Outpatient: No med refills outside of appointment time?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

neolandrover

Full Member
10+ Year Member
Joined
Jun 7, 2011
Messages
20
Reaction score
18
I recently heard about a private practice physician who does not refill medications outside of appointment times. I'm curious if any practicing psychiatrists here employ similar rules? Or is it too harsh?
 
I refill medications as long as the patient is adherent with their recommended follow-up (at least every 2-months). I do my best to not prescribe new medications outside of appointments.
 
I do if overall patient is generally compliant, has been stable and missed apt due to rational reason, controlled substance not more than 5 days.
 
IF there was a rational reason for the no show I would refill for them, but would stop if it became a pattern. There are some patients, more unstable, I want to keep closer tabs on and I specifically give them rx to cover them until the next appointment and insist they come in for refills.
 
That's likely a rule to encourage patients to keep appointments but not one that is enforced 100% of the time.

In FM I prescribe enough medication to get to the next time I want to see you. If you run out before you schedule (either because you forget or had to reschedule or whatever) I'll do a few weeks of meds from a phone call but no more than that generally speaking.
 
I do refills, even stimulants for well established patients, you really do get to know your patients and if someone is chronic no show they may get a few days till their next apt with a warning that they'll get no further refills (this is a fellows clinic). I think in PP one can structure it how they want, depending on how much of a customer service friendly take you want, expect most cash patients to demand refills called same day etc..
 
That policy seems too harsh, and ignores the process of weighing risks and benefits / using your judgment. Is it really better to have someone who runs out of their medications stay off until you can see them next? In most cades I doubt it.
 
That's likely a rule to encourage patients to keep appointments but not one that is enforced 100% of the time.

In FM I prescribe enough medication to get to the next time I want to see you. If you run out before you schedule (either because you forget or had to reschedule or whatever) I'll do a few weeks of meds from a phone call but no more than that generally speaking.

This.

I have a “policy” that refills are meant to happen in appointments, and I try to stress this. If life happens, I do provide 1 month refills as long as an appt is scheduled within 1 month.
 
I do refills all the time outside of appointments if the patient has been following up as advised. Especially for SSRIs.
 
An attending during my residency in his PP billed for everything : refills, late cancellations, copy of records, forms to fill. Regardless, he was flooded with private insurance patients and somehow made 500k ish and worked 30 hours a week.
 
I agree that that seems a bit harsh to me, though it also depends on what medications are being requested. Controlled substances are a no-go - if someone is on BZDs, I warn them of withdrawal symptoms, encourage them to present to an ED if they present with significant withdrawal, and try to schedule an urgent appointment with them as soon as possible, usually as a double-book.

For things like antidepressants, I will typically refill them as these are relatively benign. Obviously I would like to see the patient to see how they're doing, but I justify the risk of discontinuing and the potential for a subsequent decline as greater than the risk of not seeing the patient.

Other things are on a case-by-case basis, but I will typically provide a refill to get them to their next scheduled appointment. If they no-show after that, I will typically ask the front staff to check in with the patient and see what the deal is.
 
I agree that that seems a bit harsh to me, though it also depends on what medications are being requested. Controlled substances are a no-go - if someone is on BZDs, I warn them of withdrawal symptoms, encourage them to present to an ED if they present with significant withdrawal, and try to schedule an urgent appointment with them as soon as possible, usually as a double-book.

For things like antidepressants, I will typically refill them as these are relatively benign. Obviously I would like to see the patient to see how they're doing, but I justify the risk of discontinuing and the potential for a subsequent decline as greater than the risk of not seeing the patient.

Other things are on a case-by-case basis, but I will typically provide a refill to get them to their next scheduled appointment. If they no-show after that, I will typically ask the front staff to check in with the patient and see what the deal is.

I was always taught to give enough med till their next appt with me. So if that was 1-2 weeks or 5 days then that was it. For established pts who are stable seeing me monthly for 1 year maybe that is different. I def feel how you treat refills in the first 2-3 visits of a new patient sets the boundaries for the future.

From a purely business stand point, most of the docs in my area NEVER give refills longer than 1-3 months MAX for non controlled and never more than 1 month max for controlled and even less depending on certain patients. They have an extender who typically just refills meds while the physician sees the unstable cases. I would imagine this is a very lucrative model and leave it at that.
 
I want to be stricter but don't know if I can get myself to do it. I have patients where I'll start a new med or change the dose. Then, instead of following in 1 month as I said, they'll call to schedule a follow up 1 month later (at which point they've taken their last pill and so need the refill from me nearly right away). At that point, my next available appointment is another month away. These same patients frequently then call 2 weeks later to reschedule their follow up another few weeks back.

