Wednesday, March 16, 2011

Should doctors charge patients who "no-show" for appointments? No.

A recent Medical Post column, “Finding Value” (March 8, p.26), caught my eye. Written by Dr. Jonathan Marcus, (bio: ... a family doctor and entrepreneur in Toronto. He writes and speaks on practice management with an emphasis on uninsured services) “How to explain no-show charges to patients” offers docs a script to encourage patients to pay for appointments they missed.

Before I share some of Dr. Marcus' tips, I want to say that it is accepted business practice in some professions (including medicine) to charge clients who don't keep their appointments. The rationale is solid: You reserved my time and have to pay for it regardless of whether or not you attended the appointment.

Having said that, I think there are 2 ways to look at no-shows. The traditional approach is that the patient is at fault and should bear the cost. Another approach is to consider how the appointment system a medical office uses may be a factor in missed appointments.

In specialty practices, long wait times for consultation mean some patients will honestly forget about their appointment. In Saskatchewan, some of our patients travel from the north and may have limited travel resources. We may have sent an appointment time that is inconvenient because of work, school, child care, etc.

In our practice, we've decided not to charge patients for missed appointments for various reasons, not the least of which is we don't want the nuisance of running a collection agency.

I think I could agree to disagree with Dr. Marcus on the relative merits of charging for no-shows. But, I'm uncomfortable when I read his suggested script for convincing patients to pay up. As I can't find a link to the article, I'll quote liberally and try to be true to the context.

In a previous article, he had offered suggestions on how office staff can collect outstanding bills. In the current article, the bill is still outstanding.

However, if your staff is unsuccessful, here's what you can do to get paid most of the time while maintaining a good doctor-patient relationship.

This is part most doctors are going to be uneasy with. We don't often have experience with the nitty-gritty business side of medical practice, and are worried that we'll affect the relationship with our patients.

During your patient's appointment, deal with his or her health concerns first, of course. Then bring up the outstanding bill.

We're off to a good start. I would be very uncomfortable with asking my patient for money before dealing with their medical problem. I think it would sour the entire visit. Also, I wouldn't want to surprise my patient with a no-show charge. I suspect that one of Dr. Marcus' previous articles suggested posting a waiting-room notice explaining the no-show policy.

Patients may give reasons for missing appointments and I recommend you waive bills for excuses such as family illness, etc. You might want to reduce rather than waive fees if the patient has financial difficulties. Paying a few dollars keeps patients accountable and reduces future no-shows, while respecting their financial situation.

Now I'm in the judge and jury. I have to decide if their story is worthy of a break. (In the case of a family illness, would my patient have to bring a doctor's note? To a doctor?) How will I judge their degree of financial hardship?

It’s important that you discuss outstanding charges in a nonjudgmental, relaxed manner. The first thing I say to patients is, “I’ve been your doctor for (however many) years. I love our doctor-patient relationship and hate to have to charge you for this.”

Is this a mixed message? I love our relationship, but I’m going to charge you for missing an appointment.

I may add, “This fee is not a punishment. It just covers the cost of running my practice.”…

…By this point, most patients have agreed to pay.

Some patients may still hold out. When this happens, I remind them I usually see patients on time for their appointments and I’m able to do so because I don’t double-book. The flip side is that I expect them to respect my time by paying for appointments they miss.

Dr. Marcus runs his clinic on time, but what about the other doctors to whom he is offering advice. If they don’t run on time, and/or double-book, are they still entitled to bill for no-shows? The real “flip side” is allowing patients to submit an invoice for the time they spend in the waiting room beyond their scheduled appointment.

At this point the situation is usually resolved. Rarely, patients continue to protest. If they do, I then say, “Someone has to be responsible for the missed appointment and there are only two people in the room – you and me. Who should it be?” It’s incredibly difficult for a patient to look you in the eye and decline to accept financial responsibility when you say this.

I mentally role-played saying this line to a patient, and it made me cringe. If a patient couldn’t look me in the eye because of something I said, I would be ashamed of myself. I have all the power in the relationship. Surely my patient would be concerned that their care may suffer if they don’t whip out their wallet, pronto.

