Tuesday, June 27, 2006

No Show

I hate it when patients don't show up for their scheduled appointments.


I have a solo private practice, it's just me-- no partners, no staff, no secretary. I run on time and I don't double book. Patients know that the time is theirs, I tell them this before the first appointment: The time is reserved for you, if for any reason you're not going to keep the appointment, please call and cancel. I tell patients on the first day that I bill for any appointment not cancelled at least 24 hours in advance, with the exception of weather emergencies or the sudden onset of an illness (in other words: I don't want to be infected or vomited on). Any appointment that is simply not kept is billed in full and the cost of a missed visit can't be passed on to an insurer. I've said it, and a few years ago I wrote it and handed it out on a sheet of Office Policies.

My first few years in practice, I was lax about enforcing the late cancellation/ no show policy. I hate charging people for a service they don't receive, especially since it seems that most of my patients struggle a bit financially. At some point, I realized my schedule was mayhem. People didn't show up, or they called asking for a different time-- I like to be accomodating and would shift when I could, but I started to feel like each day was a juggling routine, and the number of No Shows and Late Cancellations escalated, often for reasons such as conflicting Karate lessons, or I Forgot. I quickly figured out that if I value my time at Nothing, the patients do as well.

I still am a bit ambivalent about it and often debate with myself what to do. If I call and find the patient, we can develop a plan -- to reschedule or for him to come in for the remainder of the time-- and at least I can do something else with the time. If not, I am held hostage in my office, waiting to see if the patient is simply caught in traffic or enroute. I could rant about why is it that I have to repeatedly call patients on their mobile phones to ask if they're coming, only to be told at 15 minutes after the hour that they're almost there-- they couldn't phone first to let me know they're running late/? Another post for another day.

I still sometimes let the Late Cancellation folks slide, though my neighbor told me she still puts it on their statement with a notation "Fee forgiven due to..." and I've adopted this practice, even if it's just to write "Fee forgiven, one time only." The repeat offenders, I bill, even if I feel badly about it.

So yesterday, I left the clinic and went to my office. My first patient did not show up. He's done this before, several times, and I was unable to reach him on the phone and the bill is in the mail. The background is that in the past, I've spent the better part of a weekend worrying about him and ended up having someone go to his house when I could not reach him anywhere for days: he was busy and hadn't checked his messages in some time, but was alive and well. My next patient also didn't show up. This gentleman has been in treatment with me for years, and has only once or twice missed his weekly session. He always comes on time, and he called last night saying it was important that we meet and he came in today at a time that was convenient for me-- I let yesterday's missed visit slide with a One Time Only notation. Today, I had a late cancellation from someone who had switched work shifts to help a desperate colleague-- the catch: she'd switched shifts several days ago and had exhausted her One Time Only (which I believe was actually two or three times) pass several missed visits ago. Still, this patient works several jobs and struggles to keep up-- I feel badly charging for the missed visit.

In the public psychiatry clinics where I've worked, No Shows are always a problem. The clinics get the bulk of their revenues from Medicare and Medicaid and billing is not allowed if the service isn't rendered. In effect, the therapists' time is valued at Zero, there is little disincentive for patients to come, or even to call, if they can't come (or if they oversleep or if something better comes up or if they don't want to talk about the yucky things going on in their life). In some clinics, patients are discharged if they miss three appointments, but that's never been the case in the clinics I work in, and across the board, Community Mental Health Centers sport a 30% No Show rate (sorry, I should have a reference and a link, plus I think it was actually only 29%).

It comes up with Pro Bono patients as well, and when I've offered free care through Maryland's Pro Bono Counseling Project, I've taken to adopting a No Show fee-- if you show up, care is free, if you blow me off, there is a nominal fee meant to discourage people from abusing my time.

Do these measures work? Mostly, I think so-- it's much less of a problem than it used to be, though I did just write about 3 patients who didn't come in the last two days, and I didn't even mention one of the patients at the clinic who didn't show....

27 comments:

Spiritual Emergency said...

Hmmm. Okay, how about I'll pretend (not too hard) that I'm clueless and I'll offer a casual bystander's assessment of the situation.

