Late arrivals, late cancellations, and missed appointments are the bane of every medical practice. They reduce your revenue, leave you with pockets of unusable space in your day, and may deprive other patients of the care they need. If you think about it, the true cost of a missed appoint isn't just the appointment that the patient missed because he/she will want to reschedule, taking up yet another appointment slot. This means the true cost of a missed appointment is two appointments, not one. In this article, we will look at ways to discourage and prevent missed appointments.

How can you deter late cancellations and missed appointments?
1. Have a written policy on cancellations, missed appointments, and their consequences. Make sure the late policy is clear, concise, explains why there is a policy, gives the minimum time to cancel an appointment without penalty, and details the consequences for late cancellations and missed appointments. Make the policy a clearly notable part of your paperwork, not part of the fine print, so that patients can't miss it.

Having a written policy, will help you, and any employees, react to late cancellations and missed appointments consistently. Inconsistent adherence to the policy will leave your patients unpleasantly surprised in the event you do charge a missed appointment fee. Some patients may even argue with you when you charge for one missed appointment if you routinely wave or neglect to charge the fee without rhyme or reason. No one likes trying to collect money from angry patients. Having a policy doesn't mean that you won't take true emergency situations into account, just that there are guidelines in place to help the office cope with the impact of missed appointments and to allow your patients know what to expect.

Give your patients notice of any changes to the policy and have them sign the updated policy at their next appointment. Providers who see the same patients every week or two, will find it easier to give advanced notice of a policy change than those who only see patients every few months.

2. Have a missed appointment fee. Do you remember the first time you noted that a doctor's office had a late cancellation or no-show fee? Knowing that there is a missed appointment fee will motivate patients to keep track of their appointments.

The fee will also help you. While you are providing a much-needed health care service, this is also your livelihood. A last-minute cancellation or no-show means you lose out on revenue for that lost appointment. Imagine that you have 7 late cancellations and 3 no-shows in a week and you average 24 appointments a week, earning an average of $70/hour in insurance payments. This means you earned $700 less this week. $700 in lost revenue could mean that you can't pay all your bills this month or that you can pay the bills but that you won't be able to take your salary, forcing you to dip into your emergency fund. With a $50 missed appointment fee, you could recoup up to $500 of your lost revenue.

What should go into your cancellation policy?
I. An explanation of why you have a policy is a good way to start off the policy. Metropolitan ENT & Facial Plastic Surgery, located in Alexandria, VA, has a very nice explanation of why they have a cancellation policy:

"We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly 'full' appointment book."

http://www.metropolitanent.com/webdocuments/Cancellation-Policy-Auth-Release.pdf (2009)

This paragraph emphasizes the impact of late cancellations and missed appointments on the treatment of patients, encourages patients be courteous and conscientious of other patients' need for treatment. This is a kind way to explain to any patient why it is important to give proper notice and helps them to think not only about their own life issues but also to try to be cognizant of the impact their actions can have on other patients who also have their own life issues.

II. Definitions and consequences . The cancellation policy should include the definitions of late cancellations, late arrivals, and no-shows as well as their consequences.

Minimum Time
Two of the most common cancellation policies are a 24-hour and a 48-hour cancellation policy. Another option is to set specific time on the business day before the appointment. This will help avoid cancellations of Monday appointments after the office closes on Friday, when you have no chance to fill them.

Each specialization has its own requirements for patient scheduling: counselors can often fill cancellations within a day or two while surgeons need one to two weeks to obtain authorizations for surgical procedures. If you aren't sure what the minimum cancellation time should be, consider how long it usually takes to fill an open appointment (or the average time it takes to obtain an authorization) and let that help you determine the minimum cancellation time. Check the cancellation policies of the peers in your area to see what their cancellation policy looks like.

Consequences:
A) A flat fee which is based upon an average of your insurance contracted rate. Set a fee that you feel has weight without being a real budget killer (some offices charge $25, but this might not be a large enough sum to make keeping the appointment worthwhile. A larger sum, $50 for example, is still doable but has a greater impact on the patient and is, therefore, a greater deterrent). If you find that your fee isn't working, you can always raise the rate. One psychiatric nurse practitioner I know raised her missed appointment fee to $75 and her late cancellations and no-shows dropped dramatically.

B) A graduated fee schedule:
1 st Missed Appointment: $0/forgiven (because life happens)
2 nd Missed Appointment: $50
3 rd and future Missed Appointments: $75

C) A three-strike policy: all patients who have three late cancellations or missed appointments in a year are discharged. You set the maximum number of occurrences and the time frame to fit your practice.

D) Charge a deposit to reschedule. The deposit can either be a missed appointment fee that must be paid before the patient is permitted to reschedule or it can be a deposit that is paid when the patient reschedules which you apply towards a missed appointment fee; apply, in part or in full, to the patient's copay, deductible, or co-insurance for his/her next appointment; or refund back to the patient at his/her next appointment.