The net result is that I'm now giving nearly 3 months of some new/changed med without a follow up, or I have to find some free/unbillable time to do a half follow up by phone. Alternatively, I refuse one of these refills and see what happens when patients withdraw from SSRIs or whatever.

I think I need a better way to keep track of which patients do this so when I do see them again, I can lay out more clearly and strictly my rules and then not feel as bad in not providing extra refills later.

Also, I'm hospital employed doing outpatient C&A.
 
I want to be stricter but don't know if I can get myself to do it. I have patients where I'll start a new med or change the dose. Then, instead of following in 1 month as I said, they'll call to schedule a follow up 1 month later (at which point they've taken their last pill and so need the refill from me nearly right away). At that point, my next available appointment is another month away. These same patients frequently then call 2 weeks later to reschedule their follow up another few weeks back.

The net result is that I'm now giving nearly 3 months of some new/changed med without a follow up, or I have to find some free/unbillable time to do a half follow up by phone. Alternatively, I refuse one of these refills and see what happens when patients withdraw from SSRIs or whatever.

I think I need a better way to keep track of which patients do this so when I do see them again, I can lay out more clearly and strictly my rules and then not feel as bad in not providing extra refills later.

Also, I'm hospital employed doing outpatient C&A.

Your situation may be more complex as the fault sometimes is with the family and parents. I schedule all patients prior to them leaving the appt for a follow up and require if a conflict arises they call and change it asap. Refills only till the next available appt if that means 5,7, 10, 14 day supply. If you let a patient get away with the refill game early on, more than likely it will happen more often. Strict early on and lax later has worked pretty darn well for me.
 
I think the vast majority of folks not wanting to refill meds w/o appointment is ultimately a business decision, not a medical one.

If you gave psychiatrists a panel of X patients and said we will pay you 300k a year to manage these folks however you please and you can work as many or few hours as you think is needed to manage them, then I guarantee way more folks would be refilling prozac over the phone.
 
I think the vast majority of folks not wanting to refill meds w/o appointment is ultimately a business decision, not a medical one.

If you gave psychiatrists a panel of X patients and said we will pay you 300k a year to manage these folks however you please and you can work as many or few hours as you think is needed to manage them, then I guarantee way more folks would be refilling prozac over the phone.

Perhaps this is true for some. For me even in my telepsych job for patients that miss appts they only get enough meds till they can schedule with me and i make them come in and get checked by a clinical nurse and the whole encounter is documented. There is 0 financial incentive for me in this.

Also, is there any other business or profession where you can get a service ( in this case a refill which may i add comes with liability) without paying for it? Would a mechanic, dentist, plumber, lawyer, accountant ever provide service to ANY extent where their professional service was required with liability and do it for free? Medicine is a business first and foremost in this country.

The beauty is everyone else in the game is always taking advantage of doctors in any and every way possible and using guilt primarily to do it while they make the real money in healthcare. If physicians unionized from the beginning in this country the profits insurance companies get would be ours and the balance of where money in healthcare should be would be skewed to those making the actual clinical decisions.
 
Last edited:
Perhaps this is true for some. For me even in my telepsych job for patients that miss appts they only get enough meds till they can schedule with me and i make them come in and get checked by a clinical nurse and the whole encounter is documented. There is 0 financial incentive for me in this.

Also, is there any other business or profession where you can get a service ( in this case a refill which may i add comes with liability) without paying for it? Would a mechanic, dentist, plumber, lawyer, accountant ever provide service to ANY extent where their professional service was required with liability and do it for free? Medicine is a business first and foremost in this country.

The beauty is everyone else in the game is always taking advantage of doctors in any and every way possible and using guilt primarily to do it while they make the real money in healthcare. If physicians unionized from the beginning in this country the profits insurance companies get would be ours and the balance of where money in healthcare should be would be skewed to those making the actual clinical decisions.
eh, in primary care a stable patient on anti-HTN meds, and a whole host of other stuff, much of which I think may actually be more dangerous than say, SSRIs (but also may be quite dangerous to run out of) can get a year's worth of refills without being seen again, and it's NBD

granted, what you're using the SSRIs for very often warrants more f/u than this by virtue of what you're treating, perhaps

I imagine it may be more an issue of liability to not want to refill a psych patient's meds sight unseen, especially if there's been recent changes, especially someone who's having a hard time following up (might suggest social issues that would impact tx)

OTOH if my pt is a just a general ponyshow about getting in for refills on their metoprolol, whatever that might say about their mental health doesn't necessarily mean I'm doing wrong by refilling it after a cancellation, so it is a different beast

it's a different game, but I give people until their next scheduled appt, and then if they cancel, until the one after that, and I warn them at that point that 3 mos is the maximum time I'll give them to get in and get refills. I feel like with good documentation that stepwise way to go is justifiable, but then again, it depends on how risky the condition and the medication vs sudden d/c as well.

