Private Practice people what is your no show rate? Strategies to reduce?

[ChudsMgee]

How many no shows do you guys get? I have had a couple days in a row with a pretty absurd no show rate that has been irritating to say the least. I have been way to lax and haven't enforced the no show fine that is on my intake forms.

I had a day with 17 appointments turn into 9 after no shows and reschedules..... This isn't the norm for me as there are usually 1-2 in a 16 patient day and oftentimes people will pop out of the woodwork and I can fill the gaps but I don't overbook my calendar like some people.

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[WisNeuro]

Are you insurance, or cash-based?

 

[finalpsychyear]

no show no call is automatic 150 charge signed by patient part of intake document with card on file. I use to require new intakes to pay a deposit for a slot at one point to "hold" a spot but now that i cherry pick new patients i don't need to do that. I have nearly 100% show rate and can't remember the last person who no showed no called since policy in place. Exceptions are made with illness and so forth and the option to virtual visit if can't physically attend.

 

[romanticscience]

Late cancellations (<48h) or No-Shows are $150. Waived for the following:
- Once for any reason, annually.
- If re-scheduled <24h within the business week.
- Sometimes, another will be waived if the person is super reliable.

 

[ChudsMgee]

Are you insurance, or cash-based?

like 80% insurance, 20% cash

 

[ChudsMgee]

no show no call is automatic 150 charge signed by patient part of intake document with card on file. I use to require new intakes to pay a deposit for a slot at one point to "hold" a spot but now that i cherry pick new patients i don't need to do that. I have nearly 100% show rate and can't remember the last person who no showed no called since policy in place. Exceptions are made with illness and so forth and the option to virtual visit if can't physically attend.

My intake does state "● No shows/rescheduling with less than 24 business hours notice: full session charge. For example, if you or your child’s appointment is on Monday at 4pm, you will communicate your cancellation no later than the previous 1 day earlier● at 4pm; if an appointment is on Tuesday at 10am, you will communicate no later than the day before Monday at 10am."

I think I'll just have my wife start informing all patients that no show fees are now enforced when she does the appointment reminder messages. See what happens

 

[calvnandhobbs68]

I have been way to lax and haven't enforced the no show fine that is on my intake forms.

There's your problem, you need to enforce the fees. People who get pissed off and leave were probably going to keep no showing anyway, people who grumble and pay the fees will keep showing up and people who just pay it and don't say anything know they were in the wrong and expected to get charged anyway probably.

I always charge for actual no-shows. Late cancels (<24hrs), I'm a little more flexible on, especially if they reschedule within a week or two but still will enforce it if it's for something dumb or forseeable.

2-3 late cancels or no-shows in a day is a lot for me. Usually run 0-1.

Also yes, have your wife remind patients if they call to late cancel that there's a late cancel fee that will be assessed as outlined in their intake paperwork. I bet that cuts down on the number of late cancels significantly.

 

[clausewitz2]

No-show (defined as not arriving within first 15 minutes without advance notice): full-freight, whatever the appointment would cost out of pocket.

Cancellation with less than 24 hours notice: $100. I am considering making this 48.

Everyone gets one of each for free. I am pretty rigid about this. I will waive it if someone is hospitalized. If someone is ill when they log on to the appointment I will happily reschedule them without a fee; at least they tried.

 

[smalltownpsych]

I use scheduling dynamics to winnow out the less committed and likely no shows. I have considered implementing no-show fees, but not sure it makes as much sense in a psychotherapy practice as it might in others. A big part of what I am working with patients is often around boundaries and unhealthy control dynamics so I tend to integrate commitment and involvement into the treatment. For some of my patients, being “punished” for a no show is the opposite of what they need from me. For others, being scheduled three weeks out or more since my schedule is fairly full is the natural consequence and the boundary they need.

 

[WisNeuro]

like 80% insurance, 20% cash

Some insurers/payor have rules about no-show rates/fees, so make sure you check those out.