What’s the next step if a patient digs in their heels and refuses to pay? The implication is that the doctor will end their relationship. (The relationship he loves…)

Having this conversation with patients reminds them of important aspects of the doctor-patient relationship: commitment, concern for patients’ well-being, reliability, timeliness and responsibility. This strengthens the relationship, decreases future no-shows, and helps you collect payment smoothly.

I’m not sure how this policy demonstrates concern for patients’ well-being, but it certainly does put the onus on them for timeliness. However, timeliness in the doctor-patient relationship cuts both ways. Patients will sometimes semi-jokingly say they feel like sending me a bill for the time I kept them waiting. If I were to charge them for missing an appointment, I bet I would actually see some similar invoices from them.

I suspect this tactic will decrease no-shows, but perhaps by driving patients away from the practice. Of course, given the difficulty people have in finding a family doctor or seeing a specialist, patients are unlikely to abandon a doctor, regardless of how they are treated. Once again, all the power is in the doctor’s hands.

If Dr. Marcus and I have such opposite views, then who’s right? We could argue, or we could collect the evidence. The evidence we look at depends on our goal.

If we implement his strategy with the intent of maximizing practice income, then we should compare the additional revenue from no-show patients with the cost of collecting that revenue. Include staff time and the even-more expensive physician time spent convincing patients to pay up. The value of the missed appointment should be discounted in the equation as the time was likely spent in some other useful activity, such as returning calls or reviewing lab results. Is there some way to calculate the value of lost goodwill?

If our goal is to reduce no-shows, then we could compare the no-show rates in two similar practices with different no-show charge policies. Comparing my Saskatoon urology practice with Dr. Marcus’ Toronto family practice is apples and oranges, but it’s interesting to note that he reports a no-show rate of 10-15%. Our clinic’s rate is the same.

It’s easy to be critical, so let me offer a suggestion for an alternate script for “no-show patients”:

I noticed that you missed your last appointment. Because your well-being is important to me, I want to find out how I can help you with appointments in the future. Is there a particular time of day that you prefer? Could my staff call you the day before the appointment as a reminder?

If you can’t make an appointment, I appreciate it if you can call as soon as possible. That will let me schedule another patient in that time, and that helps shorten our clinic’s wait time. Then, the next time you call for an appointment, I’ll be able to see you promptly.

Dr. Marcus’ advice may win the battle, but I fear it will lose the war.


  1. I cannot believe a physician actually wrote something that was so blatantly about HIS needs, and so not about his patients needs. I was so happy to see your alternative script. I believe as a patient, i would be much more inclined to ensure i remembered to cancel an appointment with you, than put up with that egotistical jerk who will charge me for missing an appointment

    1. In defense of the Dr. who does charge for missed appointments. In the medical office I work in, many times I am not paid on payday, and I have to wait until enough money comes in before I can get paid. It really IS about keeping the doors open. It's a business just like any other business. I notice the people who miss appointments tend to be repeat offenders....that is they have missed 10 appointments, not 1 or 2. People assume Doctors have oodles of money. This is not always true, and patients should absolutely be held responsible for booking appointments and failing to keep them.

  2. Thanks for the comment. Sounds like you want to have a relationship of mutual respect and trust with your doctor. Interesting.

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  3. Dr. Jonathan MarcusMarch 27, 2011 at 8:02 PM


    Thanks so much for taking the time to read and to analyse my article.

    I've had a chance to review your blog and I think it's great what you're doing. I think more doctors should to get online and engage in conversations. I like that you write on topics about improving patients' experience with the healthcare system.

    I think that you and I have a lot in common. I see that Advanced Access is a much discussed topic on your blog. I recently wrote an article in the Medical Post about the importance of doctor timeliness and I discussed advanced access. I'm writing two other follow up articles about other ways to achieve timeliness. I run my own office with a modified form of Advanced Access. Patients can almost always get a same day appointment and I'm never more than 15 minutes behind schedule.

    Although I advocate charging for missed appointments, I specifically tell doctors who don't run on-time that they should not bill for missed appointments. I think it's hypocritical to hold patients accountable when doctors don't respect patients' time.

