Patient No-Shows: Everything Practice Managers Need to Know
Industry Best Practices for Measuring and Reducing Patient No-Shows
Clinical Billing Best Practices Billing Best Practices
Patient no-shows permeate medical practices, across specialties, locations, and practice model. While no-shows consistently cause problems for practices, not all practices track their no-show rate or realize the impact that even a couple no-shows can have on both their processes and their revenue. There are many reasons that patients fail to make their appointments and there are demographic similarities across patients who no-show more consistently than others. Practice Managers have worked hard to reduce no-shows using a variety of strategies, but often those strategies involve manual processes or difficult-to-enforce policies, resulting in a lesser impact than originally thought. With the rise of EHR’s, Meaningful Use, and innovation in healthcare, the industry has developed some best practices to offer practice managers that require little manual work and have shown to decrease no-show rates by over 50%. This definitive guide explores the underlying cause of no-show behavior, outlines best practices, and shares how they work to reduce the manual workload of practice staff, serve patients better, and ultimately reduce patient no-shows.
Practice Management Has Many Challenges, No-Shows Doesn’t Need to Be One
Practice Manager. Clinical Manager. Patient Access Manager.
Your title can be one of many and your background may be clinical, administrative, or financial. Regardless of how you got here and the title that graces the bottom of your email signature, you’re an integral piece of keeping one or more physician practices running smoothly and efficiently. And it’s a tough gig sometimes, balancing staff and physician needs, billing, insurance, patients, and scheduling staff. Let’s make it easier starting with the biggest problem, no-shows.
Who does it, why, and what you can do to change it
You’ve experienced it: idle physicians, waiting patients, and last minute vacancies– no-shows put patients behind in their care and negatively impact downstream processes. Most healthcare consumers are unaware of how no-shows impact healthcare for everyone, but the statistics reveal far-reaching repercussions:
- Patient no-shows cost the healthcare industry $150 billion annually
- For a primary care physician, each missed appointment equals roughly $150-$200 in lost revenue. For surgeons, this is closer to $500.
- Patients who fail to show up for their appointments often require more expensive emergency care later on. These higher costs get factored into healthcare costs for everyone else
“For specialty practices that often have long wait lists, a patient no-show means that a wait-list patient has been waiting too long to see a physician and more importantly, could have had a spot on the schedule, but didn’t have the opportunity. Timing and access is everything for our patients.” –Sadaf Tehrani, Director Patient Access and Scheduling, Children’s Hospital Colorado
Here’s What We Know
You can’t fix what you don’t track.
Our customers tell us that their number one challenge in running a practice is staffing, specifically managing without a full staff and juggling the patient load when a nurse calls in. If your practice averages two no-shows daily, as one specialty practice shared with us, this equals approximately $104,000 in missed reimbursement annually. You can add 1-2 full-time staff members to your practice with that money. Every practice should be tracking their no-show rate. Without accurate numbers to work with, your efforts to fix this issue will be frustrating at best. If you do stumble across a brilliant solution, quantifying your progress will be difficult and the data misleading. How you define a “no-show” is just as important as establishing a way to track it. In our experience, we’ve seen two common mistakes that can unintentionally result in misleading data:
- Including cancellations and appointment changes into their no-show rates
- Marking a no-show as “canceled”
Practices in both of these scenarios struggle because they are operating with bad numbers.
Defining a Patient No-Show for Measurement
For benchmarking, a no-show is defined as a patient who never arrived for a scheduled appointment and gave no prior notice.