 

[calvnandhobbs68]

Some insurers/payor have rules about no-show rates/fees, so make sure you check those out.

Sure you should always be aware of your insurance contracts but I'm boarded on most panels of the major insurance companies (Cigna, Aetna, UHC, BCBS, another major regional company) and none of them have any issue with no show fees, in fact they're an explicitly "non covered" charge. Even Tricare lets you charge no show fees.

Medicaid insurance plans are the only plans I've seen issue with not being able to charge no show fees.

 

[WisNeuro]

Sure you should always be aware of your insurance contracts but I'm boarded on most panels of the major insurance companies (Cigna, Aetna, UHC, BCBS, another major regional company) and none of them have any issue with no show fees, in fact they're an explicitly "non covered" charge. Even Tricare lets you charge no show fees.

Medicaid insurance plans are the only plans I've seen issue with not being able to charge no show fees.

For the major insurers, most will not have any prohibitions. Add Medicare along with Medicaid though, as ones who do.

 

[calvnandhobbs68]

For the major insurers, most will not have any prohibitions. Add Medicare along with Medicaid though, as ones who do.

Nope.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5613.pdf

 

[WisNeuro]

Nope.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5613.pdf

I stand corrected, for some reason I thought Medicare prohibited this. Doesn't affect me much as I generally only get 1-2 no-shows from clinical appointments a year, and those are usually because a patient became hospitalized. Having a waitlist for your specialty that is 4+months at most places tends to motivate people to show up.

 

[allantois]

Why are they no showing? Are you sending out appointment reminders? Does anyone call the patient when they aren't logged in for their appointment?

 

[clozareal]

I have a 2 business day policy of rescheduling otherwise they pay for the appointment. If they contact me within 2 business days wanting to rescheduling, I let them know I'll be charging them the full appointment fee to do so. Almost always, they will find a way to make it work. The person I said that to this week was because "I thought it was supposed to be Thursday, not Tuesday" like they didn't have access to the online calendar in my portal, get an email and text message reminder 2 days beforehand, and confirmed it at the last appointment several times verbally.

No show = full fee. I will always charge. If there was a legitimate reason, I will refund. Otherwise, if they complain and don't have a good reason (good reasons being emergency, so sick they can't do a telehealth appointment from bed, hospitalized, death in family), I likely won't refund. I can count the number of no shows on one hand in the past year because of this policy.

Intake appointment = fully paid for before being able to book. I've only had it once that there was a no show to an intake appointment and they didn't reschedule but they also didn't ask for a refund.

I work with a lot of kids and parents with ADHD and TBI so executive functioning isn't that high, but enforcing these rigid structures helps them get the treatment they need.

 

[ChudsMgee]

Why are they no showing? Are you sending out appointment reminders? Does anyone call the patient when they aren't logged in for their appointment?

I think maybe because I am too lenient. They get email reminders twice before the appointment and a text message reminder the day beforehand.

 

[clausewitz2]

I have a 2 business day policy of rescheduling otherwise they pay for the appointment. If they contact me within 2 business days wanting to rescheduling, I let them know I'll be charging them the full appointment fee to do so. Almost always, they will find a way to make it work. The person I said that to this week was because "I thought it was supposed to be Thursday, not Tuesday" like they didn't have access to the online calendar in my portal, get an email and text message reminder 2 days beforehand, and confirmed it at the last appointment several times verbally.

No show = full fee. I will always charge. If there was a legitimate reason, I will refund. Otherwise, if they complain and don't have a good reason (good reasons being emergency, so sick they can't do a telehealth appointment from bed, hospitalized, death in family), I likely won't refund. I can count the number of no shows on one hand in the past year because of this policy.

Intake appointment = fully paid for before being able to book. I've only had it once that there was a no show to an intake appointment and they didn't reschedule but they also didn't ask for a refund.

