Module 1: Reducing Patient No-Shows
It happens to even the best-run practices at least once or twice a week: The day is running like clockwork; patients, physicians, nurses, and office staff are waltzing around in a carefully choreographed dance; and then... Mrs. Smith doesn’t show up for her 2:30 appointment. Not only does this throw a wrench in the rhythm of the day, but it also costs the practice precious time and money.
While it might seem like no-shows and late cancellations are just an inevitable part of running a physician’s office, there are ways to minimize this problem.
In this module, we will...
- Define no-show rate.
- Discuss why a practice’s no-show rate is important.
- Explore common causes of no-shows.
- Identify strategies to reduce no-shows.
- Explain how to benchmark your practice’s no-show rate and create a plan to reduce it.
What’s Your No-Show Rate?
Anyone working in an allergy practice knows that no-shows are a problem, but not every practice knows its no-show rate. Here’s a quick definition:
No-show rate: The percentage of appointment time lost because patients don’t show up or cancel at the last minute
To calculate your practice’s no-show rate, simply divide the number of no-shows (including late cancellations) by your total number of weekly appointments.
Total number of weekly appointments
For example, if your practice typically sees 50 patients each week, and you have five no-shows, your no-show rate is 5 divided by 50, or 10 percent.
Determining your practice’s rate gives you an objective starting point from which you can make changes to address it. No-show rates vary by practice, but they’re typically somewhere between 5 and 10 percent (although they can be much higher). What influences a practice’s rate? Some factors include:
- Geographic location
- Patient demographics
- Scheduling practices
- Types of payers (commercial insurance, Medicaid, self-pay)
- Appointment types (new patients vs. established patients; appointments booked far in advance; appointments for certain types of tests or procedures)
We’ll cover some of these factors in more detail when we discuss common causes of no-shows later in the module.
The Cost of No-Shows
Since a no-show or late cancellation sometimes provides a respite in a busy day, it can be tempting for staff to celebrate the occasional missing patient. But what do no-shows really cost your practice? There are two big costs to consider:
- Lost revenue
- Reduced patient access to physicians
Let’s take a closer look at each of these.
It should come as no surprise that no-shows cost your practice money. “Just how much money?” you might ask. Well, consider that a no-show or late cancellation leaves you no time to fill an appointment slot, so your practice’s fixed costs (rent, utilities, staffing, and so on) now have to be spread across fewer visits. If you typically make $200 per visit, and you have 5 no-shows each week, that amounts to $52,000 in lost revenue every year.
At $200 per visit, 5 no-shows a week costs $52,000 a year!
Believe it or not, that estimate is on the conservative end.
Reduced Patient Access to Physicians
The other cost of no-shows is in the form of time—both yours and your patients’. With the scarcity of specialists and growing demand for services, our time is precious. Physicians don’t have time to waste on patients who don’t show up, and patients don’t have time to wait longer than necessary to get an appointment at your practice. If your practice is booking appointments weeks or months in advance, you know how important each appointment slot is to the health of your patient population.
Now that you have a clear idea why you should care about your practice’s no-show rate, let’s explore some of the common reasons patients don’t show up for appointments.
Common Causes of No-Shows
What keeps patients from showing up as scheduled? You probably have a few ideas already, but let’s look at the most common reasons for no-shows and late cancellations. Patients miss appointments because...
They didn’t get an appointment confirmation.Perhaps your practice has a solid appointment confirmation system, but no system is perfect. Patients miss confirmations because their contact information is out of date, they don’t have voice mail or their voice mail is full, or they didn’t get the message you left until it was too late to call back and rebook.
They don’t feel connected to the physician or staff.New patients tend to have higher no-show rates. This makes sense when you consider that people are more likely to show up when they have a personal connection to their care provider and feel engaged in their treatment plan.
They booked their appointment far in advance.Patients who make appointments months or weeks in advance are more likely to simply forget about their appointments. Sometimes they’ve managed to see another physician in the meantime and they forget to cancel their original appointment. Or they might just start to feel better, making them forget why they made the appointment in the first place. This can be particularly relevant in cases where you need to wait for a patient’s reaction to subside before you can reliably test for an allergy—often, patients feel better before their next scheduled appointment and do not return.
They’re confused about the need for the appointment.This can happen with scheduled follow-up appointments. If the patient’s symptoms have improved, she may not understand why she should still come back for a follow-up. Sometimes these patients cancel the day of their appointment, but it’s often too late to book another patient.
They have personal issues preventing them from showing up.Patients might have transportation problems—their car broke down, or they missed the bus that would have gotten them to their appointment on time. Or they might have financial issues and are worried about being able to pay their copays or high deductibles. They might also have simple scheduling conflicts. Patients from certain demographics or with certain types of insurance (or no insurance) may be more prone to no-shows than others, so it’s important to keep track of these factors to help pinpoint the causes of no-shows.
Strategies for Reducing Your No-Show Rate
With all of the various causes for no-shows, you might be wondering what you can possibly do to prevent them. Well, you’ll never be able to prevent them all, as some people will genuinely have personal emergencies that get in the way of their appointments. But you can certainly prevent many of them with a comprehensive approach that includes some or all of the following strategies.