Incentives Instead of Consequences?
Instead of negative deterrents, like the three-strike policy, you could reward the patients who show up on time. Chantal Halmos suggests a small cash discount or credit towards the appointment (which, she does point out, is prohibited by certain insurance companies!) and Lori Boyer and other suggests a weekly or monthly drawing for patients who show up on time for a small prize. Incentives aren't always the answer and may be time consuming or financially prohibitive for the small or solo practitioners out there. Whether you use consequences or incentive, or some combination thereof, do what works best for your practice and does not violate your insurance contracts!

III. Signature line . Make your patient accountable. Have them sign a copy of the policy or initial each provision of the policy to show they have read and agree to the policy. You can even include the cancellation policy with other office paperwork but however you do it, get an acknowledgement, in writing, of the cancellation policy and keep it in the patient's file.

How can you prevent late cancellations and missed appointments?
A written cancellation policy and a missed appointment fee will help deter missed appointments but you can also be proactive to help prevent missed appointments.

1. Appointment reminders. Appointment reminder can come in many forms from phone calls and text messages to email reminders and will help prevent late cancellations and missed appointments. The downside to appointment reminders is that either you (or your staff) need to spend time making calls or sending text messages or email reminders, and phone call reminder can be especially time consuming.

Instead of doing the reminders yourself, you can hire a company to send reminders by text or email for you. You will have to format your information so that the company can import it into its system. You can get around the fee by doing those yourself, but again, they will take time.

Another option is to convert a cellphone number into an email address, so that reminder texts can be sent as if they were email reminders and replies come back to your email account, not a cellphone. Text reminders are also more effective than voice mails since text messages have higher rate of being read than voice mails (do you know anyone who simply returns your phone calls without bothering to listen to the voice mail you left?).

Reminder Examples
The wording of your reminders can serve "as an invitation for people to reschedule," says Dan Clements in his article How to Reduce Cancellations, Reschedules and No-Shows: Our Strategy . (2008) In her article Appointment Cancellation Policy: Tips + Sample , Chantal Halmos agrees: "Stop telling your patients to cancel appointments!" (2015) When you include language about cancelling the appointment in the reminder, you make it easier for patients to consider cancelling/rescheduling the appointment.

Text Reminder:
This is a reminder of your appt on Tuesday, March 1 st at 4pm with Dr. Smith. Please call us at 623-555-5555 if you have any questions.

Email Reminder:
Subject Line: Appointment on Tuesday, March 1 st at 4pm

Dear John,

You have an appointment with Dr. Smith on Tuesday, March 1 st at 4pm at the Glendale office (Optional) . Please reply to this email to confirm your appointment.

Thank you,
George De Santos
Scheduling

Dr. P.R. Smith
Glendale Office:
1354 W Main St
Glendale, Az 85338
Phone: 623-555-5555

Phone Reminder:
Hi John, this is George from Dr. Smith's office. (if patient asks how you are, be sure to ask how he/she is doing!) I was just calling to confirm your appointment for Tuesday, March 1 st at 4pm (office location if necessary). (If patient confirms, confirm the appointment. If patient cancels, ask if he/she would like to reschedule while you have him/her on the phone). See you Tuesday. Have a nice day/evening/weekend/holiday.

VM Reminder Message:
Voicemail reminders offer the potential for HIPAA violations, especially if you are leaving the message on a home or office voicemail, which may or may not be private. Discretion is key. You may choose to say the doctor's name or you may leave it off and only include the call back phone number. The same for the patient name, since you don't want to confirm that anyone is a patient. One way to avoid some of the uncertainty is to ask your patients if you can leave messages for the patient at main phone number they give you. Take note of those who prefer you not leave a message.

Hi John (name optional) , this is George calling to confirm your appointment on Tuesday, March 1 st at 4pm. Please call the office at 623-555-5555 if you have any questions.

2. Remind patients of the fee. When patients call to cancel their appointments without proper notice, don't just cancel or reschedule their appointments. Remind them of the cancellation policy and of the fee. This will motivate some patients to make their appointments to avoid paying the missed appointment fee.

3. Limit the repeat offenders. Patients who routinely late cancel or no-show appointments have the greatest impact. Don't allow repeat offenders to abuse your time. Determine what is a reasonable number of missed appointments and then discharge anyone who exceeds this limit.

If discharging patients seems too extreme, take other steps to limit the impact of repeat offenders. Limit the number of appointments that a patient can schedule in a set time, whether they make it to the appointment or not.

4. Make appointments appear scarce. This is another way to limit the effects of repeat offenders but could be applied to all patients who cancel late or miss appointments. Dan Clements explains that by "[t]elling a patient that [he/she] can't get another appointment for two months delivers the message that a) you're in demand (always good for business) and b) they need to respect the appointments they've made." (Clements 2006) When the patient calls to reschedule, not having another available appointment for weeks or months may motivate the patient to keep the appointment they currently have.