As long as I'm going to play casual bystander, I'm going to imagine that your office is open 7 hours a day -- that's 8 hours with 1 hour off for lunch). If you're like most of the psychiatrists I'm aware of (and let's face it, you might not be), a session runs 50 minutes. In my neck of the woods, 50 minutes with a psychiatrist will run you 150 dollars. 7 x 150 = $1050 a day x 5 days = $5250 a week x 4 weeks = $21 000 a month. Congratulations! You just (theoretically) earned in one month, $5000 more than I earned last year.

Naturally, you do have expenses -- rent, electricity, telephone, stamps, insurance, professional fees, etc. I don't know what that adds up to on a monthly basis so I'm going to have to guess that after those bills are paid you still have a sizeable chunk of change in your pocket.

Meanwhile, the way I see it, anyone who is running their own office with no staff and no secretary must be awfully busy. It wouldn't surprise me if you stay late at night or come in on the weekends to catch up on paperwork.

I think that a fair compromise would be that in the 10 minutes you have before a client shows up you put on a spot of tea. Then, cup in hand, cozy up in a chair and review your client notes before they arrive. Give them a maximum late window of 15 minutes during which you get to relax, drink your cup of tea, and stare dreamily out the window if you'd like.

If they don't show up within those 15 minutes, put your tea cup aside and invest the next 45 minutes in catching up on paperwork, or vacuuming, or polishing the front windows. Charge your client for the 15 minutes of late time (working with our theoretical figure of $150 that's $37.50) and chalk the rest up to recovered weekend and evening time. If you have enough no shows, you might even decide that you like it better that way as does your family -- not to mention your clients who probably don't make anywhere near $150 an hour before expenses.

Anyway, that's my opinion. Take it or leave it as you see fit.

Dinah said...

Interesting perspective, let me counter.

I don't work full-time, a family decision, no one's problem. I did earn more than $16,000 last year. The first year I earn $252,000 I'll invite everyone to the party.

Since Monday's frustration was the reason for my blog, let me tell you about Monday. From 9 to 1, I worked at the clinic. As a consultant, I'm paid $75/hour--minus insurance, parking, all expenses related to maintaining my license (granted I have to do this anyway), Uncle Sam, and Social Security. From 1 o'clock to 2 o'clock, I usually supervise a resident in a volunteer faculty capacity, but not this week. From 1 to 2, I walked the half mile to my parking space, drove to my office, opened my waiting room, got that spot of tea, and read the mail. I had patients scheduled at 2 o'clock (who is seen at a discounted fee and for whom I arrange to medications at no cost) and at 3 o'clock-- I didn't schedule 4 o'clock because I had to get the kid to the orthodontist and he's on Summer Schedule. Neither patient showed up, neither called to cancel: this I see as basic Consideration no matter how many millions a year I reap in. Not to mention the other patients who wanted that time. So yes, the furniture got polished and some journals got read, but it's not just about the money-- forgive me if it sounded that way-- but I would have rather either been working, or simply gone unpaid and had the time at home with the child who was left bored and unattended for 8 hours.

If only the hour by hour details of my life were as logistically as efficient as you suggest.

Even if your doctor brings in the big bucks, it's nice to call him, or your mother, or your best friend, or anyone else you've scheduled with, if you're not going to show up for an appointment.

Jennifer said...

SE...even though SR said it wasn't about money, I don't think you realize just how expensive having your own practice is. Not only do they have overhead costs, but they also have to pay all the taxes that your employer would normally take care of. All of that is a good chunk of the $150/hr. And if SR takes insurance, that cuts even more. And for someone who invests that much money and time into school and their training, I think they should get the amount they charge.

If someone in private practice doesn't work...they don't get paid. They have bills and their family to take care of. I know I'd be pretty pissed off if I showed up for work and my boss made me sit for 30-40 minutes (unpaid) only to find out that they didn't have work for me. That's a huge waste of my time and a loss of income for me.