Confirm, Confirm, Confirm
The simple appointment confirmation is a really effective way to prevent no-shows. Chances are your practice already does this in some form, but you might need to review and improve your methods. Here are some best practices when it comes to confirming patient appointments:
Collect the right information.During patient registration, make sure you collect at least two ways to reach the patient. Ask for home, work, and mobile phone numbers, as well as an email address. If the patient provides a mobile phone number, ask if they prefer a text or voice confirmation (or both). Verify the patient’s contact information every time they make an appointment, and ask about their preferred modes of contact.
Use the right language.Make sure to say (or write) that you’re calling with an appointment confirmation, not a reminder. A reminder sounds like a suggestion, while a confirmation implies that the patient has already made a commitment to be there. For example, have front desk staff (or your automated recording) say:
“I’m calling to confirm your appointment with Dr. Donahue on Wednesday, August 7, at 2 p.m. Please be sure to call our office at 555-567-8912 if you need to make any changes to this appointment.”
Confirm at least 48 hours in advance.An additional advantage here is that you have time to fill any cancelled appointments. Many practices have found it works best to call to confirm two days before the appointment, and then send a follow-up text (if the patient has consented to receive texts) two hours before the appointment. Confirming two days in advance rather than the day before the appointment ensures that if the patient cancels, you’ll still have time to fill the appointment. If the patient needs to stop a medication, such as an antihistamine, a certain amount of time before an appointment, be sure to call to remind them to do that.
Implement a Practice-Patient Agreement.A practice-patient agreement is a covenant between the practice and the patient. In it, you can establish the practice’s commitment to be available to the patient when necessary and to run on schedule as often as possible. In return, you ask patients to meet certain expectations, including keeping appointments and providing ample notice (usually at least 24 hours) if for some reason they can’t.
Determine Consequences for No-Shows
What actions will the practice take in the case of no-shows? The consensus is that the specific no-show policy, e.g. three strikes, should not be in the practice-patient agreement, only brought up when incidents occur so practices have some leeway for special circumstances. You don’t need to spell all of these out in the practice-patient agreement, but it’s a good idea to have internal guidelines to help staff deal with these incidents. Here are some to consider:
Implement a three-strikes-and-you’re-out policy.If a patient breaks the no-show policy three times within a specified amount of time, they’ll be discharged from your practice.
Collect down payments from repeat offenders, patients who are likely not to show up, and patients doing specialized testing.After a patient’s first no-show offense, remind them of the practice’s policy, and consider asking for down payments for future appointments. If you have patients who are likely not to show up, such as self-pay customers, you can also ask them to pay a down payment in advance. Also, if you’re seeing a patient for specialized testing, such as a patch kit, you can ask for a down payment to encourage them to keep the appointment.
With any of the above policies, you can choose whether to notify patients in writing or verbally, depending on what suits your practice. This provides flexibility in case of special circumstances—there’s no need to discharge a patient who has missed appointments due to a true hardship.
In addition to appointment confirmations and a clear practice-patient agreement, strategic scheduling can help you limit the costs of no-shows. How? Here are some tactics to try:
- Limit daily appointment slots for patients from demographics that are likely to no-show. The “typical” no-show patient varies from practice to practice, but you can study your no-show rates to determine if certain people are likely to miss appointments.
- Consider overbooking, especially if you notice that your no-shows are most likely to happen at a certain time of day (such as early-morning or late-afternoon appointments). You can double-book these slots and potentially avoid lost time and revenue if one patient doesn’t show up. Of course, you also risk irritating patients and doctors when all patients show up and put you behind schedule.
- Reserve a few same-day slots for patients to schedule last-minute. This discourages booking far into the future, and it helps patients with acute conditions get seen faster. There’s a chance you won’t fill all the slots, but you will soon learn the correct number of slots to reserve through experience. And the next tactic can help fill open slots.
- Keep a list of patients who can come in on short notice. If an appointment opens up because of a last-minute cancellation, or you haven’t filled one of the reserved same-day appointments, you can call these patients to fill the slot. And they’ll be happy to get in sooner, so it’s a win-win.
Benchmarking and Creating Your Plan
Now that we’ve explored common causes of no-shows and some strategies to address them, let’s talk about how to put a no-show improvement plan into place at your practice. Creating a plan involves four steps:
- Benchmark your practice’s no-show rate.
- Gather data on the causes of patient no-shows.
- Identify the top causes of no-shows for your practice.
- Implement strategies to address those causes.
Let’s walk through these steps.
Benchmark Your No-Show Rate
This step should be fairly simple, and you might have already done it using the formula we covered at the beginning of the module. Here it is again for review:
No Show Rate and Costs Calculator
No shows per week
(including late cancelations):
*required Total # of weekly appointments: *required Your no show rate is: Cost per each no show: $ The cost of your no shows is:
It’s also a good idea to compare your no-show rate to your own on-time performance. Is your office chronically running behind? If so, this might make it easier for patients to justify missing their appointments. If possible, address long wait times in your plan so that patients feel valued and are more likely to show up.