While there is no way to eliminate them completely, there are several things you can do to reduce late cancellations and missed appointments: have a cancellation policy in writing; ensure patients and office staff alike are aware of the policy and the consequences; enforce the policy consistently; remind patients of the late cancellation fee when they call to cancel; use phone call, email, and text messages to remind patients of upcoming appointments; and limit repeat offenders by scheduling their next appointments weeks or months out or by discharging them. We hope this information helps you reduce late cancellations and missed appointments.

References
Articles about cancellation policies and reducing cancellations

American Medical News. 2010. No-Show Rates Lowest When Patients Called by Human Being. June 28. Accessed April 16, 2019. https://amednews.com/article/20100628/business/306289954/6/ .

Bohnett, Charlotte. 2017. Four Ways to Reduce Patient No-Shows. July 23. Accessed April 16, 2019. https://www.webpt.com/blog/post/four-ways-reduce-patient-no-shows .

Boyer, Lori. 2018. No Show Policies That Won't Scare off Patients. January 26. Accessed April 16, 2019. https://www.solutionreach.com/blog/no-show-policies .

CareCloud. n.d. Measuring the Cost of Patient No-Shows. Accessed April 16, 2019. https://www.carecloud.com/continuum/measuring-cost-of-patient-no-shows/ .

Chin, Sharon. 2018. Tips for ODs: How to Handle No-Shows and Late Patinets. August 08. Accessed April 16, 2019. http://blog.startyouruprise.com/how-to-handle-no-shows-and-late-patients-patient-scheduling .

Clements, Dan. 2008. How to Reduce Cancellations, Reschedules and No-Shows: Our Strategy. March 25. Accessed April 16, 2019. http://practitionersjourney.com/2008/03/how-to-reduce-cancellations-reschedules-and-no-shows-our-strategy/ .

. 2006. Reducing Cancellations and Reschedules. April 05. Accessed April 16, 2019. http://practitionersjourney.com/2006/04/reducing-cancellations-and-reschedules/ .

Cloud-Moulds, P.J. 2012. Why You Need a Medical Practice Cancellation Policy. November 17. Accessed April 16, 2019.https://www.physicianspractice.com/why-you-need-medical-practice-cancellation-policy .

. 2018. Here's Your New Patient Cancellation Policy. January 23. Accessed April 16, 2019. https://www.physicianspractice.com/patient-flow-wait-times/heres-your-new-patient-cancellation-policy .

Easer, Joseph S., MD. 2017. No-shows. May 16. Accessed April 16, 2019. https://www.mdedge.com/clinicalneurologynews/article/138300/practice-management/no-shows .

FSA store. 2019. Missed Appointment Fee: Reimbursement Is Not Eligible with a Flexible Spending Account (FSA). Accessed April 16, 2019. https://fsastore.com/FSA-Eligibility-List/M/Missed-Appointment-Fee-E503.aspx .

Halmos, Chantal. 2015. Appointment Cancellation Policy: Tips + Sample. February 04. Accessed April 16, 2019. https://www.remindercall.com/appointment-cancellation-policy/ .

McDermott, Erica. 2014. Turn Your No-Shows into Yes-Shows. March 03. Accessed April 16, 2019. https://www.webpt.com/blog/post/turn-your-no-shows-yes-shows .

ReminderCall.com. 2014. How to Help Customers Remember Appointments. April 08. Accessed April 16, 2019. https://www.remindercall.com/remember-appointments/ .

Incentives
Gonchar, Michael. 2018. How Well Do Rewards and Incentives Work to Motivate You? October 30. Accessed April 16, 2019. https://www.nytimes.com/2018/10/30/learning/how-well-do-rewards-and-incentives-work-to-motivate-you.html .

Halmos, Chantal. 2015. Reducing No Shows with Patient Incentives? May 07. Accessed April 16, 2019. https://www.remindercall.com/reducing-no-shows-incentives/ .

Laurie T. Martin, Joie D. Acosta, Teague Ruder, Matthias Schonlau, and Allen Fremont. 2009. Patient Incentives to Motivate Doctor Visits and Reduce Hypertension Disparities. Accessed April 16, 2019. https://www.rand.org/pubs/technical_reports/TR1167.html .

Cancellation policy examples:
Colon & Rectal Surgery Associates. 2019. Cancellation and No Show Policy. Accessed April 22, 2019. http://www.colonrectal.org/CancellationandNo-ShowPolicy.cfm .

Metropolitan ENT & Facial Plastic Surgery. 2009. Cancellation Policy/No Show Policy For Doctor Appointments and Surgery. October. Accessed April 16, 2019. http://www.metropolitanent.com/webdocuments/Cancellation-Policy-Auth-Release.pdf .

Nature Cures Clinic. 2019. Cancellation and Missed Appointment Policy. Accessed April 16, 2019. https://naturecuresclinic.com/cancellation-and-missed-appointment-policy/ .

Wedberg, Robin C., MD. 2019. Missed Appointment Policy. Accessed April 16, 2019. https://www.robinwedbergmd.com/missed-appointment-and-cancellation-policy.html .