Telepsych and No-Shows/Late Starts

[Stagg737]

I've briefly mentioned this in other threads, but hoping for a wider set of opinions. I'm at an academic center and do 5-8 hours of outpatient telehealth per week in a semi-consultation model where the goal is to get people back to their PCP. Usually I see people for 6-12 months total before I'm able to send them back, but have a handful that I have seen and continue to see chronically becuase the clinic was previously run as a continuity clinic when it wasnt' supposed to be and some of these patients legitimately need a psychiatrist and not just a PCP.

That all being said, I have what I feel is a ridiculous rate of patients no-showing, cancelling same day, or forgetting their appointmnent until my MA calls them 5 minutes into the appointment time. When I reviewed the numbers last summer, I had a 7% no-show rate (not that bad) but same-day/late cancellation rate of ~20%. On top of that I'd say almost 50% of my patients aren't on time for their appointments and our MA has to call them. It might be less than that, but certainly feels like at least 50%.

The late patients are annoying but fine. However the no-show/late cancels kill me as my FT gig is inpatient C/L and I'm paid based on production. So when I get afternoons with a bunch of no-shows or late appointments, it affects my pay as I can't just run off to staff consults or see someone in the hospital in the 15 minutes between patients. Since it's an employed position and many of these patients are medicare/medicaid, I also can't bill for no-shows, so it's basically just uncompensated down time.

So my real question to all those outpatient docs who see a fair amount of people via telehealth: How often do people cancel or forget their appointments and show up late or reschedule? Other than billing for no-showing appointments, what all do you have in place to minimize this?

I feel like when I was a resident doing outpatient full-time my no show rate was nowhere near this high and I was the COVID year when we exclusively did telehealth for 6 months. Curious what others' experiences have been.

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[ObsequiousAplomb]

In my outpatient practice, less than 5% of appointments are late cancels or no-shows. I take insurance for 90% of patients and cash for 10%. I do not see Medicaid.

I have a system that sends reminder texts 2 days before the appointment and another the day of. I also have a system that allows patients to make the appointment, and they tend to respect those times well.

If someone no-shows or late cancels, we have a frank discussion the next visit. When someone no-shows repeatedly I charge them. If I get too frustrated, then I discharge them for no-shows or late cancels.

When I was in residency, I had 10% no-shows for Medicaid. I would call them personally if they were late even one minute. That cut down on no-shows a lot. The clinic also had a similar text message reminder system.

 

[Stagg737]

In my outpatient practice, less than 5% of appointments are late cancels or no-shows. I take insurance for 90% of patients and cash for 10%. I do not see Medicaid.

I have a system that sends reminder texts 2 days before the appointment and another the day of. I also have a system that allows patients to make the appointment, and they tend to respect those times well.

If someone no-shows or late cancels, we have a frank discussion the next visit. When someone no-shows repeatedly I charge them. If I get too frustrated, then I discharge them for no-shows or late cancels.

When I was in residency, I had 10% no-shows for Medicaid. I would call them personally if they were late even one minute. That cut down on no-shows a lot. The clinic also had a similar text message reminder system.

So we do have a text message reminder that goes out either 24 or 48 hours prior to the appointment (I think 24) with the appointment link, time as well as time zone specification, and a reminder that they must be physically in-state. My MA gets on the link 10 minutes before the appointment start time and if a patient isn't on within 3-5 minutes she calls them.

For example today I only had 4 patients (all f/ups). The first and last were same day cancellations and both of the middle two had to be called to get on. This is pretty standard rates for me. I have referred quite a few people back to their PCPs and "fired" 2 patients (aka, I won't see them for future referrals).

 

[lobstar]

In general, it seems like collection/RVU based payment in heavy Medicaid/Medicare clinics are just really difficult. I think it is very challenging to remedy. Things to consider:

- What the above posts mention, such as taking it upon yourself or a staff member to repeatedly call patients, having a reminder system of some kind.
- Discharging patients from clinic or charging them money for no shows--things you probably can't do in an employed academic position.
- Consider double-booking or scheduling 15-20 minute visits rather than q30--again probably not ideal, but an option.
- Could also try to renegotiate your pay to be more salary or hourly for the time you spend in these clinics to entirely remove the no show issue.

It's just very challenging for fee for service when patients don't show up due to a million psycho social and economic factors you have no control over.

 

[ObsequiousAplomb]

It sounds like your system is already more extensive than mine. I think that maybe the patient population / purpose of the clinic is the biggest contributing factor. I imagine op CL is a higher no-show rate than what I see.

