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 By Neil B. Gailmard, OD, MBA, FAAO, Editor November 25, 2009 - Tip #407 
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More on No Shows

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I was very pleased to get such a large reader response from the recent tip article on no shows. I can't always tell in advance what will press your buttons, but that one did. I received some great questions and comments. I'll share some of them here and we'll dig a little deeper into this issue since it is a topic many ECPs are interested in. I got a good chuckle on the email from one doctor who said he had time to respond to my article because he had two no shows this morning!

Here is a breakdown of issues and questions. Reader email excerpts are italicized and my comments follow.

What about repeat offenders?

     While I generally agree with you that a harsh no show policy is poor customer service, you did not address the habitual offender. What do you suggest doing when a patient is a no show several times, or when two family members with appointments the same day are no shows?  Is this when you double book the patients?  If so, what do you do on the occasions when everybody shows up?

     I agree with everything that you said about office policy for No Shows.  Believe it or not we actually have patients that will No Show without any call (not even a courtesy call at the last minute) - REPEATEDLY.  We're always gracious, understanding, and happy to see the patient; however, we ask that they walk in at a time that is convenient for them (rather then reschedule them for a 4th time).  I think this is very generous to the patient and fair to the practice.  It also usually works well with the type of patient that can't be bothered with appointments, and if correctly expressed, they feel special and accommodated rather than rejected.

     What about repeated no shows, e.g. chronic? Do you have the same policy? We use a tiered approach: once three no shows- patient is double booked. Once six or more- walk-in only (no appointment, although we guide the patient as to when we want them at office, this improves daily flow for us, but, at the same time we do not count on the patient showing until the patient is actually in the office and waiting). Patient can "earn" way back to normal status by five shows in a row. Patient still wins because we do not refuse service.

I agree that there may be some patients who are simply so bad at keeping appointments that the practice must take some action. Since my clinical routine is highly delegated to staff and we save doctor time as much as possible, it is easy for us to double-book a patient and still handle it easily if both show up. The converse of that is true also: because we are highly delegated, a no show does not have as big of a negative impact on wasting doctor time.

But it's important to not take action too aggressively. It would depend on how frequently your office has repeat offenders that require special handling. It should be rare. Be careful that the policing of no shows does not become such a big focus for your staff that it alters your office culture. If staff members put great effort into tracking no shows and enforcing policies that restrict service, that negative mindset can become pervasive.

What about loss of income?

     I enjoyed and agree with your philosophy on the no show patient and how it helps define the culture of the practice. The patient you did not discuss, however, is the one who has been a no show three appointments in a row. These patients typically do this year after year because they know they can. With an average income of over $300 per refraction being a common benchmark, you can easily lose over $900 of income annually with these patients. That is $9000 over ten years per Mrs. Chronic No Show. How do you handle this case?

     We differentiate between patients that no show rarely to occasionally and those that no show regularly. If a patient is a chronic no show we send them a card letting them know they will need to pay for the exam in advance. We do strive to provide a high level of customer care and will overlook an occasional no show but some patients seem to no show way too much. I think at some point you have to look at the economic downside of their no shows. Just like if a patient is not paying their bill, we will obviously not just look the other way, but try to collect that balance. Thanks for all your good tips. This is not necessarily a disagreement but distinguishing there are different levels of patients not showing for appointments.

     Your advice seems in direct conflict with advice about not taking certain insurance plans, i.e. profitability. A practice can't tolerate no shows and be profitable. You buried the best advice in the article, double book. I have my staff double book them at the end of the day with the last patient (the no show of course gets attended to second). If the patient doesn't show, we all go home a bit earlier vs. many staff waiting around for the next patient to show.

We have to be careful to see the big picture. I would argue that a practice could tolerate no shows (to a higher level than the average practice) and be extremely profitable. The understanding and caring approach that is obvious in those cases speaks volumes about the customer service and that can drive demand beyond belief. Most practices suffer from insufficient demand. Higher demand can allow you to charge higher fees or bring in an associate doctor. In fact, extremely high demand is a major factor in allowing a practice to be able to drop a vision plan!

We also must recognize that the missed appointment did not require the work to be done. If the patient had shown up, the slot would have required work that carries a certain average revenue value, but the work was not done. The doctor and staff worked on something else instead. Of course, the secondary work may not have produced any direct income, but something else could have and should have been done. The time slot need not be a total loss.

What about Medicaid or other lower profit cases?

     I don't know if you see many Medicaid patients, but would your policy be any different if you saw a lot of Medicaid patients, who tend to have a higher no show rate?

     The vast majority of no show appointments in my office are Medicaid patients.  Many times, the patient will book appointments with several doctors and show up for the one that is most convenient.  They do not have to pay for the services so they really don't care.  I try to be understanding and don't fuss if the patient calls and cancels at the last minute.  But when they confirm the appointment the night before and then just don't show up, I get upset.  I allow three no shows before the patient is listed as "walk in only." Thanks for your column.

I agree that profitability should be a consideration and I should have mentioned that. In fact, if the profit margin is extremely low per case, the practice may not be able to deliver high level customer service. Service may have to be bare bones with no luxuries.

How should I handle families, especially on Saturday?

     I receive your tip of the week e-mails every week and I usually enjoy reading them.  I just wanted to let you know that I agree with most, if not all of your great tips.  I especially like the one this week about your view on patient no-shows.  I have the same attitude you do about it, and more than half the time they apologize about missing the previous appointment.  The only thing that is hard about this approach is when you have a family of four who no-show three weeks in a row on Saturday mornings (half-day), and they take up four of your 30-minute slots!  Try that one!  Anyway, thanks again for the weekly e-mails.

     How would you handle a family of three or four that takes up an hour to 90 minutes of appointment time and no-shows on two or three different occasions?  This doesn't happen often, but it sure puts a big gap in the schedule if there are no walk-in appointments.  I really enjoy your weekly tips!  Thanks in advance.

I'm still looking at this from the patient's point of view in these cases and I can see why a mom might like to bring the whole family at once, and have it on a Saturday. We do make an extra strong effort to discuss the importance of letting us know in advance if they have to cancel and we work hard to confirm without voice mail two days in advance.

Am I just encouraging more bad behavior?

     Just to play devil's advocate... If bad behavior by patients (i.e. no shows) is tolerated, and there are no consequences, doesn't it encourage more bad behavior?  Thanks.

     It can definitely differentiate your practice from others.  I've often wonder though, if you handle these things the way that I think is best, am I building a practice that caters to irresponsible, inconsiderate patients!?  Too much of a good thing can be bad. Keep it up!  Love your articles and always look forward to reading them.  They are often the topic of our weekly team meetings.

I don't think our practices can really make much difference in teaching the public how to behave. I would rather my practice get better at handling the public then try to filter the people in some way. I am quite certain that letting the patient win is good for business and that is all I care about.

Are confirmations really happening?

     Neil, I am curious if other ECPs have complained about an increase in no-shows.  In the past two years, it seems to have become epidemic in my practice, many times even after the appointment was confirmed by phone the previous day.  We have done nothing different so far, but this is an extremely frustrating problem.  Thanks for your weekly efforts...always find a pearl in there somewhere!

Be sure that staff members are really confirming appointments. It is pretty easy to just let the task go one day and realize that no one noticed. And if fewer patients show up, it actually makes for an easier work day. We have staff members initial the confirmation worksheet and we spot check occasionally by asking patients if they received a phone call. We are also using automated email confirmations more than ever. Another idea is to use one of the companies that provide automated voice confirmations; they really work well and they do not turn people off.

Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week

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Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.

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