Rx refills without a future appointment

[SpongeBob DoctorPants]

When seeing patients in clinic, I always try to make sure that I prescribe enough medication with the appropriate number of refills to ensure that my patients do not run out before the next recommended follow up visit.

Sometimes patients are not able to return within the recommended time, or may need to reschedule, and in those cases I am happy to renew their prescriptions as long as a return visit is scheduled.

Frequently, however, I get refill requests from patients who have not yet scheduled a return visit. Generally, I will renew the prescriptions for one month and have my office staff get the patient scheduled. Many times, this does result in the patient getting scheduled and returning for follow up. Occasionally, however, there are patients who have a bad habit of not scheduling, and I may renew their prescriptions 2 or 3 times before I see them again. Recently, I put my foot down when a patient had not returned in five months after I had made a medication change at their last visit and recommended coming back a month later, and decided there would be no additional refills ordered until the patient is seen again in clinic.

I am wondering how other practices handle refill requests. As my practice grows and gets busier, I can see myself becoming less lenient with refilling prescriptions between visits if there is no future appointment scheduled. After all, it takes time to look into each chart and review the treatment plan to determine if the refill is appropriate. I have heard of some practices refusing to renew prescriptions without a future appointment; some may limit this to controlled substances only, while others apply this rule to any prescription. What kind of policy is most commonly followed, and what do you do in your clinic?

---

Members don't see this ad.

 

[TexasPhysician]

I’ve seen clinics that do 0 refills outside of appointments. They give the policy up front and give 1 month extra refill at appointment.

I generally do 1 refill with scheduling within 1 month.

My past academic center did 1 auto refill and then a 2nd with warning that its the last until follow-up.

 

[NickNaylor]

In our resident-run clinic, I’m more or less strict depending on the patient and the medication being requested. For someone with simple remitted MDD needing a refill of an SSRI, I will just send in the refill. My thought is that it is a fairly benign medication and I would rather not introduce the risk of decompensation simply because a patient cannot make the appointment.

Any controlled substances require an appointment, no exceptions.

For most other situations, I will typically provide a large enough supply to get the patient to their next scheduled appointment. If they miss that appointment, then I will typically ask the front staff to call the patient and ask them to schedule an appointment as soon as possible as I will need to see them before they get additional refills.

Fortunately, I have very few to no patients that recurrently don’t show to appointments yet request refills on their medications.

 

[Liquid8]

I will schedule followup visits at the end of each appointment and provide enough medication to last until that time. If patients cancel this and call wanting a script, we have some legalities to fall back on and I will advise my staff to inform them that I am legally unable to provide a script if I haven't seen them in the last six months. Have to say that it doesn't happen that often, and patients will often see their GPs for non-stimulant/benzo scripts. If they try this with the latter, GPs will often refer them back to me if they think something is up.

If a patient tells me they have run out earlier due to using more than prescribed or losing scripts, I will generally write a script for a reduced amount, limit the amount that can be dispensed at any one occasion or send the script directly to a specific pharmacy if I think there's a risk of diversion. If a pattern develops despite these measures, I'll insist on more frequent reviews or look to discharge.

 

[Trismegistus4]

This is another one of those issues I have no control over in the clinic I work in. Prescription renewal requests are handled by an MA, and if the patient doesn't have a future appointment scheduled, they will make the patient book one, then only give enough pills to last until that appointment. I've asked the MAs at our office whether this was because of something I said at some point, and they said no, it's been a longstanding policy of this organization across all locations. It's annoying because I think the patients get the impression they're not getting a refill until they've seen me again, because they often take first available--when I get a short-notice cancellation and the slot gets refilled, it's often for this reason. Whereas as long as it's not a controlled substance, I'd have been fine continuing it for another month, as long as they do come back eventually, and would rather have that half hour off.

Any controlled substances require an appointment, no exceptions.

No exceptions? What do you do when someone is on a chronic benzo, and is worried about going through withdrawal? I hate giving it to them in that scenario, but I'm worried about liability.

 

[zolof]

This depends on where you work. If your at a clinic with a lot of support staff or in residency training, is completely different than your solo or small group private practice. Not only liability concerns but financial ones.

 

[WingedOx]

Fortunately, I have very few to no patients that recurrently don’t show to appointments yet request refills on their medications.

I wish that was the case, however, not exactly a realistic expectation in the VA setting.

 

[st2205]

This is another one of those issues I have no control over in the clinic I work in. Prescription renewal requests are handled by an MA, and if the patient doesn't have a future appointment scheduled, they will make the patient book one, then only give enough pills to last until that appointment. I've asked the MAs at our office whether this was because of something I said at some point, and they said no, it's been a longstanding policy of this organization across all locations. It's annoying because I think the patients get the impression they're not getting a refill until they've seen me again, because they often take first available--when I get a short-notice cancellation and the slot gets refilled, it's often for this reason. Whereas as long as it's not a controlled substance, I'd have been fine continuing it for another month, as long as they do come back eventually, and would rather have that half hour off.