 

[comp1]

I mean no show rates vary vastly based on location and population. I'm not sure if that info is helpful. Regardless of where your population falls on the bell curve, it sounds like you or your bosses are unhappy with the no show and/or late rate. So it might be a good idea to work on reducing that. Can you extend your system to text them 10 minutes before their appointment starts in addition to a week before and the day before? I think part of the problem is the MA here. I haven't seen a system like this where a MA is so heavily involved in telehealth real time. If the MA is already waiting 5 minutes to call, has to get ahold of them and then connect them to you, that's eating up a huge chunk of the appointment time. Instead of that, could you take that over and leave the MA to handle future scheduling? This time is already blocked off for you. This way you could get them in right away or convert it to a billable phone appointment. Of course if you can't reach them immediately, then you leave a voice message and hand if off to the MA to reschedule.

 

[ObsequiousAplomb]

I mean no show rates vary vastly based on location and population. I'm not sure if that info is helpful. Regardless of where your population falls on the bell curve, it sounds like you or your bosses are unhappy with the no show and/or late rate. So it might be a good idea to work on reducing that. Can you extend your system to text them 10 minutes before their appointment starts in addition to a week before and the day before? I think part of the problem is the MA here. I haven't seen a system like this where a MA is so heavily involved in telehealth real time. If the MA is already waiting 5 minutes to call, has to get ahold of them and then connect them to you, that's eating up a huge chunk of the appointment time. Instead of that, could you take that over and leave the MA to handle future scheduling? This time is already blocked off for you. This way you could get them in right away or convert it to a billable phone appointment. Of course if you can't reach them immediately, then you leave a voice message and hand if off to the MA to reschedule.

Correct me if I'm wrong, but didn't stagg say that the MA is on 10 minutes early, and if the patient isn't on 5 minutes early, then they call? Because if that's not what's being done, I would recommend that.

5 minutes in a zoom waiting room is nowhere near as unpleasant as 5 minutes in a real waiting room.

 

[ObsequiousAplomb]

So we do have a text message reminder that goes out either 24 or 48 hours prior to the appointment (I think 24) with the appointment link, time as well as time zone specification, and a reminder that they must be physically in-state. My MA gets on the link 10 minutes before the appointment start time and if a patient isn't on within 3-5 minutes she calls them.

For example today I only had 4 patients (all f/ups). The first and last were same day cancellations and both of the middle two had to be called to get on. This is pretty standard rates for me. I have referred quite a few people back to their PCPs and "fired" 2 patients (aka, I won't see them for future referrals).

It seems like, if possible, your clinic may want to move the notification earlier enough that patients can reschedule. Then, once rescheduled, the MA should be pulling people off of a wait list. I may be totally wrong here, my experience is that patients are more likely to know 2-3 days before whether or not they really can make it, and as long as the second notification is far enough out that an MA can fit in someone off a wait list, your time could be more productive.

Btw, a little jealous an MA can do all this for you, though I'm glad I don't have to pay one.

 

[calvnandhobbs68]

I’m suspecting a lot of this is your patient population and insurance mix. If people have no penalty for missed appointments, they’re gonna miss them. One way to “penalize” them is to say you’re not providing any additional medication unless they schedule/have an appointment and then provide just enough to get to that next appt. Another way is to discharge them.

You can have no show fees for Medicare patients btw, your system just isn’t doing it. It’s just Medicaid patients you can’t.

 

[comp1]

I re-read it, the OP's MA isn't calling until 5 minutes IN to the appointment (at least from the first post, second post is less clear). That's too late. You've lost like a third of the talk time for the appointment and the MA hasn't even connected you to the patient yet. I'm sorry, but it really does seem like the MD needs to be the one making the real time no show calls (and converting to phone appointment right away if not possible to get on video). I also honestly just find this a weird use of a MA, to be frank. It's interjecting a 3rd person into what should be a real time conversation between two people. The MA's role should be scheduling and rooming in person patients. Maybe conceptually the office thought this was like rooming? But it's not and it's not working regardless.

 

[TexasPhysician]

Medicare patients should be charged a no-show fee.

Medicaid patients should always be over-booked if working on production.

 

[J ROD]

In residency we had a "refill" clinic for those that missed appointments, they had to show up several times in a row to get back into the regular clinic and have more than a 15 min appt with their regular provider. Seemed to work well for the Medicare/Medicaid pop.

Personally in my clinic now I have around a 10% no show rate maybe even less. Best I have ever had. My nurse hunts them down with calls day before and day of. I also do not give refills past their next appt. And only allow refills for a month if they have to miss and reschedule. I do have about 25% showing up late but I work around it well and explain to them they have certain time on this visit as they did not respect my time or theirs. I then reschedule them for a proper visit in a month.