I work with a lot of kids and parents with ADHD and TBI so executive functioning isn't that high, but enforcing these rigid structures helps them get the treatment they need.

I really need to start doing this. I pushed my intakes to 90 minutes which I think means I do a much better job and am happier with the outcome, but also a no-show is really painful, as people no-showing to intakes have a tendency to disappear completely.

 

[clozareal]

I really need to start doing this. I pushed my intakes to 90 minutes which I think means I do a much better job and am happier with the outcome, but also a no-show is really painful, as people no-showing to intakes have a tendency to disappear completely.

My intakes are 90 minutes at the minimum up to 5 hours depending on the complexity of the case and I make them pay for it before I allow them to schedule. It's thousands of dollars up front but I really am able to provide much better, comprehensive patient care when I get a chance to spend more time with them with the evaluation as well as talk to collateral to get a fuller picture.

One of the reasons why I have a long appointment is that I am the rare psychiatrist that still does a physical exam: thyroid nodule check, listen to heart for murmurs and prolapses (the anxiety case I did an intake on this week has a systolic murmur that has never been found), full neurological exam including cognitive exam, listen to lungs for asthma and other pulmonary issues that can contribute to physical symptoms, look into nostrils and roof of mouths and do the cottle maneuver and more if they complain of insomnia (if you didn't rotate in sleep medicine in residency/fellowship, I would urge all psychiatrists to get extra training in sleep medicine), do throat exams (I did catch strep throat that had been untreated for 3 weeks in a child/teen), do a full visual field exam to make sure they don't have a large pituitary adenoma/strokes/etc, get my own labs and imaging and home EKG and home sleep apnea testing, do a catatonia exam if there are concerning symptoms, abdominal exam for hepato/splenomegaly or other tumors, and of course get vitals including orthostatic vital signs and waist circumference if needed. I try to use as much of my medical education as possible.

 

[reca]

My intakes are 90 minutes at the minimum up to 5 hours depending on the complexity of the case and I make them pay for it before I allow them to schedule. It's thousands of dollars up front but I really am able to provide much better, comprehensive patient care when I get a chance to spend more time with them with the evaluation as well as talk to collateral to get a fuller picture.

One of the reasons why I have a long appointment is that I am the rare psychiatrist that still does a physical exam: thyroid nodule check, listen to heart for murmurs and prolapses (the anxiety case I did an intake on this week has a systolic murmur that has never been found), full neurological exam including cognitive exam, listen to lungs for asthma and other pulmonary issues that can contribute to physical symptoms, look into nostrils and roof of mouths and do the cottle maneuver and more if they complain of insomnia (if you didn't rotate in sleep medicine in residency/fellowship, I would urge all psychiatrists to get extra training in sleep medicine), do throat exams (I did catch strep throat that had been untreated for 3 weeks in a child/teen), do a full visual field exam to make sure they don't have a large pituitary adenoma/strokes/etc, get my own labs and imaging and home EKG and home sleep apnea testing, do a catatonia exam if there are concerning symptoms, abdominal exam for hepato/splenomegaly or other tumors, and of course get vitals including orthostatic vital signs and waist circumference if needed. I try to use as much of my medical education as possible.

How often do you change management as a result of your extensive physical exam?

 

[clozareal]

How often do you change management as a result of your extensive physical exam?

The exam is guided by the history. I only do a particular exam if there is something concerning about the ROS for it. It's enough for me to want to keep doing it. Here's several of my clinical management changing based on physical exam:

• Concentration issues and fatigue thought to be due to ADHD improved with deviated nasal septum repair which resulted in less headaches and better sleep.
• A patient with weight loss and increased appetite thought to be due to depression, had thyroid nodule associated with high TSH with high T4 needing to be worked up, resulting in papillary thyroid cancer dx
• Patient with palpitations on Vyvanse with split S2, found to have undiagnosed pulmonary hypertension on echo
• RBBB on EKG for a kid with autism who had PFO repair as a child who has ADHD and needing to start stimulant but I wanted to get that cleared first
• Bradycardia and hypotension in a kid with ADHD even though he's on max dose of stimulants, needing cardiac clearance before I would continue to change ADHD medications (was considering alpha agonist)
• Low vitamin B12 and high methylmalonic acid levels needing workup for pernicious anemia and other causes prior to treating depression and cognitive decline
• Kid with strep throat for past 3 weeks feeling malaised and having some tachycardia on intake, wanting to get that treated before changing his medications for anxiety

These are just a few examples in my private practice of 1 year.