    I expect patients to be responsible and respect my time but of course I have patients with medical and psychiatric conditions where I understand that they may not be able to take responsibility. I see depressed people, those with dementia and those under extreme social hardship. I don't charge them for missing appointment and I phone them to see how they're doing. I'll take your comments as feedback that I did not make these views adequately clear. This was due to length limitations of the article.

    We may not agree on everything but I look forward to reading your blog and perhaps discussing other issues in the future.


  4. Hi Jonathan,

    Thanks for leaving this comment to clarify your policy. As you said, it's impossible to give all the details in the limited space you had in your article. I still wonder what the goal for no-show fees is: to modify patient behaviour, or to help the physician's financial bottom line? If the former, we should be sure that it actually works, because it seems like it could hurt the physician-patient relationship.

      When a scheduled appointment at a VIM clinic or with a referral specialist is missed by the
      patient, valuable physician time is wasted. To help reduce the number of missed appointments,
      many VIM Alliance clinics have established no show policies.
      Since each VIM clinic establishes their own policies independently, the no show policies vary
      with each VIM clinic. The policies outlined in this document are a few examples of policies
      used by VIM Clinic Alliance members.
      Medical Outreach Ministries in Montgomery, AL: With three no shows for clinic
      appointments, the patient receives a warning letter. A fourth no show results in a dismissal from
      the clinic. Failure to keep a scheduled referral appointment results in a dismissal from the clinic.
      VIM in Jacksonville, FL: The clinic uses a three strike policy which is outlined, along with
      other patient expectations, in the “Welcome to VIM” document. Patients are asked to initial
      each line item and sign the document to show they understand the consequences of missed
      appointments. A warning letter is sent after the second no show. However, most letters never
      reach the patient because the patient has often failed to communicate a change of address to the clinic.

  5. Some further clarification....

    In my article, the final bit of communication to patients about collecting for missed appointments, 'Who should be responsible, me or you?'.... this wasn't resonating with doctors. I agree that although it has a flow of logic to it, it comes across as aggressive. And I almost never use it in practice. I can count on one hand the number of times I've said it. I have removed this component of my writing an speaking. I find that patients do pay for missed appointments when I approach it from a position of reason and fairness, which is the basis for the rest of the approach I described.

    As for me being the judge of excuses, I am certainly not that. I take what people say at face value. If they give me an excuse, I take their version and I tell my receptionist to. I tell them that in the event of a misunderstanding such as a patient telling me that they never booked a particular appointment, to always err on the side of the patient's version of the story.

    I go out of my way to make sure that patients can be seen conveniently and timely. I work in a business tower and my patients value this greatly. They understand that in order for me to work this way they need to take full responsibility for appointments to the best of their ability. I think I've lost very few patients over my policy but I've gained many more who tell me they heard how conveniently I provide service. In the rare event that I, as a family doctor, see a social or medical emergency, I take my time and run late because at that point the priority is the situation at hand.

    When I reported my no show rate of 10-15%, it's a rough estimate. Our policy has changed patient behaviour and this rate has fallen since we started dealing with things the way I described.

    The collection for missed appointments has helped our office's bottom line, which I believe is good for the practice as a whole.

    My solution isn't for everyone. The article was aimed at those who do charge for missed appointments.... how they could collect and maintain a good doctor-patient relationship. Of course, no one likes to pay for missed appointments. But my patients seem to understand particularly in the context of our entire relationship and how we choose to run our office in a convenient way.

    Again, individual doctors need to make a number of decisions as to how they manage their time. I'm explaining some of these options.

    1. "My patients seem to understand ..." perhaps you should actually ask them how they feel about it. Your whole premise is based on how this policy serves you, not how your patients feel about it.

  6. I accidentally cut off my intro to the above response. It was... 'Thanks for your gracious response Kishore.'

  7. Thanks to all for an interesting exchange. Dr. Marcus has not addressed two central points raised by Dr. Visvanathan: that a missed appointment is not invariably down time for the doctor, and thus not invariably lost income; and that the power imbalance between physician and patient makes "contract enforcement" highly uneven.

