copyright © 2003-2007, Gil Weber, MBA. No part of this newsletter may be reproduced or distributed in any form whatsoever without the author’s prior written authorization.

These materials are intended to provide useful information about the subject matter covered. The author believes that the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the materials are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.

The materials are not intended as legal advice, nor is the author engaged in rendering legal services. The materials are not intended as a replacement for individual legal or professional advice. Information contained herein is presented only for illustrative purposes, and it should not be used to establish any fees or fee schedules, nor is it intended and it should not be construed as encouraging any user of the materials to take any actions that would violate any state or federal antitrust laws, tax laws, or Medicare or Medicaid laws.

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