 

[ObsequiousAplomb]

The exam is guided by the history. I only do a particular exam if there is something concerning about the ROS for it. It's enough for me to want to keep doing it. Here's several of my clinical management changing based on physical exam:

• Concentration issues and fatigue thought to be due to ADHD improved with deviated nasal septum repair which resulted in less headaches and better sleep.
• A patient with weight loss and increased appetite thought to be due to depression, had thyroid nodule associated with high TSH with high T4 needing to be worked up, resulting in papillary thyroid cancer dx
• Patient with palpitations on Vyvanse with split S2, found to have undiagnosed pulmonary hypertension on echo
• RBBB on EKG for a kid with autism who had PFO repair as a child who has ADHD and needing to start stimulant but I wanted to get that cleared first
• Bradycardia and hypotension in a kid with ADHD even though he's on max dose of stimulants, needing cardiac clearance before I would continue to change ADHD medications (was considering alpha agonist)
• Low vitamin B12 and high methylmalonic acid levels needing workup for pernicious anemia and other causes prior to treating depression and cognitive decline
• Kid with strep throat for past 3 weeks feeling malaised and having some tachycardia on intake, wanting to get that treated before changing his medications for anxiety

These are just a few examples in my private practice of 1 year.

I thought pulmonary hypertension was only diagnosed on right heart cath

Otherwise, I definitely agree with ensuring the deviated nasal septum gets repaired, as someone who suffered until their mid-20s and finally was able to breathe nasally. Definitely would have done those workups you mentioned, but they also sound like the history did most of the workup anyway.

 

[tr]

My intakes are 90 minutes at the minimum up to 5 hours depending on the complexity of the case and I make them pay for it before I allow them to schedule. It's thousands of dollars up front but I really am able to provide much better, comprehensive patient care when I get a chance to spend more time with them with the evaluation as well as talk to collateral to get a fuller picture.

One of the reasons why I have a long appointment is that I am the rare psychiatrist that still does a physical exam: thyroid nodule check, listen to heart for murmurs and prolapses (the anxiety case I did an intake on this week has a systolic murmur that has never been found), full neurological exam including cognitive exam, listen to lungs for asthma and other pulmonary issues that can contribute to physical symptoms, look into nostrils and roof of mouths and do the cottle maneuver and more if they complain of insomnia (if you didn't rotate in sleep medicine in residency/fellowship, I would urge all psychiatrists to get extra training in sleep medicine), do throat exams (I did catch strep throat that had been untreated for 3 weeks in a child/teen), do a full visual field exam to make sure they don't have a large pituitary adenoma/strokes/etc, get my own labs and imaging and home EKG and home sleep apnea testing, do a catatonia exam if there are concerning symptoms, abdominal exam for hepato/splenomegaly or other tumors, and of course get vitals including orthostatic vital signs and waist circumference if needed. I try to use as much of my medical education as possible.

Wow. I look in people's mouths for signs of OSA a fair amount and I do take bp in my office but that's about it.
Honestly I don't think I would recognize a murmur if it walked up and slapped me in the face. Don't tell my preceptors from med school.

Although to be fair, few of those cases you mentioned seemed like they needed the laying on of hands to occur in order to be picked up. Maybe the split S2; but history and appropriate labs/testing seem like they would cover most of them.