Lastly, professionals, when you look at what it means to be a professional by definition, do plenty of things to carry out their duties that aren't billed directly, and it is just sorta part of the service. I've had mechanics, dentists, lawyers, and accountants all work this way.

I get it that psych is sorta special with liability and f/u, and that the amount of "long distance medicine" that could in theory be practiced safely, isn't because liability is a real concern.
 
I'm mostly objecting to this idea that in some cases you can't just provide refills without an appt. Also that professionals don't do plenty of work for which they don't bother to bill you for, or helps you but isn't billable.
 
I think the vast majority of folks not wanting to refill meds w/o appointment is ultimately a business decision, not a medical one.
Perhaps, though not true for me. I'm salaried and currently without an RVU bonus structure, so I have no financial incentive to see patients. Yet I still made my post above complaining about this. Giving refills outside of the appointments I planned gets in my way of managing these conditions as I've been trained to do and as per standard of care.
 
Perhaps, though not true for me. I'm salaried and currently without an RVU bonus structure, so I have no financial incentive to see patients. Yet I still made my post above complaining about this. Giving refills outside of the appointments I planned gets in my way of managing these conditions as I've been trained to do and as per standard of care.
THIS is totally fair.
 
Perhaps, though not true for me. I'm salaried and currently without an RVU bonus structure, so I have no financial incentive to see patients. Yet I still made my post above complaining about this. Giving refills outside of the appointments I planned gets in my way of managing these conditions as I've been trained to do and as per standard of care.

I agree with you and am in the same boat. I was just pointing out that I imagine the overall “standard of care” would dramatically shift overnight if the overall system wide payment models changed and were no longer based on number of patient encounters. Psychiatrists would realize they only had to show up at work 20hrs a week for same salary if they did half their refills by phone. And the journals would be full of editorials extolling the virtues of not interrupting our patients lives.
 
I do refills, even stimulants for well established patients, you really do get to know your patients and if someone is chronic no show they may get a few days till their next apt with a warning that they'll get no further refills (this is a fellows clinic). I think in PP one can structure it how they want, depending on how much of a customer service friendly take you want, expect most cash patients to demand refills called same day etc..
Don't you need a paper copy for psychostimulants? In Michigan we can call in anything I prescribe except stimulants . I don't have an EMR at my small private practice nor at the clinic where I work.
 
I recently heard about a private practice physician who does not refill medications outside of appointment times. I'm curious if any practicing psychiatrists here employ similar rules? Or is it too harsh?
I will do 3 months with a stable patient that I have worked with for awhile and like others said a week or 2 to get them through until the next appointment . In Michigan stimulants have to be on paper and I don't have an EMR at either of my outpatient jobs. The clinic where I work a few days a week started a new policy that controlled substances won't be given outside of an appointment . It hasn't happened yet but the question of not refilling benzos needs to be addressed. If a patient runs out and they have a seizure? The clinic has started all patients on a controlled substance sign a long contract for controlled substances which includes this as part of it but I can still see it being an issue.
 
I'm pretty sure my (now former) Psychiatrist worked on a case by case basis when it came to med refills outside of set appointments. So I wouldn't have expected newer patients to be allowed that leeway without a very good reason & some laying down of rules and expectations, but I know with me once I got past the 12 month mark, & trust et al had been established, then as long as I wasn't totally abusing the privilege I could ask for the occasional script outside of a scheduled appointment. So for example early on you might only be given leeway if you missed an appointment for genuine health reasons, not because you'd accidentally double booked yourself, or were having car/transport issues; and even then when you were allowed a bit more leeway once a pattern of trust etc had been established, it wasn't like you could be ringing up every second appointment going, 'Er hi, can't make it today, gimme a script anyway, please?'

Having said all that I did personally stick to only asking for refills outside of appointments when I really needed to; such as waking up one morning with a shingles rash and knowing that there were immuno-compromised patients attending the same clinic (automatic 'do not attend' for me), or the time when the trains were shut down without warning after someone had thrown themselves in front of one. Regardless I did still try and at least schedule a 5 minute checkup phone call for the same day (if possible), and a proper follow up appointment asap. I'm also pretty sure had I started abusing these sorts of privileges I would've eventually been read the riot act and sent back to square one.
 
Top