 

[Ironspy]

a late cancellation (<24h) is the same as a no show. I cannot treat patients who I do not see. If I cannot meet regularly with a patient in clinic, I transfer them to another setting.

 

[FlowRate]

Agree with what everyone else said. Our combined unfilled late-cancel/no-show rate is around 10-15%. I probably call 20% of patients due to them being late or having issues with connecting to the telehealth visit. I think our system may also send a same-day text with the appointment link.

How many times do you allow people to be late before you discharge? When I was in residency, patients got two warning letters and then discharged if there was a third no-show in a row.

In our current system, we limit refills for patients who are past due for appointments. We don't usually cut people off unless they basically refuse to see us for multiple additional months, though.

 

[Candidate2017]

Wait, is the outpatient Medicaid teleclinic based production? If so, might as well take a vow of poverty. Or are you just ticked you can't fill the time with C/L production? Either way, academic + Medicaid population + telepsych is the triumvirate of dysfunction.

Commercial insurance population is basically zero percent no-show when it comes to telepsych. After a few minutes, just pick up the phone, "Where u at? Log tf on."

 

[Stagg737]

So some additional info. This is a small clinic (~5 hours a week and <50 patient panel at any given time, usually in the 30-40 range). This is a clinic that our academic center has a contract with a state organization for, so not even technically run by our academic center, and the MA works with the state organization where I see patients that otherwise would not be able to see a mental health prescriber. So that's why she's so involved with the set up and with appointments. A lot of these patients go to local clinics 4-7 hours from where I am and then are connected to me through her. Some patients use their own devices, but some do not. Ironically, the ones who use their own devices are usually the ones cancelling, not the ones going in to a clinic. Our hospital has multiple services (psychiatry and endocrine are the big ones) who have this set up, so some of the policies with how they're run are out of my control, but the MA (who is a centerpoint for all these services) is very flexible with me since I'm the only psychiatrist.

- Discharging patients from clinic or charging them money for no shows--things you probably can't do in an employed academic position.

I’m suspecting a lot of this is your patient population and insurance mix. If people have no penalty for missed appointments, they’re gonna miss them. One way to “penalize” them is to say you’re not providing any additional medication unless they schedule/have an appointment and then provide just enough to get to that next appt. Another way is to discharge them.

You can have no show fees for Medicare patients btw, your system just isn’t doing it. It’s just Medicaid patients you can’t.

I do "discharge" quite a few by referring them back to their PCPs since that's the goal of the clinic anyway. Correct that I can't charge for no shows. Also, unfortunately can't renegotiate pay as it's just not worth it for the clinic (3 possible pay models in our department and the one I'm on makes the most sense by far, even with this clinic sucking some RVUs). To the bolded, I already provide minimal medications unless they truly don't need to come back and the PCP can just fill the meds, but it doesn't stop some from missing/same day cancelling and rescheduling for a couple weeks later.

I re-read it, the OP's MA isn't calling until 5 minutes IN to the appointment (at least from the first post, second post is less clear). That's too late. You've lost like a third of the talk time for the appointment and the MA hasn't even connected you to the patient yet. I'm sorry, but it really does seem like the MD needs to be the one making the real time no show calls (and converting to phone appointment right away if not possible to get on video). I also honestly just find this a weird use of a MA, to be frank. It's interjecting a 3rd person into what should be a real time conversation between two people. The MA's role should be scheduling and rooming in person patients. Maybe conceptually the office thought this was like rooming? But it's not and it's not working regardless.

See the initial paragraph about the MA. I usually have my MA call them both because she has to check them in for her organization and so I can respond to messages from medicine teams about consults I saw that morning or address other inbox stuff. I have started having her call patients within 2 minutes of the appointment time if they're not there so it wastes less time if they forgot. Hasn't changed the no show/late cancel rate though. Also, where I'm at does not allow us to bill for appointments converted to phone calls. If I can't visually interact with them for at least a few seconds I'm not allowed to bill.

 

[Stagg737]

a late cancellation (<24h) is the same as a no show. I cannot treat patients who I do not see. If I cannot meet regularly with a patient in clinic, I transfer them to another setting.

The problem here is there is no other setting other than their PCP. There's only 2 CMHC-like clinics in that 1/3rd of the state and some of my patients are 2+ hours away from the nearest psychiatrist/psych NP. It's literally me or nothing for quite a few of them as they can't afford online services (a couple don't even have internet).

How many times do you allow people to be late before you discharge? When I was in residency, patients got two warning letters and then discharged if there was a third no-show in a row.