• Concentration issues and fatigue thought to be due to ADHD improved with deviated nasal septum repair which resulted in less headaches and better sleep.
  • unexplained fatigue I do initial lab w/u and then refer to sleep and/or PCP usually
• A patient with weight loss and increased appetite thought to be due to depression, had thyroid nodule associated with high TSH with high T4 needing to be worked up, resulting in papillary thyroid cancer dx
  • TFTs
• Patient with palpitations on Vyvanse with split S2, found to have undiagnosed pulmonary hypertension on echo
  • Props to you for your PE skills on this one, although the c/o palpitations would prompt me to hold the stim and get EKG
• RBBB on EKG for a kid with autism who had PFO repair as a child who has ADHD and needing to start stimulant but I wanted to get that cleared first
  • EKG
• Bradycardia and hypotension in a kid with ADHD even though he's on max dose of stimulants, needing cardiac clearance before I would continue to change ADHD medications (was considering alpha agonist)
  • Vitals/EKG
• Low vitamin B12 and high methylmalonic acid levels needing workup for pernicious anemia and other causes prior to treating depression and cognitive decline
  • B12 level
• Kid with strep throat for past 3 weeks feeling malaised and having some tachycardia on intake, wanting to get that treated before changing his medications for anxiety
  • why would they bring a sick kid to the shrink's office in the first place

 

[clozareal]

Wow. I look in people's mouths for signs of OSA a fair amount and I do take bp in my office but that's about it.
Honestly I don't think I would recognize a murmur if it walked up and slapped me in the face. Don't tell my preceptors from med school.

Although to be fair, few of those cases you mentioned seemed like they needed the laying on of hands to occur in order to be picked up. Maybe the split S2; but history and appropriate labs/testing seem like they would cover most of them.

• Concentration issues and fatigue thought to be due to ADHD improved with deviated nasal septum repair which resulted in less headaches and better sleep.
  • unexplained fatigue I do initial lab w/u and then refer to sleep and/or PCP usually
• A patient with weight loss and increased appetite thought to be due to depression, had thyroid nodule associated with high TSH with high T4 needing to be worked up, resulting in papillary thyroid cancer dx
  • TFTs
• Patient with palpitations on Vyvanse with split S2, found to have undiagnosed pulmonary hypertension on echo
  • Props to you for your PE skills on this one, although the c/o palpitations would prompt me to hold the stim and get EKG
• RBBB on EKG for a kid with autism who had PFO repair as a child who has ADHD and needing to start stimulant but I wanted to get that cleared first
  • EKG
• Bradycardia and hypotension in a kid with ADHD even though he's on max dose of stimulants, needing cardiac clearance before I would continue to change ADHD medications (was considering alpha agonist)
  • Vitals/EKG
• Low vitamin B12 and high methylmalonic acid levels needing workup for pernicious anemia and other causes prior to treating depression and cognitive decline
  • B12 level
• Kid with strep throat for past 3 weeks feeling malaised and having some tachycardia on intake, wanting to get that treated before changing his medications for anxiety
  • why would they bring a sick kid to the shrink's office in the first place

True. Many of them probably didn't need a physical exam but it will change my strategy on what to do next and some were not physical exam but getting labs/testing. The one with the strep throat is dealing with anxiety and recent low appetite but that was because his throat hurt, not because he was anxious. So I just decided to look in there.

The decision point I more so run across is whether to get brain imaging in my neuropsych cases. If there is a cranial nerve or peripheral nerve deficit, then I will get imaging and refer to neuro but I guess I could just refer to neuro from the get go. Often times, the waitlist to get in is really long and the care gets delayed.

 

[forchinet121]

no show no call is automatic 150 charge signed by patient part of intake document with card on file. I use to require new intakes to pay a deposit for a slot at one point to "hold" a spot but now that i cherry pick new patients i don't need to do that. I have nearly 100% show rate and can't remember the last person who no showed no called since policy in place. Exceptions are made with illness and so forth and the option to virtual visit if can't physically attend.

