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....