How to Calculate Your No-Show Rate
Take the total number of patients that did not show up for their appointment and divide by the total number of scheduled appointments (if you remove appointments that no-show, be sure to add them back to calculate). No-Show Rate = No-Shows / Scheduled Appointments* *remove walk-in appointments
Reasons Patients No-Show
Though anyone can be guilty of failing to show up for an appointment, patients most likely to miss their appointments include those who:
- are single
- are 34 years of age or younger
- are on Medicaid or have no coverage at all
- Have chronic conditions
- are older and are recently widowed or divorced
- live 60 miles or more from the clinic location
It’s tempting to blame patients for their failure to show up for an appointment or communicate their need to reschedule. However, there are so many contributing factors to a missed appointment, and often times, we don’t realize that our own practices have contributed to the problem. There are several studies available about why patients skip their appointments, after working with our clients and reviewing all the research, we’ve identified the following most common reasons patients don’t show up: Forgetfulness: This one may seem obvious, but this is the #1 reason patients report as the reason for not showing up for their appointments. To compound this problem, 24% of patients in one survey said they tried to cancel their appointment but couldn’t. Time: many patients report inconvenient appointment times as their reason for failing to show up for their appointments. Cost: while the rate of insured patients has dropped in recent years, copays, deductibles, and out of pocket expenses have risen dramatically. Fear: there are lots of things that give patients anxiety about visiting their provider and as healthcare professionals, we often overlook these things. Procedures, bad news, and disapproval from the physician are all sources of anxiety that often times get the best of patients. Demographic barriers: language and age are two examples of demographic barriers that can result in a patient no-show. Consider the elderly patient who no longer drives: if their transportation falls through at the last minute or they forgot about their appointment until the night before and didn’t have time to make arrangements, they will have no choice but to skip their appointment.
Strategies for Reducing No-Shows
The great news is that we can impact nearly every reason listed above with patient-centered communication. Of course, for every great strategy is one that didn’t pan out. We’ve seen it all and from where we stand, these are some things we don’t recommend.
Charging patients for the missed appointment.
Roughly 25% of physician practices charge some kind of no-show fee and there are compelling arguments on both sides of this practice. At the very root of this practice is the hope that charging a fee will force a patient to connect value to a physician’s time, will recover a small portion of lost reimbursement, and will alter patient behavior even if a practice never intends to collect the fee. If your practice does employ a no-show policy, it’s important to ensure that your patients are aware of the policy. In a recent survey, MGMA found that 41.6% of patients surveyed, who missed an appointment, said they were unaware of their doctor’s no-show policy. While most practices will see some reduction in no-shows when implementing a fee for missed appointments, it also creates additional work for staff to enforce and fails to address many of the underlying reasons that patients miss their appointments. It’s also important to note that in some states, Medicaid doesn’t allow physicians to charge patients for missed appointments and Medicaid patients are one of the more likely patient types to no-show.
Recorded Reminder Messages
While pre-recorded reminders have a place in your strategy for reducing no-shows, they fall short as a stand-alone solution because they don’t offer patients the ability to respond in real time. This means that in order to confirm or reschedule, your patient will still have to call the office, listen through the phone tree, select an option, and wait for someone at the front desk or in scheduling to pick up. This said, combined with some other bi-directional solutions, automated reminder messages (voicemail) can definitely impact your no-show rate.
Double Booking Appointments
This strategy banks on the probability that a patient won’t show up for their appointment, which doesn’t solve anything, it only seeks to hedge your bets about patient behavior. When everyone shows up as scheduled, the results are long wait times, frustrated patients, and minimal time with a provider— all of which put the hard-earned reputation of the practice in jeopardy and require double the work for staff. While double booking may serve as a short-term solution, in the end it requires more work for the same amount of money.
Best Practices & Tangible Solutions
As you move towards solving your no-show problem, keep it simple. Aesthetics are important but resist the urge to grab the shiniest solution you see, your goal should be to engage your patients in a way that is intuitive and reduces work for your staff. Here are some best practices that have the ability to revolutionize your practice for both your patients and your staff.
Automate Appointment Reminders
Automation is key to implementing a solution that is sustainable over time and can grow with your practice. Make a list of all the manual activities your staff is doing to engage patients and reduce no-shows. We are willing to bet that most, if not all, of those manual processes could be automated—freeing up the valuable time of your staff.
“We used to have nurses call the high-risk families every couple of days prior to their appointment to remind them, which isn’t the best use of a nurse’s time.” – Katie Schuman, Associate Clinical Manager, Children’s Hospital Colorado
Automating processes also reduces the risk of errors and gaps in communication. If reminders don’t require the time and attention of a human, they won’t get reprioritized when the clinic has a rush or is short-handed for a day.