    Once we take blatant self-interest out of the equation, there might be real merit in Dr. Marcus's suggestion, with an important modification. How about this:
    1. If the patient fails to persuade that the reason for the missed appointment is legitimate, the patient pays.
    2. If the physician is more than 15 minutes late for an appointment, he pays. After all, the patient has appointments too, her time is valuable, plus parking, etc., etc.
    3. But you don't pay each other - you put the money into a practice charitable donations fund.
    4. And if you really want to be public spirited, don't claim a charitable donation tax credit, so the rest of us don't have to subsidize your joint failings.

    1. In my office, we do charge patients for no shows, but also credit patients if we no show them (and of course a good reason leads to no charge for patients or our staff). For instance we've had occasion to cancel patients last minute for a media appearance of mine and in those cases, we credit the patient the same $s we'd charge them if they'd no showed us.

      Can't have a one way street and claim it's fair.

  8. I like it! How about a small change to part 1: Rather than making the patient "persuade" the doctor, nurse or receptionist of the legitimacy of their reason for missing an appointment, leave it up to an honour system. Let patients know about the charitable donation option and let them decide whether or not their reason was legitimate.

  9. In my office, the patient selects the appointment time when they call to make an appointment. We do not select it for them unless it is a procedure that needs to be done at a certain time and they are told this well in advance. Secondly, we do not double book. Thirdly, all patients receive a reminder call the day before. Despite these efforts, I am still amazed at the number of no shows. Therefore we charge for no shows unless there is a legitimate excuse. And finally, we are almost always on time. When we are not on time, the main reasons are patients coming late, patients making appointments for checkups then asking us to deal with several problems, insurance verification problems, patients failure to bring their new insurance information or authorizations, and emergencies. These are all beyond our office's control.

  10. Why would they charge them? Don't all doctors book at least a couple of extra patients a day so they don't lose money on these patients? Certainly that would be the view of most patients, the way they wait so long and then are rushed in and out in 2 minutes or so.

    Also, older people and those with memory problems would be paying the most money. What's especially bad is even though so many people are aging now, no one calls to remind them of their appointments the next day anymore either, like they used to. Some doctors might "hope" they would forget so they could bring in extra money.

  11. I actually missed an ultrasound, first thing in the morning at 7:30 AM a few weeks ago. Did I ever feel awful about that! It was just that I had so many other appointments that week that, in my mind, they were over for the week. I was actually extremely upset about missing it! Again though, if they had called the day before, I wouldn't have missed it.

    There's the thing about rapport too, between doctor and patient. The more patients feel their doctors care more about money than about them, the less close they will feel to them. Patients may care equally about money, and then next thing you know, there are lawsuits coming up.

  12. As a psychiatrist I book patients for one-hour appointments. If I can only see 6-7 patients in a day, one no-show is a significant amount of lost income. If it happens because of carelessness or lack of regard, it produces a lot of resentment - how would my patients feel if I wasn't listening to them during our appointments or I forgot to show up? To me, giving patients a bill helps to keep resentment from building up - at least I have let people know how it impacts me if they don't show up. With respect to doctor-patient relationship, I think it keeps things honest - to say nothing and act as though sitting idle for an hour and losing 15% of my income for the day doesn't bother me would not be authentic. Things were different when I received a salary whether or not patients showed up - it still bothered me if I thought people didn't take the time seriously, but at least I got paid and had time to do other things. That changed when I started working fee-for-service.

    If the person feels that the missed appointment was due to circumstances beyond their control or an honest misunderstanding then I would let it go. Along the lines of the suggestion in Dr. Marcus' article, I think there is a "look me in the eye" test - if the person can look me in the eye and say without any guilt that it was not their fault, that's good enough for me. Conversely, if my clinic ran perpetually late, my work was sub-standard, I only saw people for the money, or I didn't give patients my full attention when they were there, I don't think I could look them in the eye and bill them for not coming.