Is this for your own practice or as an employee?

 

[futureapppsy2]

• Kid with strep throat for past 3 weeks feeling malaised and having some tachycardia on intake, wanting to get that treated before changing his medications for anxiety
  • why would they bring a sick kid to the shrink's office in the first place

Practically, because they waited many months for the appointment, canceling would mean waiting weeks, if not months, for a new appointment, and/or being tagged as a no-show could either result in fees or moving them towards getting discharged from the practice. If you (generic you) don't want people to come in sick, then systems shouldn't punish people for not coming in (there's been a lot written on this in the I/O and public health spheres around "presenteeism").

 

[calvnandhobbs68]

Practically, because they waited many months for the appointment, canceling would mean waiting weeks, if not months, for a new appointment, and/or being tagged as a no-show could either result in fees or moving them towards getting discharged from the practice. If you (generic you) don't want people to come in sick, then systems shouldn't punish people for not coming in (there's been a lot written on this in the I/O and public health spheres around "presenteeism").

I suppose you mean the system shouldn’t “punish” people for cancelling their appointment. They knew the kid was sick before that day and could easily cancel over the 24 hour window most places have for a late cancel. There’s absolutely no reason someone should late cancel/no show in this particular scenario.

It’s probably better practice to reschedule this patient in a few weeks anyway when you can get a better assessment of what he’s like when he’s NOT sick with strep.

 

[futureapppsy2]

I suppose you mean the system shouldn’t “punish” people for cancelling their appointment. They knew the kid was sick before that day and could easily cancel over the 24 hour window most places have for a late cancel. There’s absolutely no reason someone should late cancel/no show in this particular scenario.

It’s probably better practice to reschedule this patient in a few weeks anyway when you can get a better assessment of what he’s like when he’s NOT sick with strep.

I agree it’s best not to have a kid come in when sick for a number of reasons, but I’m actually using “punish” in the broader, behavior analytic sense. If a person has to wait additional weeks or months for an appointment that they want their kid to go to if they cancel, they’re going to not cancel. I had an appointment with a GI recently as a patient, and it took over 3 months to get. I knew if I cancelled, even with good reason, it would probably take another several months to get one. I’m a huge fan of self-quarantine, but if I were sick when that appointment came up, it would have been really hard not to go, because I would have lost out on something desired (care from that specialist) and hard to obtain. We had sick kids show up to assessment clinic because they had to wait months to get in and rescheduling would have extended that wait by months. Not saying it’s the physician’s fault, but if systemic factors punish not attending harshly, you’re going to get presenteeism.

 

[WisNeuro]

I agree it’s best not to have a kid come in when ask for a number of reasons, but I’m actually using “punish” in the broader, behavior analytic sense. If a person has to wait additional weeks or months for an appointment that they want their kid to go to if they cancel, they’re going to not cancel. I had an appointment with a GI recently as a patient, and it took over 3 months to get. I knew if I cancelled, even with good reason, it would probably take another several months to get one. I’m a huge fan of self-quarantine, but if I were sick when that appointment came up, it would have been really hard not to go, because I would have lost out on something desired (care from that specialist) and hard to obtain. We had sick kids show up to assessment clinic because they had to wait months to get in and rescheduling would have extended that wait by months. Not saying it’s the physician’s fault, but if systemic factors punish not attending harshly, you’re going to get presenteeism.

I'll second this notion. for certain specialties, the waitlists are insane. Peds neuropsych in our metro is currently at 14+months unless you are private pay. And, many families that need the services cannot afford 4k+ for the assessment. Peds psychiatry also a very lengthy wait here. I am also a fan of people staying home when sick, but there is an awful lot of incentive to break that rule in certain circumstances.