The psychiatrist I used to work for was a pushover when it came to this. I constantly had to encourage him to charge patients who blatently decided not to show up. It was even worse when he had a consultation and the person wouldn't show up (2 hr. appt). He's so busy, it's practically impossible to get an appt. with him, so when someone doesn't show up not only does it cost him time and money, but it also keeps another patient from seeing him who would show up. That's what really bugs me about it.

I'm a firm believer that if there is not a good reason for not showing up for an appointment, charge the full amount. I would never do that to anyone. And if it was an accident, you would see me on the phone right away asking them to forgive me and I would take the responsibility. I would expect the same of the doctor if they didn't show up.

**end of my rant**

Spiritual Emergency said...

Interesting perspective, let me counter.

It seems to me that would only be fair.

The first year I earn $252,000 I'll invite everyone to the party.

I was planning on having t-shirts printed and selling them at retail, myself.

Since Monday's frustration was the reason for my blog, let me tell you about Monday...

I would want you to know that I read that passage with interest, and I appreciated it. The reason being is that I noted that I was essentially a mostly clueless bystander. I'm not a psychiatrist who runs an office.

I don't know your hours, your expenses, your experiences, or your life. All that I can bring to the table is my experience, just as all you can bring to the table is yours. I put my experience on the table, you put yours on the table, and now, we can look at it and if we're open to it, grasp a larger perspective. When this conversation is over and done with, we're both going to walk away. Ideally, we'll do so with a larger frame of reference.

If only the hour by hour details of my life were as logistically as efficient as you suggest.

The bottom line seems to be this: you both resent that your clients don't call to cancel and you also feel guilty charging them when they don't. My suggestion is that you put an end to that by putting some firm boundaries in place. You're willing to wait (and charge for) that first 15 minutes of no-show time. After that, "ownership" of the time reverts to you and you can use it to your own personal use and benefit while side-stepping the guilt that comes with charging full price.

Even if your doctor brings in the big bucks, it's nice to call him, or your mother, or your best friend, or anyone else you've scheduled with, if you're not going to show up for an appointment.

For what it's worth I agree that the world could be a better, kinder place with the infusion of a little more common courtesy. Unfortunately, reality happens. People get busy, they get sidetracked, they can be forgetful or downright inconsiderate. The other reality of the situation is that your loss is nowhere near the equivalent of their loss. Set your boundaries, level the playing field, use your free time to your best advantage, and stop feeling guilty about charging too much for what was nothing-at-all on one side and more-than-nothing on the other.

Next time a client doesn't show for their 3:00 appointment, you're free to go at 3:16 and they're $37.50 out of pocket. Let them walk up and rattle your locked door -- they'll learn something from it at a fee they can afford to pay.

Everyone's only slightly discontent.

Spiritual Emergency said...

If someone in private practice doesn't work...they don't get paid.

Put it in perspective Jennifer -- if someone doesn't have the money, you don't get paid. I don't have $150 an hour to spare. As a result (but only partly) I didn't commit to a therapeutic relationship with a psychiatrist. The bad news is, the one in my head was better (and cheaper) than what $150 an hour could buy me.

In the game of ecomonic life it's important to remember that bread is best buttered on both sides. If psychiatry prices itself out of the range of the common man, it will soon find itself dependant upon only the uncommon. Insurance companies on the other hand... they like the thriftiness of the common. Heaven forbid if they ever decided they like my angle more than yours, and they might. In spite of wherever I've been and who I've been there with, I think that would be a bad thing.

Spiritual Emergency said...
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Roy said...

I can't tell if this is a who's got it better or who's got it worse thread.

I used to undervalue my time, and charged accordingly. After doing that for a couple years, I quickly learned I couldn't afford to be the pushover. I later decided to work for a hospital, cuz I discovered I liked treating pts more than I liked running a business.

But here is how I wised up:
30 minute massage: $60
30 minute nail job: $45
Hair done: $80
15 minute plumber call: $135
New pair of shoes: $115

50 minutes of mental health check-up or whatever you call it: Priceless

Spiritual Emergency said...

But here is how I wised up:
30 minute massage: $60
30 minute nail job: $45
Hair done: $80
15 minute plumber call: $135
New pair of shoes: $115


Hmmm. If that's your benchmark, I'm willing to wager you're already drawing from a smaller and more select clientele. Meantime, you forgot this one...