Gather Data on the Causes of No-Shows
You already know the common causes of no-shows generally, but in this step, you’ll want to drill down to the specific causes of no-shows at your practice. How do you find this information? You’ll need to train front office staff to ask patients why they missed appointments and to track what they find.
This can be a sensitive question to ask. In some cases, such as late cancellations, a patient might volunteer the reason she’s missing her appointment, in which case your staff can document that reason. For example, maybe the patient calls to say her car broke down and she can’t make it, so she’ll need to reschedule. When a patient simply doesn’t show up, though, front desk staff will need to follow up with the patient within 48 hours. Here are some tips for those follow-up calls:
Express concern for the patient’s well-being, and ask if everything is okay.
For example: “Hi, Mr. Brown. We were sorry to miss you at your appointment with Dr. Hernandez this morning, and I just wanted to make sure everything is okay.”
Often, a patient will voluntarily explain their reason for not showing up. If he or she doesn’t, you can gently ask. Make sure the question is not framed in an accusatory way.
For example: “Our practice is working on gathering data about missed appointments so that we can better meet our patients’ needs. May I ask why you weren’t able to come in? Did you receive your automated appointment confirmation call? Is this contact information I have for you correct?”
Be sure to reschedule the patient’s appointment, and at the end of the call, courteously remind him or her about your practice’s no-show policy.
For example: “You are confirmed for an appointment with Dr. Hernandez next Tuesday, the 15th, at 10:30 a.m. You’ll receive a confirmation call two days before. Please remember that if you miss another appointment without giving us 24 hours’ notice, our policy is to require a deposit of $50 when you schedule your next appointment. We’d much rather just see you next Tuesday, though! Please give us a call if you have any questions or can’t make it for some reason.”
A patient’s stated reason for missing an appointment is just one piece of data you’ll want to collect. You’ll also want to keep track of objective details that might influence no-shows. You might have the ability to do this with your practice’s scheduling software. If not, you can create a shared spreadsheet where staff can enter information. Here’s what you’ll want to track:
- Appointment day and time
- Appointment type (new vs. established patient; new issue or follow-up)
- Date the appointment was made
- Patient’s demographics and insurance carrier
- Patient’s diagnosis and reason for visit
- Patient’s reason for cancellation/no-show
- Whether appointment was confirmed
- Express concern for the patient’s well-being, and ask if everything is okay.
Identify the Top Causes of No-Shows
Once your staff has kept track of no-show data for a sufficient period of time—a couple of months at minimum—you’ll hopefully start to see some trends in your data. What are the top causes of no-shows for your practice? Maybe patients who are scheduled for early-morning Monday appointments are the most likely not to show up. Or maybe patients with higher copays often miss their appointments. Make a list of the top causes of no-shows so you can begin to address them.
Implement Strategies to Improve Your No-Show Rate
We’ve already talked about the strategies you might implement to reduce your practice’s no-show rate. These include:
- Good appointment confirmation practices Collect accurate contact information
- Confirm, rather than remind
- Call at least 48 hours in advance
Implement a practice-patient agreement
- Explain your commitment to patients and what you expect in return
Determine consequences for no-shows
- Consider implementing a three-strikes-and-you’re-out policy
- Collect down payments from repeat offenders or for patch testing or other testing with specialized equipment
Adjust your scheduling practices
- Limit daily appointment slots for patients likely to no-show
- Consider overbooking
- Reserve a few same-day appointment slots
- Keep a list of patients willing to come in on short notice
So how can you figure out which ones will be the most beneficial to your practice? Refer to the top causes you identified, and go from there. If many no-show patients say they didn’t receive a confirmation call, you’ll know you need to refine your practice’s confirmation procedures. If most of your no-shows happen at the same time of day, you can double-book those appointment slots to minimize lost time and revenue. If you have long-standing patients who seem to be used to treating their appointments as optional, you can create a new practice-patient agreement that spells out expectations and consequences of missing multiple appointments.
Let’s get started in reducing your no-show rate with these simple steps:
- Calculate your monthly no-show rate over a three-month period to determine your monthly average.
- While you’re collecting this data, ask your front desk employees to start tracking the reason for each no-show. Consider using a shared spreadsheet to record this information.
- Examine the no-show data you’ve collected to identify patterns and/or top causes.
- Review strategies to reduce your no-show rate, and figure out which ones to try based on the top causes you’ve identified.
- Keep calculating your no-show rate each month, and continue to track each no-show reason. That way you can see whether the strategies you’ve implemented are working. You may need to tweak your strategies as you work to continuously improve your no-show rate.
While no-shows are a costly and sometimes frustrating part of running an allergy practice, you’ve seen that it is possible to reduce them with the strategies we’ve explored in this module. Take some time to track data and understand the no-show rate at your practice, and make the appropriate policy changes to address them. Chances are you’ll be seeing more of your scheduled patients very soon!
Sources (provided by ACAAI):