 

[randomdoc1]

I have noticed it is best to have firm, specific and consistent boundaries. If it's something truly unforeseen and the patient made their best efforts, I'm willing to work with that. However, situations where something is foreseeable and it was likely a preventable lapse on the patient end--they get charged. In my intake papers, that is highlighted, it's mentioned in their text message reminders, on our voicemail greeting, in signs posted in the waiting room. The message is clear as heck. In every provider, whenever there is leniency, I have witnessed skyrocketing no show and late cancel rates--it is basic human behavior. A double wammy is when the provider has a not so busy schedule--then the patient starts to feel like they can just drop in whenever and not have to take attendance seriously. So it's good to be busy and we need to make a living too. Obviously, attendance issues create a major financial hit on the provider and the clinic. Patients seem to not care if we get paid or not. However, another way I phrase it to patients is to make sure slots do not go unused. Without that policy, easily a 50% no show rate would happen which puts stupid barriers to access to care for those who are committed to actually attending. I tell the patient, I am sure they would not appreciate it if others wasted slots they could have used and they'd have to wait longer. So let's try to make this all work for each other and try our best to make good use of the time and scheduling. They seem to get that.

Examples of when I charge:
-if someone is sick but had enough foresight to be able to cancel in advance
-someone has another obligation (e.g. work/event/appointment) but they did not cancel with us in advance when they could have
-patient forgot
-patient felt too emotionally distressed (I'm talking small potatoes like they got into a mild spat with SO or something)
-once had a patient who claimed to have a heart attack every week---we had a sit down and talked this through and he never did it again (I didn't charge but made it pretty clear the attendance patterns was not cool)
-I also tell the patient to NOT rely on text message reminders. This is a courtesy done by the clinic and the ultimate responsibility is on them--they knew the moment they scheduled, when the appointment is. So "I did not get a text" is not an excuse.

Examples of when I do not charge:
-unexpected sudden onset of illness
-work emergency
-major family emergencies (although again, I look and see what the pattern is--if there is a recurrent pattern of chaos eating into attendance, the patient really needs to work on this)

 

[clozareal]

In this situation, they had no idea the kid was sick with strep throat. Just that he was feeling a bit crummy, no fever, itchy throat. Thought it was viral. Regardless, they kept their masks on (both parents and child) until I asked to see the throat, which had clear patchy exudates with tonsillar and pharyngeal erythema and palatal petechiae.

I agree with the fear of cancellation. Perhaps I should have something in my policies to indicate as such. I typically have 2-3 intake appointments for children so it wouldn't be difficult to wait a week for the 2nd intake which would then be the first. I do have my current patient's families reaching out to me when a kid has a fever or is sick and ask to do telehealth if we can't reschedule, which I'm 100% okay with. I don't charge for rescheduling when someone is sick and being considerate of my health (and my family's). 75% of my practice is CAP so I'll also have to have a policy for adults too since I usually just do one intake with them.

 

[clozareal]

Examples of when I charge:
-if someone is sick but had enough foresight to be able to cancel in advance
-someone has another obligation (e.g. work/event/appointment) but they did not cancel with us in advance when they could have
-patient forgot
-patient felt too emotionally distressed (I'm talking small potatoes like they got into a mild spat with SO or something)
-once had a patient who claimed to have a heart attack every week---we had a sit down and talked this through and he never did it again (I didn't charge but made it pretty clear the attendance patterns was not cool)
-I also tell the patient to NOT rely on text message reminders. This is a courtesy done by the clinic and the ultimate responsibility is on them--they knew the moment they scheduled, when the appointment is. So "I did not get a text" is not an excuse.

Examples of when I do not charge:
-unexpected sudden onset of illness
-work emergency
-major family emergencies (although again, I look and see what the pattern is--if there is a recurrent pattern of chaos eating into attendance, the patient really needs to work on this)

Ugh I got this twice with the same patient, albeit the mother has executive functioning issues herself from a TBI. "I didn't get an email reminder" despite my EMR doing it automatically so I know they must have gotten it or it went to spam. She complained about the no show fee. She's one of my richest patients. Go figure.

