No More No-Shows

May 1, 2003

Understanding the problems that lead to no-shows can go a long way toward improvement

How many of your patients would earn a "perfect attendance" certificate? Take a look at your no-show rate and you'll see. While some practices experience no-show rates as low as 1 percent, others' are as high as 60 percent. Regardless, no-shows always cause lost revenue, wasted time, reduced productivity, and plenty of frustration.

"If a practice's no-show rate is high, it has a huge impact on the planning for the day," explains Vince Giacolone, vice president of clinical operations services for BSM Consulting Group in St. Louis. "Certainly, it can have a serious economic effect, too."

While you may never achieve perfect attendance among patients, you can take some steps to help them keep their appointments. Understanding the problems that lead to no-shows and implementing plans to prevent them -- many of which are easy and cost-effective -- can go a long way toward keeping this frustrating and expensive problem under control.

Why patients fail to show

It's no wonder patients miss appointments when the kids have to be picked up from school, the boss needs a quarterly report by 5:00 p.m., and there's a traffic jam on the highway. A patient's appointment with you is just one thing among many competing for their time and commitment.

They may simply forget about the appointment, especially if it was made weeks or months in advance. Others overlook the importance of keeping medical appointments -- not realizing the inconvenience that not showing up might cause your practice -- and decide to "do it another time."

"The main reason I have found that patients don't show up is because they don't think they are going to be missed -- they figure the practice is busy, the doctor is rich, so what's one less patient," says Giacolone. "They don't know the effect it has on you."

Some patients may even avoid appointments because they are anxious, or because they feel that there is some stigma attached to it. This is especially common for psychiatric practices, or for procedures that may be embarrassing or uncomfortable, such as mammograms or colorectal cancer screenings.

Payer mix can have something to do with no-shows as well -- certain patient populations might not have dependable transportation, childcare, or the ability to leave their job to keep an appointment.

And don't underestimate the importance of a strong physician-patient relationship, either.

"The patient-physician relationship is very important," explains Elizabeth Woodcock, MBA, FACMPE, director of knowledge management for Physicians Practice. "Practices in which physicians rotate a lot, including residency clinics, or those that employ locum tenens, tend to have higher no-show rates. Patient loyalty can make or break your no-show rate."

Communication is key

"Patients have to be made to understand the importance of showing up," Giacolone says. "Physicians and staff alike have to educate the patient on the importance of returning."

There are more than a few ways to keep in touch with patients -- and using more than one line of communication boosts your chances of getting the word out about upcoming appointments.

While patients are in the office, physicians should communicate to them how important it is to keep upcoming or future appointments, particularly in terms of the patient's health. New patients should be made familiar with cancellation and no-show policies. Before the patient leaves, or while scheduling their next visit, office staff should clearly communicate the date and time of their next appointment, and provide an appointment card or other printed reminder of upcoming visits.


Practices should have a system to place reminder calls to patients, preferably 24 to 48 hours before the appointment. It's even a good idea to ask patients to call back to confirm they received the reminder message and that they will keep the appointment. See "Can Telephone Technology Help?" for more about tools that can help make reminder calls easier -- and more effective.

E-mail is a low-cost, relatively easy way to send reminders, and many patients have access to it. However, there are privacy and liability issues related to the use of e-mail with patients. You should only use e-mail with the patient's permission and you should also provide automatic notification that the physician and the patient have received the e-mail, create internal systems for receiving and responding to e-mails, and document e-mails that have been sent. For more information and guidelines, visit www.medem.com and click on "E-mail With Your Doctor?" in the For Physicians section.

Though more costly and time-consuming than phone or e-mail reminders, many practices find that sending postcards or letters reminding patients of upcoming appointments is the best way to keep no-shows at a minimum. Mail may be the best way to reach certain populations, such as the elderly, who can forget about phone messages and may not have access to e-mail.

Maximize access

Some practices have minimized no-shows by implementing open-access scheduling, in which a portion of the day's appointments are left open for patients who call to be seen that day, or advanced access scheduling, in which all patients receive an appointment within 24 or 48 hours.

For example, Kaiser-Permanente Panorama City Medical Center in California has tried a variety of advanced access scheduling systems, from leaving the entire schedule open for same-day appointments, to their current system of using half of their appointments for same-day appointments and the other half for pre-booked appointments.

"Using all same-day appointments certainly reduced our no-show rate dramatically, but the downside was that it didn't meet all of our members' needs. Some people need to book appointments ahead of time so they can schedule time off from work and so on," explains Virginia Amborsini, medical director for the center. "Our current system is producing no-show rates between 5 percent and 10 percent, which is excellent. Plus, same-day appointments are a real patient-pleaser."

Do you offer early morning, evening, or weekend appointments that are convenient for patients? Offering early morning or evening appointments one day a week, or opening the office one Saturday a month can go a long way toward getting patients to show up when they are supposed to.

And keep in mind that, while it may feel great to have your appointment book full for the next six months, is it any wonder that patients forget an appointment or can't make a visit they scheduled months in advance?

"We have found that the farther out an appointment is scheduled, the higher the no-show rate," Amborsini says. "We don't book out any further than six weeks."

Establish policies

To avoid misunderstandings, establish a clear-cut policies and consequences for no-shows, and stick to them. No-show and cancellation policies should be detailed and specific. For example, how far in advance do you expect appointment cancellations to be made? How late can a patient be before they are considered a no-show -- 15 minutes? 30 minutes? What are the consequences of missing an appointment without notice -- a penalty fee, reduced access to the practice, termination?

Know that while some practices have begun to charge for no-shows (as much as $15 to $25) that may not be the answer. You can end up overtaxing your billing department and angering patients. According to Woodcock, a no-show penalty can get patients' attention, but it may be more trouble than it's worth.

Include a detailed outline of your cancellation and no-show policy in your patient handbook, if you provide one, or a printed version of the policy to every new and existing patient. An abbreviated version of the policy can also be posted in a visible area of the waiting room or near the front desk.

No-shows liability


Adding insult to injury, no-shows may also pose a significant liability risk. Patients who miss appointments and suffer injury as a result may have a viable lawsuit if they have evidence that their physician did not give clear directions or make reasonable efforts to make sure the patient complied with their advice, including follow-up appointments.

"It's a very serious, very valid point -- from a liability standpoint, physicians have to protect themselves," says Giacolone.
To be safe, keep clear, consistent records of missed appointments, and follow up on no-shows. If a very ill patient misses an appointment, every effort should be made to find out why, as soon as possible. While follow-up calls can be time consuming, they can be well worth it if they prevent problems.

"We always provide some kind of follow-up to no-shows, whether it's just documenting it in the chart or sending out a letter letting the patient know they missed their appointment," says Amborsini. "Sometimes the physician even personally calls the patient. Our action depends on the circumstances, but there is always follow-up."

By some estimates, patient no-shows cost practices up to $20,000 per doctor, per year. Add that to the lost time, wasted resources, potential harm to patient health, possible liability, and the frustration physicians and their staff experience, and there's no good reason why you shouldn't be doing everything you can to make sure your patients make their appointments.

"Appointments are our most precious commodity in daily operations," Amborsini says. "We make every effort to keep our no-shows under 10 percent."

Cassie Gainer can be reached via
editor@physicianspractice.com.

This article origianlly appeared in the May 2003 issue of Physicians Practice.