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  16. Any way you slice it, charging for a no-show is about punishing the patient for a "wrong-doing". Most likely, the no show was unintentional, and the patient will already feel bad about it. When he gets charged he will feel shame and anger. The patient relationship is damaged, and likely the patient will go elsewhere. So any future income from this patient will disappear. Forgiveness fosters goodwill and loyalty, and a continued relationship. Help someone get better, don't punish them for their mistakes. Mr. Visvanathan is right-on in his assessment of human relationships. That's just the way it works. Anytime you are "right" and someone else is "wrong", there will be a loss of trust. This is not the "brand" that you want to build for your practice: "We run a tight ship. Shape up or ship out."

  17. My Doctor is a walk in Doctor and he also had patients. I called the office and spoke with the secretary. She said I can schedule you for an appointment two weeks from now or you can come in as a walk in tomorrow. I said ok i'll come in as a walk in tomorrow. I went to see the Doctor and everything went good.

    In the mail I received a letter saying I now owe 50 dollars for a Doctor appointment I missed. I called and the secretary said I must take this up with the Doctor.

    This really is horrible. Who do you think they will believe me or their secretary? I now have to suffer for someone elses mistake and they will just think i'm lying. I wish Canada would make it manditory to make Doctors have IRV or voice recording systems so you can prove you either did make an appointment or not.

  18. The doctor–patient relationship has been and remains a keystone of care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation, and support are provided. I don't think money could differ this relationship. Money is not important than life.

  19. I am surprised and out of thoughts when I read this post. The relationship between a doctor and patient is very important for both. The discussion about money is not right think. Money should not be a very important part of it. Life is more important than money.
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  20. Can Alberta doctors charge a no show fee to a sixteen year old, who booked his own appointment without his parents knowledge and then forgot the appointment? A reminder phone call never came to my son or myself. Legally, can either of us be forced to pay?

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  22. I showed up for my appointment one hour late instead of one hour earlier because I made a mistake. The receptionist turned me away and charged me with a no-show fee. I apologized and asked that the no-show fee be waived. I said I showed up but the mean receptionist turned me away and insisted I was no-show and therefore I should pay. She even showed me the no-show agreement I signed. Nowhere in that agreement did it say late-show fee. I always waited an hour or more in the waiting room before being seen, but they don't pay me for the wait time. It should be a wash. The doctor and the receptionist said they can not pay me for waiting.

    1. I am looking forward for the day that technology and automation starting to make some of the doctors obsolete ... this day is not that far, and it would be much closer if it wasn't for the most doctor's resistance to technology. We should see a shift of attitude when that comes.

      I am not a big fan of automation in general, but the feeling is ... like when Rogers and Bell were ripping Canadians off, and the market showed signs that the big players from US may come up to the great white north ... do you remember the attitude change from Bell and Rogers and the adds they took out. More competition is great in the field of medicine, especially if they need to compete with technology and automation and a doctor over the web from the "Cloud" that would tell you about your test results. That day is coming.

  23. I just received a $25 fee from my Urologist. It is not the 25 bucks that is bothering me. I am looking for every excuse not to go back ...
    This is an annual check up. The appointment was setup last July, since then, my mother's health is deteriorated immensely and she is a palliative ... I have been spending every extra second of the day with caring for the parents. In addition, I have lost my phone a few months ago where the appointment was recorded. But these are my problems and not his.

    What bugs me is that doctor's office is refusing to make reminder calls. However they didn't have any problem or lack of time sending me the invoice on the day that I missed the appointment. If they made an effort calling a day or two prior to the appointment then all would have been fine. They could set up a scheduled email to go out at the time of booking, that cost them nothing extra, but no they can't bother.

    Again, it clearly isn't the $25 that is bugging me as it is costing a lot more to search, read and comment on this issue. At this point my doctor is just rubbing me the wrong way, and does he want to lose a patient for that?! I'll find out soon. I may book an appointment and will likely refuse to pay ... it should make a for an interesting conversation to say the least. I can imagine if I was older and more in need of urgent care I would just pay and get it over with, but if he doesn't hear from me, that elderly patient in need doesn't stand a chance of ever getting that appointment reminder call.

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