 

[clausewitz2]

Ugh I got this twice with the same patient, albeit the mother has executive functioning issues herself from a TBI. "I didn't get an email reminder" despite my EMR doing it automatically so I know they must have gotten it or it went to spam. She complained about the no show fee. She's one of my richest patients. Go figure.

You don't get rich by wasting money on silly doctors and their no-show fees.

I also have had the experience of people complaining about no-show fees usually being the ones who can most easily afford it. I expect it has a lot to do with those sorts of people having had more experiences where complaining about something like this got them what they wanted in dealing with institutions/businesses/etc.

I especially love the people who complain about not getting an email reminder when they had managed to attend the previous six appointments without having received an email reminder just fine.

 

[Candidate2017]

I find that no show rates are initially 20%. But you can whittle them to close to zero from a few concepts I learned back in training:

1. Consistent no shows are discharged. You gotta show up. That's a basic kindergarten rule. I run on time, respect people's time, and expect the same. Chisel out the panel you want.
2. Offer telepsych as an option. Rule of thumb: if you make something easy and convenient to use, people will utilize it.

 

[allantois]

The exam is guided by the history. I only do a particular exam if there is something concerning about the ROS for it. It's enough for me to want to keep doing it. Here's several of my clinical management changing based on physical exam:

• Concentration issues and fatigue thought to be due to ADHD improved with deviated nasal septum repair which resulted in less headaches and better sleep.
• A patient with weight loss and increased appetite thought to be due to depression, had thyroid nodule associated with high TSH with high T4 needing to be worked up, resulting in papillary thyroid cancer dx
• Patient with palpitations on Vyvanse with split S2, found to have undiagnosed pulmonary hypertension on echo
• RBBB on EKG for a kid with autism who had PFO repair as a child who has ADHD and needing to start stimulant but I wanted to get that cleared first
• Bradycardia and hypotension in a kid with ADHD even though he's on max dose of stimulants, needing cardiac clearance before I would continue to change ADHD medications (was considering alpha agonist)
• Low vitamin B12 and high methylmalonic acid levels needing workup for pernicious anemia and other causes prior to treating depression and cognitive decline
• Kid with strep throat for past 3 weeks feeling malaised and having some tachycardia on intake, wanting to get that treated before changing his medications for anxiety

These are just a few examples in my private practice of 1 year.

This is some Oliver Sacks stuff

 

[medium rare]

Examples of when I charge:
-if someone is sick but had enough foresight to be able to cancel in advance
-someone has another obligation (e.g. work/event/appointment) but they did not cancel with us in advance when they could have
-patient forgot
-patient felt too emotionally distressed (I'm talking small potatoes like they got into a mild spat with SO or something)
-once had a patient who claimed to have a heart attack every week---we had a sit down and talked this through and he never did it again (I didn't charge but made it pretty clear the attendance patterns was not cool)
-I also tell the patient to NOT rely on text message reminders. This is a courtesy done by the clinic and the ultimate responsibility is on them--they knew the moment they scheduled, when the appointment is. So "I did not get a text" is not an excuse.

Examples of when I do not charge:
-unexpected sudden onset of illness
-work emergency
-major family emergencies (although again, I look and see what the pattern is--if there is a recurrent pattern of chaos eating into attendance, the patient really needs to work on this)

I have the same policy/practice for no-shows/late cancellations.

I charge my full rate for no-shows or late cancellations with less than 24 hours, business day notice.

I get one, maybe two, no-shows a month.

 

[Shikima]

I have a 3-5% no show/late cancellation rate. Majority of the time it's for legitimate reasons.

 

[Jules A]

Cash practice with rare no-shows and only a few <48h cancellations. First med check no-show is a freebie after that they are charged full price. If no show for evaluation need to pay in full in advance non-refundable. Telemedicine has helped as I will contact them at around the +8 min mark to see if they forgot and a majority will log on.