Depends on the patient. I have a few people who are in situations where it can't be helped based on the limited times I'm available to them. I also see several people who are quite medically ill and are in and out of the hospital so have to reschedule. I don't count those against them. Most of the time they get 1 freebie/please make sure you're more proactive and the second time is much more stern. Ie, "no show/late cancel again and we will likely refer you back to PCP." The few times this has happened I inform them I won't see them again in the future, as I normally tell patients and PCPs that they are welcome to refer patients back to me if other needs arise or if they destabilize.

Wait, is the outpatient Medicaid teleclinic based production? If so, might as well take a vow of poverty. Or are you just ticked you can't fill the time with C/L production? Either way, academic + Medicaid population + telepsych is the triumvirate of dysfunction.

Commercial insurance population is basically zero percent no-show when it comes to telepsych. After a few minutes, just pick up the phone, "Where u at? Log tf on."

It's a mix of CMS and private insurance. Ironically the private insurance patients are just as bad, which is part of why I was asking with this thread. Idk if it's because most of these patients are true smalltown/rural or something else. Trying to triage if I'm missing anything on my end other than just being a lot harsher with "firing" patients. The bolded is definitely part of it, as there are some afternoons where I end up only seeing 2-3 people while I could have staffed with residents and made 20+ wrvus.

 

[Stagg737]

So yea, it's a very different set up for a clinic, and I sometimes have to think of it almost as a kind of charity work. Especially given my general dislike for outpatient work.

Really just trying to figure out how common missed appointments and late cancellations are for telehealth in general and if there's something I'm missing that could decrease this in my clinic other than just threatening to discharge them since that's the end goal anyway.

 

[comp1]

Omph, yes. This is more than enough to keep my hatred for any outpatient work going. Your setup sounds particularly horrible and in need of massive renegotiation with whatever company is inserting this MA. I guess if you can't rescue any billing by converting to phone (which is VERY unfortunate), it doesn't really matter if this MA "virtually rooms" them or not. Just fire aggressively. When you say that they don't have any other options, they actually also don't have YOU as an option when they don't show up to appointments. You're just harming them and others by keeping them on the panel.

 

[Stagg737]

Omph, yes. This is more than enough to keep my hatred for any outpatient work going. Your setup sounds particularly horrible and in need of massive renegotiation with whatever company is inserting this MA. I guess if you can't rescue any billing by converting to phone (which is VERY unfortunate), it doesn't really matter if this MA "virtually rooms" them or not. Just fire aggressively. When you say that they don't have any other options, they actually also don't have YOU as an option when they don't show up to appointments. You're just harming them and others by keeping them on the panel.

I will say, the MA I work with is wonderful and does a lot of legwork keeping things as smooth as they can be. The days when she's had others covering for her have ranged from barely tolerable to nightmarish, and if she left I'd be letting my bosses know I'd be done with the clinic also.

I've thought about getting really strict with all everyone but for some it would be legit punishment. To the bolded, yes and no. When it's a personality or just a laziness thing I am strict, and I've had a few of those that I've "fired". Like I said though, some of these people have situations where they don't have a choice but to miss last second. Another example other than hospitalization: special ed teacher had to have a kid in a safety hold for 20-30 minutes until police showed up and then had to do reports with the school. I saw her the next day in my open slot. I don't want to punish those people when they are usually good at giving us a heads up and are legitimately invested in getting better. Plus, my panel is almost never "full". I can usually see a new consult within 1-2 weeks after I review the referral and approve it. It's pretty rare when I have a day where I don't have at least 1 open slot (out of 5-6 slots).

One thing I have been more proactive about is screening the consults and saying no to certain patients which I think has helped. Idk if it has truly helped with no show rates, but it certainly makes the clinic more tolerable and I don't see every geri case that's clearly dementia with behavioral disturbance anymore.

 

[annoyedpsychiatrist]

im in a hospital based outpatient practice and yes for new ones the no show rate is quite high, even with reminders, as well as late people. Even on telehealth. But im seeing moderate-high acuity people, people with lots of substance use disorders, significant personality disorders, etc. Probably in outpatient physician owned clinic theyre cherry picking more the mild/high functioning pts so i would suspect those are more likely to cancel appropriately/show up on time. The referrals i get are 50% of the time dumps, or downright pointless. "Sleep doctor told me to see you to get my ambien"

 

[aim-agm]

A silver lining to the VA's obsession with metrics is that I can pull a lot of this data pretty easily.
My no-show/cancel rate looks to be ~20% (+/- 5%) with no significant difference between in-person and video visits. Patient population is similar to yours in that there are no consequences at all for no-shows/cancels (more so because practically speaking we can't terminate treatment), although I expect that overall their socioeconomic situation is significantly better.