THIS. I’m not a fan of seeing people early than originally planned for a multitude of reasons (not that there isn’t a reason to see them), but especially when there’s no need. Usually a waste of time and waste of their money.

 

[Trismegistus4]

THIS. I’m not a fan of seeing people early than originally planned for a multitude of reasons (not that there isn’t a reason to see them), but especially when there’s no need. Usually a waste of time and waste of their money.

Sometimes the front desk staff will put a note in the "notes/comments" column of the schedule that a patient walked straight out without scheduling a follow-up, and it's gotten so I could kick myself when that happens, because if I had reminded them, this scenario could have been averted. "There goes an opportunity, about 3 months from now, to have a second cup of coffee one day!" At least once a week, say on a Tuesday, I'll be looking at Thursday's schedule, and say "sweet! I don't have a 10:00 on Thursday! Someone must have canceled!" Then I check again on Wednesday, and dammit, someone's been scheduled in that slot. So I check their chart, and see that, yes, I last saw them 3 months ago, and at no time did they have any other appointment that's been canceled or rescheduled, and they've just been given a refill of 3 pills. Sometimes when they come in, I'll even ask them, med school open-ended style, "so, what brings you in for the appointment today?" And sure enough: "oh... well, I ran out of that medicine you gave me, and I called trying to get more, and they said I had to come see you." No other complaints. Really? This couldn't have waited, say, 2 weeks, when it probably would have been easier for you to get away from work?

 

[NickNaylor]

This is another one of those issues I have no control over in the clinic I work in. Prescription renewal requests are handled by an MA, and if the patient doesn't have a future appointment scheduled, they will make the patient book one, then only give enough pills to last until that appointment. I've asked the MAs at our office whether this was because of something I said at some point, and they said no, it's been a longstanding policy of this organization across all locations. It's annoying because I think the patients get the impression they're not getting a refill until they've seen me again, because they often take first available--when I get a short-notice cancellation and the slot gets refilled, it's often for this reason. Whereas as long as it's not a controlled substance, I'd have been fine continuing it for another month, as long as they do come back eventually, and would rather have that half hour off.


No exceptions? What do you do when someone is on a chronic benzo, and is worried about going through withdrawal? I hate giving it to them in that scenario, but I'm worried about liability.

Fair enough - benzos are perhaps the one exception. If I’m not concerned about abuse, I will provide them a one-month supply but advise them that no further refills will be given without an appointment and advise of the risks of BZD withdrawal. For patients for whom I am concerned about abuse/misuse, I do not call in a refill and advise them that they should come to the clinic ASAP as a walk-in (we have the ability to overbook patients so that they can be seen most weekdays) or, if they develop symptoms of withdrawal, to present to the ED.

This may be a bit draconian, but I don’t want to budge on this point as I don’t want to give off the perception that I’m fine with prescribing BZDs without visits. I would say that I have more patients than not who do not truly “need” BZDs, have been on them chronically, and who I inherited in this state. I’m working to taper essentially all of them off. Fortunately, they tend not to no-show to their appointments as they know they are necessary to continue getting medications.

 

[thoffen]

I think best to have a policy around this and to follow it. It's always harder to work on establishing limits after they have been violated, especially if the limit being set keeps moving. If someone expects an indefinite supply of meds without follow-up, terminate them per policy. Usually you have to give 30 days of being their treating provider, but that does not necessarily mean you'll Rx meds. If you think they are needing to be seen before deciding on meds, you can refer to ED or make a f/u appointment with them during that 30 days so long as you've provided a referral and notice of termination. After that time, if they still haven't made f/u care elsewhere, do not Rx meds. You've ended your treatment relationship and don't want to start a new one.

 

[shahseh22]

They get a refill for anything that's not controlled. However, if they are on a Benzo or Stimulant they need to be seen every couple of months.

 

[NickNaylor]

I think best to have a policy around this and to follow it. It's always harder to work on establishing limits after they have been violated, especially if the limit being set keeps moving. If someone expects an indefinite supply of meds without follow-up, terminate them per policy. Usually you have to give 30 days of being their treating provider, but that does not necessarily mean you'll Rx meds. If you think they are needing to be seen before deciding on meds, you can refer to ED or make a f/u appointment with them during that 30 days so long as you've provided a referral and notice of termination. After that time, if they still haven't made f/u care elsewhere, do not Rx meds. You've ended your treatment relationship and don't want to start a new one.

Being in a resident clinic with very loose therapeutic boundaries, this is a challenge. We don’t have any firm policies with respect to prescribing medications without appointments. Since the patients change residents each year, often you’re having to fight expectations from whatever the previous resident did. Makes this whole issue a bit more challenging.

 

[whopper]

This is one of those things I don't see well-addressed. I've seen some offices go as long as 3-4 months of prescriptions even if the medication is not a controlled substance, extremely safe, the pt does well on it, and there's no side effects.