Food: $150

Spiritual Emergency said...

What's really interesting about this thread is the degree of distortion at play. Many people have the impression that psychiatrists are living at the top of the food chain.

Surprisingly, at least some psychiatrists seem to have the impression that "patients" are booking their appointments between the manicurist and colorist.

I'd have more to say but I'm already late for my Pilates class.

Anonymous said...

I don't know about yours, but my pilates instructer has a message on her voicemail stating she charges for any session not cancelled 24 hours in advance, and NO, I'm not kidding.
--Dinah

NeoNurseChic said...
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Anonymous said...

I am an office manager for 3 female psychologist and we run into this problem all the time. Of the three doc's one is a stickler for the rules and charges when I think she should be more understanding. Another is a push over and forgives most all missed appointments. She takes that time to complete paper work and read CE materials. I'm not saying either is right or wrong but I have found that the one that is more forgiving has a more loyal patient base. Her main referral source is other patients. She is always booked and is currently booked until August. She begins to charge if she feels taken advantage of but at that time feels more justified...making more of a clinical issue than a financial one. On the other hand I can book any and all of you an appointment any time this week for the one who is a hard ass.
I'm sure each practice is different - it's just my observation after 6 years with these doc's.
Julie in Memphis

Spiritual Emergency said...

I don't know about yours, but my pilates instructer has a message on her voicemail stating she charges for any session not cancelled 24 hours in advance, and NO, I'm not kidding.

I should clarify, I was kidding about the Pilates instructor -- I don't have such things, I merely thought it made the perfect accessory to Roy's comparison of psychiatric services with human bling-bling.

Meantime, your Pilates instructor is welcome to make her own rules, just as you are welcome to make yours. If she makes $150 an hour per class and I miss it and she charges me for it, I'll have to work 15 hours to her 1 as penance. I think that's a little harsh although others might not have any difficulty with the cost of that lesson.

I can't afford Pilates instructors, human bling-bling, or psychiatrists. Don't worry Roy, you won't need to get out a tissue or spin the "better or worse" dial. I also seem to manage on my own without them. I'd fork out the cash for a plugged toilet though -- I've waded through some serious shit on my own but I know my own limits.

On the Same Page said...

I don't know if this will help, but an inmate called me a "F****** quack." I figured, "you can't say that to a major league umpire" (and who knows what they make per hour), so I notified him that, by statue, he was obligated to show me respect, and I was writing him up for a violation. He got 90 more days added to his sentence. As near as I can tell, at the rate of $150 per hour, that would be $324,000, enouugh to buy Roy:

5,400 30 minute massages
7,200 nail jobs
4,050 haircuts
600 hours with the plumber
2,187 pair of shoes
and apparently keep Spiritual Emergency going for 20.24 years.

This, dear ones, is why I get up in the morning.

Dinah said...

90 days in prison seems a bit harsh for being disrespectful. Remind me not to fool with you.

Roy really could use that massage time; I am a bit concerned about the haircut issue-- he might want to go to my husband's barber, Mike, who only charges $15 (would give him more than enough savings to get an extra manicure).

And you know, the NO Show post really had very little to do with money. Probably more to do with respect and basic consideration.

ClinkShrink said...

Ah yes, the prison threat. I once had an inmate threaten to "beat the...um...you know" out of me for refusing to prescribe the Thorazine he was trading for heroin. I wrote up a notice of infraction and he was given 30 days on lockup. As far as I'm concerned, the best safeguard for personal safety is making sure your patients know you take threats seriously.

Spiritual Emergency said...
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Spiritual Emergency said...

...and apparently keep Spiritual Emergency going for 20.24 years.

I'm sorry foo, I just can't make that kind of commitment to a doctor. But maybe Julie could set you up with that hard ass with the open schedule.

Roy said...

LOL, foo! "Gee, I don't know... $324,000 for 20 years with Spiritual Emergency?"

Not sure it's worth that ;-) ... and hey!, who's paying who?

Speaking of smilies... check out today's post.