At Relatient, we talk a lot about being patient-centered, it’s the force behind everything we do. Our products and best practices are designed to be invisible because we want patients to engage with their physicians without even thinking about it. We’ve learned a couple things about patient behavior and know that adoption happens when:
- We use existing technology
- The solution doesn’t require a username or password
- The solution doesn’t require the user to download an app
- A relevant message is delivered at the right time
We accomplish all of the above by utilizing tech that’s already in hands of patients, literally— with text (sms) messaging. It’s on every phone, it’s been around longer than the iPhone, and it’s easy enough for my eight-year-old to do. Check out these statistics:
- Adults under 45 send and receive 85+ texts every day, on average, while adults 45-54 send and receive 33 texts a day, and adults 55+ send and receive 16 texts a day.
- People prefer text most for scheduling or changing appointments. In fact, 78% of people wish they could have a text conversation with a business, and 64% of consumers report they are likely to think positively of companies that communicate via text.
- Text messages produce a 209% higher response rate than phone calls, and confirmation via text is 295% more successful than phone calls.
- Texting is the highest rated contact method for customer satisfaction compared to all other communication channels (Text – 90; Phone – 77; Facebook – 66).
This strategy is so effective, we’ve seen practices reduce their no-show rates by 40%-50% within weeks of implementation, giving them the ability to add appointments back to their schedule every week. We send productivity through the roof and dramatically increase revenue by getting patients that are already scheduled in the door and moving our waitlisted patients to an open slot in the schedule.
Be Strategically Multi-Modal
A good strategy is an integrated one, it doesn’t rely on one approach for every patient. While we know that text messages will reach the greatest percentage of patients, we also know that emails and voice are important components to engaging patients. The key is that every message we send can be pushed to a mobile device and we use a strategic timeline to push those messages.
Utilize Bi-Directional Communication
In other words, your patients need the ability to respond to your messaging without putting down their mobile device. According to an article on MGMA’s website, one member reported a no-show rate of less than 3% when patients are given the opportunity to confirm their appointment versus a no-show rate of 6% when patients are reminded but not able to confirm and it is even higher at more than 10% when patients are not reminded of their appointments.
Finding the Right Vendor
You’ll need some help to automate your processes and put some of these practices in place. Choosing this partner can be an overwhelming task, we want to encourage you to evaluate your options based on the things that will improve your patient satisfaction, provide new efficiencies, and reduce wasted time and effort long after go-live. Use the following checklist to help you identify a few strong contenders from which you can select the best fit for your organization.
- Functionality: Can the system accommodate multiple sites, multiple families on one contact number, and multiple modes of communication?
- Is it bi-directional? Can patients respond to the messages they receive?
- How is the product priced? Is there a cap on the volume of messages sent?
- What kind of service will you get after go-live? Will you have the option to talk to a human during the most critical hours of operation?
- Can the product integrate with your practice management system?
- How complicated is the go-live process and what kind of support will you have along the way?
- Was the product designed with its end user in mind (patients)?
- How will your vendor partner with you to keep you compliant with TCPA regulations?
- How well does this partner understand your greatest challenges and priorities? What additional expertise do they bring to the table?
We find that these are all important factors for our clients when they are evaluating their options. Jason W. Miller, CEO of Reiter, Hill, Johnson & Nevin, told us, “We didn’t want a report workaround; we wanted a seamless integration. Not an external, stand-alone, silo-ed system.”
They found that implementing Relatient’s appointment reminders eliminated 200-300 manual outbound calls per day, freeing them up to focus on incoming calls from patients. They were also able to completely eliminate all postcards and the staff costs associated with sending out reminder postcards for their practice.
Few practices are immune to the impact of no-shows and practices who don’t perceive no-shows to be a problem are often missing an opportunity to increase revenue and fill open appointments in their schedules. With the many demands placed on practice managers, resources are stretched thin and practices often rely on manual processes like phone calls and post-cards to remind patients of their appointments. Automation and patient-centered practices offer medical practices solutions to their no-show problems that operate in the background and require minimal work from practice staff. This frees staff to focus on patient care, strong documentation, and follow-up. There are many vendors in the marketplace who offer some form of patient appointment reminders, few offer the functionality and support that make automation an efficient solution for practices. Bottom line: no-shows are a hassle, but they’ve got nothing on you. Go get ’em.