Why do patients miss their appointments? The most common answer is that they simply forget. Some patients are embarrassed that they cannot afford a co-payment. Others may be frustrated when coming to your office. Perhaps a patient was uncomfortable with the way he was spoken to by the front desk staff. Difficulty finding parking, having to pay a fee for parking, or even the lack of evening hours can keep patients away. What is important to understand is that there is a wealth of information about why patients do not keep their appointments.

Investing the Time

In analyzing no-shows, I ask practitioners if they confirm their patient appointments. Many say they don't have time for that. They only confirm new patients because it is too costly to have a staff member confirming return patient appointments. Many of these same practices have invested heavily in order to attract patients, equipping the office with cutting-edge technology, and spending considerable money on advertising. Still, these same practices are experiencing a 10 to 20 percent or higher no-show rate.


Bottom Line Impact?

Remember the old marketing adage, "It is cheaper to keep current clients than it is to attract new ones"? Think of patient appointment confirmation as part of your practice's marketing program. Without realizing it, keeping a current patient can cost as much as recruiting a new one. Here's how: The average cost of marketing for a new patient can be from $50 to as high as $500. The cost of confirming an existing patient is 50 cents to $1.00 a patient. In addition, the loss of a returning patient is not only the current visit—an average of $150, but also the future value of visits—$750 for a patient who stays with a physician for five years (the average time a patient stays with a physician). Put in other terms, a new patient yields $100 ($150 less $50) where a returning patient yields $149 ($150 less $1.00). A significant difference! In my consulting I also typically hear of practices filling in the no-show slots with emergencies or that no-shows allow the staff to "catch up with the physicians." These kinds of statements can drive a motivated surgeon or dedicated administrator crazy.

I have also heard that no-shows don't really affect the bottom line. Think again. Reducing no-shows can boost the bottom line, up to a $100,000 per physician. For example, a general ophthalmologist will typically schedule 60 patients in an eight-hour day. Conservative average revenue per visit in a general ophthalmic practice is $150. Decreasing no-shows by five per day or 15 per week can add $100,800 to a practice's top-line revenue. Almost 95 percent of that added revenue will fall to the bottom line since all the other expenses—staff salaries, rent, and utilities—have already been paid. These figures can easily double in retina practices and do not include other sources of additional revenue such as optical sales, possible cataract or other surgical cases, diagnostic testing as well as laser vision correction procedures.


The Liability Risk

Another reason it is important to reduce your no-shows is risk management. Encountering a legal case as a result of a patient missing his appointment is not as uncommon as it might sound. In the process, the practice not only loses the revenue of the visit, but the patient is suing because of the missed appointment! Many ophthalmologists wonder, "How can he sue me, he did not keep his appointment?" Most malpractice carriers recommend that physicians document no-shows and any attempts made to contact the patient. Appointment non-compliance can correlate to medication non-compliance, and that can put the ophthalmologist at risk for a legal suit. While it is the patient's responsibility to keep the appointment, confirming appointments and a recall system for patients who miss their appointment will minimize malpractice risk to the practice. Remember, it not a panel of ophthalmologists on a jury, but lay people. A judge and/or a jury will be more sympathetic to a practice that has a procedure and a process in place to notify no-shows, and documentation of such attempts to reach the patient in their medical records.


Maintaining Contact is Key

How can a practice reduce its no-show rate? There are several approaches to consider:

 Confirm all appointments two business days in advance. It is best to go with a human touch, as ophthalmology is a service business, and is a highly competitive one. Tech­nicians with downtime are one source of ready labor. If you are pinched for staff, considering hiring a high school or college student. Many telephone answering services offer patient ap­pointment confirmations as a service. It is best to have cheerful, hap­py office personnel con­tacting pa­tients to confirm ap­pointments, which translates into good public relations for the practice.

 Contact no-shows immediately. Usually contacting a patient within an hour of his missed ap­pointment is the best time to re­schedule him. If you cannot reach him the same day, send a polite letter asking him to call the office as soon as possible to reschedule.

Send appointment reminders by mail. Reminders should be mailed to patients two weeks prior to their appointment. This is especially helpful for those patients who book their office ap­­pointments more than two months before their scheduled ap­pointment time. It is a fact of modern life that people overextend their daily schedules, trying to squeeze in more than the normal day can ac­commodate. Elderly patients may need to make transportation ar­rangements to get to the physician's office. In addition, a reminder al­lows the practice an opportunity to announce anything new at the office such as the addition of an associate, the opening of a new satellite facility, available evening hours or a sale in the optical shop.

 Develop a no-show policy. This policy should encourage pa­tients to contact the office no less than 24 hours prior to their appointment if they need to reschedule it. The same policy can also impose a no-show fee. The goal is not to collect a fee but to encourage patient appointment compliance. Though a difficult decision, consider dropping a patient from your practice that habitually misses appointments. One word of caution—talk to your legal counsel for the proper procedure in your state before dropping a patient from your practice.

 Send a welcome package to new patients. This packet should in­clude a description of the practice, the physicians in the practice, directions to the office, registration forms, and the practice's no-show policy.

Track Your Progress

While these tips will assist a practice in reducing its no-show rate, these steps should also be done in tandem with analyzing a practice's no-show rate/patterns. There can be variations between specialties, phy­sicians, offices and even the class of payer. It is extremely important to share this data with pro­viders. Physicians may often under-or over- estimate their no-show rate. Phy­sicians are data-driven and such information often assists in influencing their behavior. I typically include the no-show rate in a monthly summary of key statistics by physician and for the practice as a whole. I include a goal for the no-show rate by physician and by office. If you don't have a goal, how do you know if you are there? In my experience, physicians who are in­volved in the process, up to and including calling the patient themselves, often have the lowest no-show rates.

It is also useful when contacting no-show patients to survey their reasons for missing their ap­p­oint­ment. I have found that contacting pa­tients for a one to two week period of time  can reveal many issues. Some in­clude that it was too far in the fut­ure, the patient found another pro­vider, the time of day was inconvenient or the patient was not happy with his wait time during his previous exam.


Follow-up and Document!

Reducing no-shows can assist with the delivery of great medical care, promote the practice in a cost-effective manner, and increase practice re­v­enues. Analyzing data of no-show patients and informal polls of no-show patients can reveal extremely important data that does not show up in patient satisfaction surveys. Follow-up on no-shows; it is good medical practice and risk management to contact all patients who do not show for their appointment. Remember to document the phone call and/or letter in the pa­tient's chart. Reducing no-shows can significantly add to your bottom line and reduce potential malpractice risk with very little cost.