Spiritual Emergency said...
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Sarebear said...

You know, I've been planning to get a little . . . assertive with my iatrist (next Thurs, EEEEEE!) about the fact that last time, he went on a 25 minute or longer tirade, about how I was a waste of time and stuff, and then later when I got up a teeny bit of courage and said, um, I got your point after 5-10 minutes . . . and he said, well, YOU didn't speak up, so I had no way of knowing, so it was your fault that all that time was wasted too (ok, he didn't say it like that, that last fault part, but what he said was basically saying that).

Since then, I've thought, GEE, he was 20 minutes late for at least 2-3 of my appts and almost 45 minutes late for another (I'm his first appt when I come in). One of the 3 20 minute late ones was snow, so I understand that.

But HE is going on about ME??? Last time, I only spoke what I despairingly and desperately scrambled for in my brain in the vain hope that it was the information he was looking for, and cringing at the almost inevitable verbal and psychological/emotional blow from him when it usually wasn't.

Have you ever told a patient that "that was WHACKED?" repeatedly, over and over, in their face, vehemently and with MUCH derision and scorn dripping from your voice? Astonishment and condescension, really, more than alot of derision and scorn, but sort of . . . .

Gee, pardon me for thinking a psychiatrist might actually connect my worrying about a variety of things to my ANXIETY DISORDERS! Um, Hello, you just stated that you felt I had SEVERE GAD . . . . IDIOT!

Course, I didn't/wasn't able to think all this through until weeks after . . . I was so verbally abused and emotionally pummelled I didn't know which way was up.

Erp. I've gone on and on again . . .

Guess I better go be WHACKED (as if I don't have ENOUGH problems w/negative labels, he gives me another one . . . . .)

Spiritual Recovery said...
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Dinah said...

A blog (and our blog especially), isn't a place to either seek or find medical suggestions. To quote the now-defunct Shrinkette: "Talk with your doctor." Hoping this doesn't offend anyone and wishing I had the right emoticon to offer!

Spiritual Recovery said...

A blog (and our blog especially), isn't a place to either seek or find medical suggestions. To quote the now-defunct Shrinkette: "Talk with your doctor."

Ahh. My apologies. sarebear, I've removed my response from this blog. I'll either post it at yours or send it to you via your e-mail address.

Sarebear said...

I hope you don't think I was seeking medical suggestions. Just kinda venting about the whole time thing and a few extra vents came out (I sound like a volcano, eep!)

Sorry.

Nash said...

Responding to the initial post...I'm a psychiatrist in a metropolitan area, and through my years of training I've spent time in clinics (academic, VA, and community mental health), that were brought to their knees through their unwillingness to adopt a no-show fee. For example, in the clinics sporting a largely TennCare population, the no-show rate for new evals approaches 60%. A psychiatrist's service should have value, both to the psychiatrist and the patient. I wholly reject the argument that "you earn this much, so therefore you should be comfy sipping tea and staring out your window." If the psychiatrist does not value his service and time, you can be sure that the patient will not. Psychiatrists also have the uphill fight of non-parity in medical reimbursement; moreover, psychiatrists schedule more time with their patients than do family practice docs. When a patient no-shows for their 45-60 minute appointment, this has a real financial impact on the psychiatrist. The burden of failed appointments of course affects other medical specialities; but because of the reasons already mentioned, mental health practitioners are especially vulnerable to the fiscal consequences of this. Add to all this the need to financially recover from years of medical training (residency graduates are typically behind on educational loans, retirement savings, affording/buying a home). Out of respect to the service offered, the years of difficult and underpaid training to be able to render such service, and the goal of supporting oneself and family, a reasonable no-show fee is more than appropriate.

jcat said...

My p-doc charges (in local currency terms) way more than $150/hour. Actually, way more than that in direct terms as well. He's worth it.
Mostly, he is running late - anything between 15 mins and an hour. And much as I might hate getting there on time and then sitting waiting, at least I know that it's almost always 'cos he has had a patient crisis. And deep down, it reasures me that if I end up in that position and call him...he'll be there for me even if it pisses other people off.
Like Roy says...priceless.