I allow up to 6 months.

Honestly if a patient was on a medication that's safe with no side effects and lots of benefits such as an SSRI I don't even think every 6 months is needed from a medication standpoint. There is an argument to see if their mental health stability is maintained but the med itself if someone's been on it for several months with no problem is likely not going to be a problem. So that brings up another issue, what if they're seeing a therapist who can check up on this in that area. Do they really need to see you every few months?

Never answered as far as I know, but I do know that the longer the duration the more you're inviting yourself to an argument that you're not following the standard of care.

 

[DD214_DOC]

This is one of those things I don't see well-addressed. I've seen some offices go as long as 3-4 months of prescriptions even if the medication is not a controlled substance, extremely safe, the pt does well on it, and there's no side effects.

I allow up to 6 months.

Honestly if a patient was on a medication that's safe with no side effects and lots of benefits such as an SSRI I don't even think every 6 months is needed from a medication standpoint. There is an argument to see if their mental health stability is maintained but the med itself if someone's been on it for several months with no problem is likely not going to be a problem. So that brings up another issue, what if they're seeing a therapist who can check up on this in that area. Do they really need to see you every few months?

Never answered as far as I know, but I do know that the longer the duration the more you're inviting yourself to an argument that you're not following the standard of care.

Is there really a SOC for follow-up intervals? For me, it depends on many factors such as how long they've been a patient, whether compliance has been an issue, what phase of treatment they're in, duration of stability, the specific medication regimen, etc. I'm the only subspecialist of my kind serving a pretty large patient population in a system where PCP's won't take back patients on one SSRI who've been stable > 6 months and seeing a therapist in the same system. I usually don't have anyone, even those who've been stable, follow-up past 12 weeks but I am starting to push a few further out to 6 months after asking myself why I was having them back in 3.

I don't need to, "check on their stability" just in case something changes. They can pick up the phone and schedule something if it does.

 

[SpongeBob DoctorPants]

Is there really a SOC for follow-up intervals? For me, it depends on many factors such as how long they've been a patient, whether compliance has been an issue, what phase of treatment they're in, duration of stability, the specific medication regimen, etc. I'm the only subspecialist of my kind serving a pretty large patient population in a system where PCP's won't take back patients on one SSRI who've been stable > 6 months and seeing a therapist in the same system. I usually don't have anyone, even those who've been stable, follow-up past 12 weeks but I am starting to push a few further out to 6 months after asking myself why I was having them back in 3.

I don't need to, "check on their stability" just in case something changes. They can pick up the phone and schedule something if it does.

That is a good question. I am not aware of any published guidelines regarding intervals for follow-up care. I will sometimes make individualized recommendations depending on a patient's situation, but as a general rule of thumb, I will have patients return for follow up within 4-6 weeks while I am making medication changes, and extend it out to 2-3 months as progress is being made, then 4-6 months as stability is achieved. In residency I was taught that if patients are stable and coming in every 6 months, then they could likely be considered for discharge and follow up with their PCP (if the PCP is comfortable with maintaining their meds). Exceptions to this would be things like bipolar disorder or schizophrenia. However, I know a lot of PCPs aren't comfortable with any psych meds, so sometimes I will continue seeing stable cases of anxiety, depression, or even ADHD.

 

[DD214_DOC]

That is a good question. I am not aware of any published guidelines regarding intervals for follow-up care. I will sometimes make individualized recommendations depending on a patient's situation, but as a general rule of thumb, I will have patients return for follow up within 4-6 weeks while I am making medication changes, and extend it out to 2-3 months as progress is being made, then 4-6 months as stability is achieved. In residency I was taught that if patients are stable and coming in every 6 months, then they could likely be considered for discharge and follow up with their PCP (if the PCP is comfortable with maintaining their meds). Exceptions to this would be things like bipolar disorder or schizophrenia. However, I know a lot of PCPs aren't comfortable with any psych meds, so sometimes I will continue seeing stable cases of anxiety, depression, or even ADHD.

This is similar to what I do. I don't mind carrying some of the simple, stable cases on my panel. They break up the days with all the complicated stuff or new patients and make for great days when they all end up scheduled on the same day.

 

[SpongeBob DoctorPants]

I don't mind carrying some of the simple, stable cases on my panel. They break up the days with all the complicated stuff or new patients and make for great days when they all end up scheduled on the same day.

Agreed. Sometimes I think it would be nice to one day have a large panel of mostly stable patients who are coming in every 3-6 months, with the occasional new or complicated patient to keep things interesting.

 

[DD214_DOC]

Agreed. Sometimes I think it would be nice to one day have a large panel of mostly stable patients who are coming in every 3-6 months, with the occasional new or complicated patient to keep things interesting.

That's the dream. I guess in pp one could accomplish this, especially running a cash-only ADHD boutique clinic in a fancy metro area.